Every finding on record at Ashtabula County Nursing Home

Based on record review, interview and policy review, the facility failed to ensure triggers were addressed for residents with post-traumatic stress disorder (PTSD). This affected four (#3, #11, #76 and #81) of four residents reviewed for trauma informed care. The facility identified four residents (#3, #11, #76 and #81) as having a diagnosis of PTSD. The facility census was 104. Findings include: 1.Review of the medical record for Resident #11 revealed an admission date of 11/13/25 with pertinent diagnoses included post-traumatic stress disorder (PTSD), vascular dementia, psychotic disturbance and anxiety. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had moderate cognitive deficits, physical behavioral symptoms directed towards others occurring one to three days in the seven day look back period and verbal behavioral symptoms directed towards others occurring four to six days in the seven day look back period. The assessment indicated Resident #11 had a diagnosis of PTSD. Review of the care plan dated 05/29/26 revealed Resident #11 had moderate depression and recently had an inpatient psychiatric stay for medication management related to psychiatric issues and behaviors. Diagnoses included PTSD, altered mental status and depression. No triggers were identified in the care plan and there were no interventions to address PTSD related triggers. An interview on 07/08/26 at 11:04 A.M. with Certified Nurse Aide (CNA) #236 revealed she did not know Resident #11 had PTSD and was unaware of what triggered any behaviors for Resident #11. An interview on 07/08/26 at 11:11 A.M. with Licensed Practical Nurse (LPN) #294 revealed she did not know Resident #11 had PTSD and was unaware of what triggered any behaviors for Resident #11. An interview of 07/08/26 at 1:00 P.M. with LPN #282 who was identified as the Unit Manager for Resident #11 revealed she was aware Resident #11 had PTSD and his triggers were loud noises from his military service. LPN #282 stated the wife of Resident #11 informed her of the triggers. LPN #282 stated resident information regarding triggers and PTSD was passed on in report via the floor nurse. LPN #282 verified the lack of triggers in the care plan of Resident #11 within the medical record. LPN #282 stated care plans should be developed to inform staff of potential triggers. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with pertinent diagnoses including post-traumatic stress disorder (PTSD), and major depressive disorder. Review of Resident #3's care plan, last revised 04/27/26, revealed Resident #3 was at risk for a decline in mood related to PTSD, anxiety and depression. There was no documentation to address PTSD triggers or interventions for triggers related to PTSD. Review of the quarterly MDS 3.0 assessment dated 06/23 /26 revealed Resident #3 had intact cognition, inattention which fluctuated in severity, and a diagnosis of PTSD. Further review of the medical record for Resident #3 revealed a quarterly PTSD assessment was not completed. An interview on 07/08/26 at 9:25 A.M. with Unit Manager (UM) #286 revealed she was the unit manager on Resident #3's unit and did not know any of the residents' PTSD related triggers. An interview on 07/09/26 at 11:37 A.M. with the Assistant Director of Nursing (ADON) #202 confirmed there were no PTSD and trauma-related triggers in Resident #3's care plan. An interview on 07/09/26 at 1:42 P.M. with ADON #202 revealed quarterly PTSD assessments were not completed by the facility for Resident #3. 3. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), bipolar disorder, major depressive disorder, anxiety, and unspecified psychosis due to substance or known physiological condition. Review of the quarterly MDS assessment dated [DATE] revealed Resident #76 had severe cognitive impairment, inattention which fluctuated in severity, displayed physical behaviors toward others one to three days, and had a diagnosis of PTSD. Record review of the psychiatric evaluation dated 06/24/25 revealed Resident #76 had a history of dementia, bipolar disorder, anxiety, major depressive disorder, OCD, PTSD, and psychosis. The evaluation revealed Resident #76's cognition was impaired at baseline and the resident's OCD, anxiety, and agitation symptoms were at baseline. The psychiatric provider recommended continued monitoring for mood and behavioral changes. Record review of Resident #76's care plan, date initiated 04/09/18 and last revised 07/09/26, revealed no documentation related to PTSD, trauma history, triggers, calming strategies, individualized interventions, or approaches for staff to provide trauma-informed care. An interview on 07/08/26 at 9:25 A.M. with LPN #291 revealed Resident #76's PTSD was related to childhood trauma. LPN #291 confirmed she was not aware of any triggers for Resident #76 and stated the resident's behaviors were managed well with medications and psychiatric visits. An interview on 07/09/26 at 11:37 A.M. with ADON #202 confirmed in order to provide care according to the residents' individual needs, PTSD and trauma-related triggers should be included in Resident #76's care plans. An interview on 07/09/26 at 1:42 P.M. with ADON #202 revealed quarterly PTSD assessments were not completed by the facility for Resident #76. 4. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including PTSD, bipolar disorder, and unspecified psychosis. Record review of Resident #81's care plan, date initiated 06/02/23 and last revised 05/21/26, revealed no documentation related to PTSD, trauma history, identified triggers, calming strategies, individualized interventions, or approaches for staff to provide trauma-informed care for PTSD. Record review of the psychiatric evaluation dated 06/24/25 revealed Resident #81 had a history of bipolar disorder, PTSD, anxiety, and insomnia. The evaluation revealed Resident #81 was at baseline for mood and behaviors with no reported worsening depression, anxiety, aggression, agitation, psychosis, mania, hypomania, or PTSD symptoms. The psychiatric provider recommended continued monitoring for mood and behavioral changes. Review of the quarterly MDS assessment dated [DATE] revealed Resident #81 had moderate cognitive impairment, inattention and disorganized thinking which fluctuated, required assistance with activities of daily living, and had a diagnosis of PTSD. An interview on 07/08/26 at 12:00 P.M. with LPN #300 revealed when asked where staff would locate Resident #81's PTSD triggers, LPN #300 reviewed the resident's chart and stated, I don't know. LPN #300 stated she had not had any issues with the resident's PTSD since admission. LPN #300 confirmed the care plan did not address triggers. An interview on 07/09/26 at 11:37 A.M. with ADON #202 confirmed in order to provide care according to the residents' individual needs, PTSD and trauma-related triggers should be included in Resident #81's care plans. An interview on 07/09/26 at 1:42 P.M. with ADON #202 revealed quarterly PTSD assessments were not completed by the facility for Resident #81. Review of the facility policy titled Policy and Procedure: Post-Traumatic Stress Disorder (PTSD) revealed the facility would provide person-centered care related to PTSD. The policy revealed care and services would be delivered in a manner that promoted safety, dignity, choice, trust, collaboration, and empowerment while minimizing potential triggers. The policy revealed the interdisciplinary team would assess residents for trauma history or signs of trauma/PTSD upon admission, quarterly review, significant change, and as needed. The policy further revealed the care team would identify known or potential triggers, calming strategies, preferred routines, personal boundaries, communication preferences, and privacy needs. The policy revealed the comprehensive care plan would include individualized interventions to address PTSD or trauma-related needs when identified and would identify early warning signs of distress and specific steps staff should take to support the residents.

Based on record review, and interview the facility failed to ensure staff treated residents with respect and dignity. This affected one resident (Resident #57) out of four residents reviewed for dignity. The facility census was 104.Findings include:Review of the medical record for Resident #57 revealed an admission date of 06/08/24. Diagnoses included atrial-fibrillation, hearing loss, and acute and chronic respiratory failure with hypoxia. Review of the Annual Minimum Data Set (MDS) assessment, dated 04/28/26, revealed the resident had moderately impaired cognition. The resident required maximum assist for showers/bathing. Touching assist was needed for lower body dressing. The Resident needed set up or clean up assist for lying to sitting, chair to bed transfers, and toilet transfer. Review of the Health Status Note dated 05/28/26 at 4:00 P.M. revealed Resident #57 reported an incident to the Director of Nursing (DON) with the resident's granddaughter present in the room. During care, Certified Nursing Assistant (CNA) #249 was assisting Resident #57 to get dressed for the day and he felt her demeaner was rude and made a comment that upset him. Agency CNA #249 was placed on a do not return (DNR) list. The DON called the resident's daughter and spoke briefly about the situation over the phone. The daughter, social service designee, Resident #57, and DON attended a care plan meeting on 05/28/26 at 2:30 P.M. and the incident was reviewed again.Review of the interview statement with Resident #57 on 05/28/26 revealed Resident #57 reported to the DON in the morning that CNA #249 came into his room to get him dressed for the day. When she was assisting him with changing his shirt, he went to grab her hand to get help to sit up and CNA#249 replied, Don't touch me. Resident #57 indicated the CNA acted rude towards him and was not very nice during the interaction.Review of a statement from CNA #249 dated 05/28/26 revealed that CNA #249 reported to the DON that during her interaction with Resident #57 he pulled her down when reaching for her arm. CNA #249 denied saying Don't touch me. CNA #249 stated It didn't go like that. He pulled me down; told him don't pull me like that. CNA #249 demonstrated putting her hands up. CNA #249 was notified she was DNR from the facility. An interview on 07/08/26 at 9:24 A.M. with Resident #57 revealed he remembered the incident on 05/28/26 with CNA #249. Resident #57 stated he felt CNA #249 was rude and yelled something, but he could not remember what was said. Resident #57 stated she did not swat at or hit him. Resident #57 did not indicate he felt abused by CNA #249.An interview on 07/08/26 at 5:12 P.M. with the Administrator verified Resident #57 reported CNA #249 was rude and made a comment that upset him on 05/28/26. The Administrator stated the facility will DNR any agency staff that do not behave as expected. The Administrator stated CNA #249's behavior was disrespectful but not abusive and when they met with the family on 05/28/26 the family was very happy with how the facility handled the follow-up on Resident #57's concern.

Oxygen tubing: Based on observation, interview, record review and review of facility policy, the facility failed to ensure a nebulizer mask was stored in a manner to prohibit contamination. This affected one (Resident #17) of one resident reviewed for respiratory care. The facility census was 104.Findings include: Review of the medical record for Resident #17 revealed an admission date of 10/21/22 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and chronic respiratory failure with hypoxia. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had severe cognitive impairment. The assessment also revealed the primary medical condition for Resident #17 was COPD. The assessment revealed Resident #17 had shortness of breath with exertion and lying flat and was on oxygen therapy.Review of the care plan dated 04/29/26 revealed Resident #17 had an altered respiratory status. Interventions included administer medication and puffers as ordered.Review of physician orders dated July 2026 revealed active orders for oxygen at three liters per minute via nasal cannula continuously, and ipratropium-albuterol inhalation solution 0.5-2.5 milligrams/3 milliliters, Inhale 3 milliliters via nebulizer every six hours as needed for shortness of breath and or wheezing.Observation on 07/06/26 at 2:46 P.M. revealed the nebulizer mask (the mask that sits over the resident's nose and mouth to deliver an aerosolized medication mist into the airways/lungs) for Resident #17 was sitting directly on and touching the bedside table next to the nebulizer machine. The mask was not in a storage bag to protect against contamination nor was it dated as to when it was last changed.Further observation on 07/07/26 at 11:21 A.M. revealed the nebulizer mask for Resident #17 was again sitting directly on and touching the bedside table lying next to the nebulizer machine. The mask was not in a storage bag to protect against contamination nor was it dated as to when it was last changed. Licensed Practical Nurse (LPN) #295 was present during the observation and verified the nebulizer mask was on the bedside table and it was uncovered and without a date at the time of the observation. LPN #295 stated nebulizer masks are to be changed weekly on Tuesdays and dated. LPN #295 further stated the nebulizer mask was to be stored in a plastic bag when not in use to keep it safe from contaminates. Review of the undated facility policy titled Oxygen Tubing, Cannulas, and Nebulizers revealed when not in use, store oxygen and nebulizer tubing in a clean dry cool space away from direct sunlight dust and pets. Place tubing in a clean plastic bag or dedicated respiratory storage container when not in use.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure proper hand hygiene was performed during wound care. This affected one (Resident #8) of two residents reviewed for wound care. The facility census was 104.Findings include: Review of the medical record for Resident #8 revealed an initial date of admission of 04/09/19 and a readmission date of 05/03/23 with diagnoses including quadriplegia and chronic osteomyelitis unspecified (an infection affecting bone). Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact and had skin impairment of pressure areas. Review of the care plan dated 06/11/26 revealed Resident #8 was at risk for impaired skin integrity related to impaired mobility, catheter tubing, and quadriplegia. Interventions included check dressings to the coccyx and left ischial wounds, and wound care per order.Observation of wound care on 07/08/26 at 3:11 P.M. revealed three dressings for Resident #8 that were dry, intact and dated appropriately. Licensed Practical Nurse (LPN) #294 washed her hands with soap and water and donned gloves. LPN #294 then removed the old dressings to the right upper thigh and the left buttock area. LPN #294 then removed the soiled gloves and placed clean gloves on to finish wound care. LPN #294 did not wash her hands after removing the soiled gloves and placing the clean gloves on to complete wound care. LPN #294 verified she did not wash her hands after removing the soiled gloves and putting new gloves on to complete wound care.A review of the facility policy titled Hand Washing/Hand Hygiene dated 04/2010 revealed hand hygiene was the primary means to prevent the spread of infection. The policy further revealed employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with a resident, before and after assisting a resident with personal care, before and after handling peripheral vascular catheters or other invasive devices, before and after changing a dressing, and after removing gloves. The policy revealed hands should be washed before handling clean or soiled dressings, after handling soiled dressings and after removing gloves.

Based on record review, interview and review of facility policy, the facility failed to ensure education was provided to residents on the influenza vaccine. This affected two (Resident #8 and #22) of five residents reviewed for immunizations. The facility census was 104.Findings include: 1.Review of the medical record for Resident #8 revealed an initial admission date of 04/09/19 and a readmission date of 05/03/23 with diagnoses including quadriplegia, chronic osteomyelitis, morbid obesity, bipolar disorder, and major depressive disorder. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact and was administered the influenza vaccine. Review of the vaccine administration record within the medical record revealed Resident #8 received the influenza vaccine on 09/26/25 and no education was provided prior to the vaccine administration. 2.Review of the medical record for Resident #22 revealed an admission date of 12/21/24 with diagnoses including cerebral infarction, aphasia, hemiplegia and hemiparesis following a cerebral infarction. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #22 had a severe cognitive deficit and was administered the influenza vaccine. Review of vaccine administration record within the medical record revealed resident #22 received the influenza vaccine on 10/01/25 and no education was provided prior to the vaccine administration. An interview on 07/08/26 at 2:12 P.M. with Registered Nurse (RN) #202 who was identified as the infection preventionist for the facility verified Residents #8 and #22 had no record of education being provided to them or their responsible party prior to administration of the influenza vaccine. Review of the facility policy titled Vaccination of Residents dated 12/2008 revealed all residents will be offered vaccinations that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. The policy further stated prior to receiving vaccination the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations.

Based on observation, review of the posted nurse staffing data report and staff interview, the facility did not ensure all required information was including on the posted nurse staffing report. This had the potential to affect all residents in the facility. The facility census was 104. Findings include: During the initial facility tour observations on 07/06/26 at 8:10 A.M. revealed the posted document, dated 06/07/26, titled Report of Nursing Staff Directly Responsible for Resident Care had only the number of nurses, number of nurse aides, the date, and census on it. The posting did not include the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. Review of the Report of Nursing Staff Directly Responsible for Resident Care dated 06/08/26 to 06/30/26 revealed none included the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. An interview on 07/07/2026 at 4:22 P.M. with Assistant Director of Nursing (ADON) #202 revealed she was responsible for creating the daily nursing staffing posting and was unaware of the regulation requirement of including the total number and actual hours worked. ADON #202 verified she had not been posting the hours as required but would do so going forward.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, medical record review, review of a facility investigation, hospital records, facility policy, manufacturer's instructions, and interview, the facility failed to identify and implement comprehensive, individualized and adequate fall interventions to prevent a fall with injury during resident care. This affected one resident (#77) of three residents reviewed for accidents/incidents who required use of a shower gurney. The facility identified 32 residents (#3, #5, #11, #12, #21, #25, #27, #28, #29, #30, #33, #37, #41, #42, #43, #58, #59, #61, #62, #67, #77, #79, #81, #87, #89, #93, #94, #101, #103, #104, #112 and #114) who required a shower gurney for bathing. The facility census was 115. Actual Harm occurred on 01/11/26 at 3:00 P.M. when Resident #77, who was dependent on staff for showers and transfers and required substantial to maximum assistance with rolling left and right, fell from a shower gurney (a shower bed on wheels) onto the floor after Agency Certified Nursing Assistant (ACNA) #719 (only staff present in the shower room) rolled the resident away from her on the shower gurney to remove an incontinence brief and mechanical lift sling (a device used to transfer residents by use of a sling from surface to surface). As a result of the fall, Resident #77 experienced pain, an abrasion/hematoma (swelling of clotted blood within the tissues) to the right eyebrow, skin tears and/or abrasions to the top left hand, the left great toe, the right second, third, fourth and fifth toes, the right shoulder, and discoloration of the right hand and leg. Subsequently, Resident #77 was transferred and admitted to the hospital with septic shock (a life-threatening condition caused by dangerously low blood pressure and organ failure) and bilateral subdural hematomas (bleeding in the brain). The resident was hospitalized from [DATE] to 01/20/26 (nine days). Findings include:Review of the medical record for Resident #77 revealed an admission date of 07/25/25. Resident #77 had diagnoses including traumatic subdural hemorrhage (bleeding in the brain) without loss of consciousness (dated 01/12/26), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic obstructive pulmonary disease (COPD), and heart failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 had moderate cognitive impairment and impairment to his bilateral upper and lower extremities. The resident was dependent on staff for toileting, hygiene, showers, transfers and dressing, and required substantial to maximum (staff) assistance with rolling left and right. Review of quarterly Fall Risk assessment dated [DATE] completed by Unit Manager Licensed Practical Nurse (LPN) #680 revealed Resident #77 was not at risk for falls. The assessment revealed the resident was forgetful and dependent on toileting needs including checks and changes and had no history of falls. Review of nursing note dated 01/11/26 at 7:20 P.M. completed by LPN #692 revealed the shower room call light was going off when the aide alerted LPN #692 that Resident #77 fell. LPN #692 entered the shower room and saw the resident on the floor lying on his right side with his right arm tucked beneath him, and head facing towards the sink. A pillow was placed under the resident's head for comfort and vital signs were obtained. Resident #77 complained of pain in his left leg and due to the pain he was not moved. LPN #692 was unable to assess the resident's pupils due to his grimacing in pain; the resident did not lose consciousness. The shower gurney was noted to have all the rails up, but one wheel was off the gurney. The aide reported the wheel had come off which caused Resident #77 to roll off the gurney and fall. Emergency Medical Services (EMS) transported the resident to the hospital by rolling him onto a sheet then assisted him onto a gurney. Resident #77 had an abrasion/hematoma to the right eyebrow, a skin tear to the top left hand, skin tears to the left great toe and right second, third, fourth and fifth toes, a large skin tear to the right shoulder with abrasion, and discoloration of the right hand and leg. Resident #77's granddaughter was notified of the fall and being sent to the hospital. Primary Care Physician (PCP)/Medical Director (MD) #723 was also notified. Review of a nursing follow-up form dated 01/11/26 completed by LPN #692 in addition to the above nursing note revealed the incident occurred on 01/11/26 at 3:00 P.M. Resident #77 stated, I hit my face. He had pain in the left lower extremity at an unidentified pain level. Intervention to prevent re-occurrence was to have maintenance check all shower gurneys for safety. The nursing follow-up form included a witness statement dated 01/11/26 by Registered Nurse (RN) Supervisor #603 who reported being alerted to come to the B-wing shower room and upon entrance observed Resident #77 lying on his right side with the shower gurney next to the resident. The wheel was off a leg of the shower gurney, and the side rails were in the up position. Agency CNA #719 reported she had removed the mechanical lift sling and brief that was under Resident #77, and when she went to discard the brief, the shower gurney wheel fell off, tipping the shower gurney to its side and Resident #77 rolled off the shower gurney onto the floor. Resident #77 complained of pain and had a small hematoma and abrasion to the right eyebrow. He also had visible skin tears and abrasions including a large skin tear to his right forearm, abrasion to the right shoulder, and small skin tears to the right toes. Resident #77 was transported to the hospital by EMS and maintenance was to check all shower gurneys. Review of witness statement dated 01/11/26 completed by Agency CNA #719 revealed Resident #77 was in his bed and it was his shower day (01/11/26). The nurse (LPN #692) and she transferred Resident #77 to the shower gurney and then she took him to the shower room with the side rails up. She locked all the wheels so that she could remove his brief and sling from underneath him. She turned around to discard the brief in the trash can and put the sling down, and when she turned back around to start his shower, she saw Resident #77 falling off the shower gurney due to the wheel coming off the shower bed. She notified the nurse immediately. Review of witness statement dated 01/11/26 completed by Agency CNA #720 revealed she walked into the shower room and witnessed Resident #77 lying on his right side on the floor and the nurse was checking his vitals. The shower gurney was missing a wheel as it was off the bottom of gurney lying next to it on the floor. Review of nursing note dated 01/11/26 at 8:04 P.M. completed by LPN #684 revealed she contacted the hospital who reported Resident #77 was being transferred to the hospital main campus because he had a brain bleed. Review of the hospital Intensive Care Unit (ICU) History and Physical dated 01/12/26 completed by Critical Care Medicine Physician #726 revealed Resident #77 arrived at the local hospital after sustaining a mechanical fall off the wash table at the facility. Per EMS one of the wheels fell off and thus the resident fell. The Emergency Department (ED) completed a Computed Tomography (CT) scan that showed subacute/chronic subdural collection along the right cerebral convexity (outer surface of the brain) measuring seven millimeters (mm) and along the left cerebral convexity measuring six mm. He was treated to reverse his previous anticoagulant (blood thinning medication) regimen and was transported to the main campus ICU for further management including a neurosurgery evaluation. While awaiting transport Resident #77 became hypotensive (low blood pressure), so a central venous catheter (CVC) (a long flexible tube inserted into a large vein typically near the heart to provide access to medications and fluids) was placed, and he was started on medication to increase his blood pressure. The resident was a high probability of sudden clinically significant deterioration and required the highest level of physician services due to a mechanical fall, septic shock, and bilateral subdural hematomas. Review of Critical Care Progress Note dated 01/12/26 completed by Neurology Nurse Practitioner (NNP) #725 revealed Resident #77 was transported from the local hospital to the main campus due to need for neurological and trauma services and the reason for consultation was hypotension (low blood pressure). His CT showed a right cerebral convexity subdural hemorrhage. His mean arterial pressure (MAP) (average pressure in a patient's arteries) was low at 60 millimeters of mercury (mmHg) (normal levels were 70 to 110 mmHg). NNP #725 gave orders for phenylephrine (medication to treat low blood pressure) infusion to assist in increasing his MAP. Review of Neurosurgery Initial Consult progress note dated 01/12/26 completed by NNP #727 revealed he was on the wash table when the wheel fell off and Resident #77 fell off the table hitting his head. CT of the brain demonstrated subacute and chronic subdural collection to the right and left cerebral areas. Resident #77 reported a right frontal headache. Review of witness statement completed on 01/13/26 at approximately 3:00 P.M. by the Administrator revealed in person the Administrator and Director of Nursing (DON) met with Resident #77's granddaughter. They showed Resident #77's granddaughter the shower room, pictures of the old gurney, and the investigation conducted. They demonstrated on a different gurney the re-enactments they had conducted and explained that the structural integrity of the gurney was intact and that Agency CNA #719's account of the incident did not make sense. Resident #77's granddaughter reported Resident #77 stated to her in the hospital, She pushed me too hard and I went over the edge. Review of an After Visit Summary dated 01/20/26 revealed Resident #77 was discharged from the hospital back to the facility after a lengthy hospital stay from 01/11/26 to 01/20/26 due to subdural hematoma as well as treatment for pneumonia. Review of Admit/Re-admit Screener dated 01/20/26 and completed by Unit Manager LPN #680 revealed Resident #77 was readmitted back to the facility due to post fall. The resident was dependent on staff for most of his activities of daily living including bed mobility. He had slight edema to his left upper extremity/hand, scattered bruising to his left hand and forearm, bruising to his right shoulder with scabbed abrasion measuring six centimeters (cm) in length by 2.5 cm in width, and bruising to the right elbow, forearm and hand. He had two open skin tears to his right upper forearm and two scabbed skin tears to his right elbow. The resident had bruising to his right side, right hip, and bilateral knees. Also, he had bruising to the right side of his face, cheek, and above the eye with a small abrasion to his right eyebrow measuring 0.6 cm in length by 0.2 cm in width. The resident complained of pain as he stated it was a four on a pain scale (zero to ten), but no other information was noted regarding his pain. Review of nursing follow-up form under section of Summary of Investigation/Conclusion dated 01/21/26 completed by the DON revealed the incident was thoroughly reviewed by administration. A re-enactment was conducted on 01/12/26, statements were obtained from all staff involved and a risk management meeting was held to evaluate all possible explanations for how the fall occurred. Based on the findings of the internal investigation, it was determined that the shower gurney was not likely the contributing factor. The investigation revealed the incident was unintentional and the fall most likely resulted from Human Error leading to Resident #77's fall from the gurney to the floor. Interventions included the shower gurney used in the incident was discarded, all shower gurneys were assessed by maintenance, new shower gurneys were ordered, and the staffing agency was notified. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had intact cognition and had impairment to his bilateral upper and lower extremities. He was dependent on staff for rolling left and right, toileting hygiene, showers, transfers and dressing. Review of an email dated 01/28/26 at 5:38 A.M. from DON to Agency Trust and Safety Department Representative #724 revealed Agency CNA #719 was getting resident (Resident #77) ready for a gurney shower and was in the shower room. Agency CNA #719 was rolling Resident #77 to remove his brief and the mechanical lift sling when he rolled off the gurney. Agency CNA #719 reported one of the gurney's wheels came off; however, when the incident was re-enacted in several different ways/scenarios the wheel did not come off. The only way the wheel came off was when the shower gurney was lifted off the ground. Agency CNA #719's statement made it sound like it was a device error, but it was determined that the gurney was not likely the contributing factor. The email stated while unintentional, the fall most likely resulted from Human Error leading to the resident's fall from the gurney to the shower room floor. Resident #77 was sent to the hospital and admitted with two brain bleeds. Interview on 02/20/26 at 6:57 A.M. with DON and Assisted Director of Nursing (ADON)/Registered Nurse (RN) #601 revealed LPN #692 and Agency CNA #719 had used the mechanical lift to transfer Resident #77 to the shower gurney from either his chair or bed. Agency CNA #719 then transported Resident #77 on the shower gurney to the shower room to provide a shower without any issues. The wheels on the gurney were functioning. Agency CNA #719 stated she had rolled Resident #77 over side to his side to remove the incontinence brief and mechanical lift sling and undress him with the bilateral side rails up on the shower gurney. When she completed preparing him for his shower, he was lying on his back in the center of the gurney with bilateral side rails still in the up position. As she turned around to dispose of his incontinence brief and set down the mechanical lift sling, the lower left wheel on the shower gurney came off and Resident #77 rolled off the shower gurney onto the floor. They investigated the incident including demonstrated simulations and felt Agency CNA #719's account was not accurate as they were not able to get the wheel to come off with an approximate body weight of Resident #77's weight lying on the gurney without lifting the gurney up itself to have the wheel come off. The DON stated she laid on the shower gurney as they moved the shower gurney in all directions in a firm, rough manner and still was unable to get the wheel to come off. They concluded through investigation that the incident most likely was caused by Human Error and felt when Agency CNA #719 was undressing the resident and removing his incontinence brief and the mechanical lift sling, she had rolled him over too far causing him to fall off the gurney onto the floor. They also concluded it as the cause as Resident #77 had stated to his granddaughter when he was in the hospital that Agency CNA #77 had rolled him off the shower gurney. They verified Resident #77 was sent immediately to the hospital by EMS as a result and diagnosed with bilateral brain bleed. Observation on 02/20/26 at 7:29 A.M. of Resident #77 revealed he had bruising surrounding his right eye with swelling. Interview at the time of the observation with Resident #77 revealed after being asked about how the incident happened stated, She rolled me. The resident was unable to provide any additional facts. When asked if he knew if the wheel fell of the shower gurney, he opened his eyes wide and stated in an increased tone, No the wheel did not fall off, rolled me off. Interview on 02/20/26 at 7:38 A.M. and 12:08 P.M. with LPN #692 revealed she was the nurse on duty when Resident #77 fell off the shower gurney. She stated she had previously assisted Agency CNA #719 transfer Resident #77 using the mechanical lift from his bed or chair (could not remember which) to the shower gurney in his room. She stated both bilateral side rails on the shower gurney were up and Agency CNA #719 transported the shower gurney with Resident #77 lying on the gurney down the hallway into the shower room. There were no issues with how the shower gurney functioned including the wheels. She was coming out of the supply room near the shower room when Agency CNA #719 in the doorway of the shower room stated Resident #77 was on the floor. She proceeded to demonstrate in the shower room where he was positioned compared to the position of the shower gurney during the incident. She revealed when she walked into the shower room she noticed the shower gurney in the center of the room upright with bilateral side rails up and the left bottom wheel on the shower gurney was off causing the shower gurney to be slanted to the left in a downward position. The side rail on the left-hand side (the side Resident #77 fell off) was stationary and always in an upright position. When entering the shower room, Resident #77 was lying on the floor on his right side next to the shower gurney facing the shower. The resident was lying in the same position on the floor as the shower gurney was positioned including his head was where the head would be on the shower gurney and feet where the feet would be. He had a hematoma to the left side of his head, bleeding from a skin tear to his arm and was complaining of pain. EMS was immediately notified. She obtained vitals and they did not move him because of the pain he was in. EMS arrived and transported him to the hospital. The LPN revealed Agency CNA #719's account of the incident sounded off (not quite right) in regard to how the wheel came off because the wheel slid into the Polyvinyl Chloride (PVC) pipe which in her opinion was not possible especially with a person's body weight on top of the gurney unless the wheel broke off or the gurney was picked up to cause the wheel to come off. She verified the wheel was not broken as there was still approximately two inches of PVC attached to be able to slide it into the PVC frame of the shower gurney. She also stated that if the wheel at the bottom left of the shower gurney had come off then she believed Resident #77 would have slid out towards the bottom of the bed and be found positioned at the bottom left corner of the shower gurney. LPN #692 revealed when she found the resident it appeared he had gone over the side rail of the gurney landing on the floor horizontally next to the shower gurney. She specified that at the time of the incident, Resident #77 had stated Agency CNA #719 had rolled him off the shower gurney. She revealed in her opinion she felt Agency CNA #719 had rolled him too far off the shower gurney causing him to fall off the gurney. Interview on 02/20/26 at 8:15 A.M. to 9:30 A.M. with Maintenance Director (MD) #676 and Maintenance Assistant (MA) #675 revealed once a month as preventative maintenance they inspected all shower gurneys and chairs including any breaks in the PVC piping, lubricated the wheels as needed and documented it accordingly including any abnormal findings. They had not noticed any concerns regarding the shower gurney Resident #77 used. They stated at the time of the incident the set screw was missing from the bottom left wheel, but they were unsure if it was out prior to the incident or if it came out during the incident. Even without a set screw there was approximately an inch and three fourths section of PVC piping that went inside the PVC piping of the frame. Unless the wheel would break off from the PVC piping, they did not see how the wheel would fall off unless someone lifted the gurney up to slide the wheel out of the PVC piping especially with body weight on the bed. They re-enacted the incident trying to determine if the story was plausible by staff laying on the bed, moving the gurney all around in the shower room, and they could not get the wheel to come off even without a set screw. They did the re-enactment in a rough manner, even moving the bed forcefully and still could not get the wheel to come off. They then took the bed outside in the driveway and ran it up and down a hill and over potholes and still could not get the wheel to pop off. Observation at the time of the interview of the shower gurney in the facility garage revealed three wheels were intact and secured and the left bottom wheel was able to be pulled out as it did not have a set screw. Approximately the one inch and three fourths piping remained intact and was able to slide inside the PVC gurney bed frame. They demonstrated in a forceful manner by moving the gurney in all directions and over uneven surfaces that the wheel did not come off. The left side of the shower gurney (the side Resident #77 was reported to have gone over) had a stationary side rail that always remained up. They measured the top of the stationary rail to the top of the shower gurney bed to be six inches. They demonstrated that the only way the wheel came off was when they lifted the gurney up approximately three inches off the ground. When the wheel was off the shower gurney, it was slanted in a downward position towards the bottom left and they confirmed Resident #77 would have slid off towards the bottom left side of the gurney, not found with his head up towards the head portion of the gurney. They stated if the wheel came off he most likely would have slid down towards the direction the wheel came off, not up and over a six-inch stationary side rail. Interview on 02/20/26 at 10:27 A.M. with Resident #77's granddaughter confirmed in the hospital Resident #77 stated the facility staff had rolled the resident too hard and too far, right off the gurney. She revealed Resident #77 had a double brain bleed, was in significant pain, and had to be transported to the main campus ICU due to his unstable condition. The first night his blood pressure had tanked, and they were unable to stabilize it even with vasopressors (critical care medications used to increase blood pressure and improve perfusion in patients with severe hypotension or shock). They thought he was going to die. The family had a meeting with the facility who admitted it was user error as an aide had rolled him too far and he fell off the shower gurney. She felt it was what happened especially since Resident #77 had stated that to her while in the hospital, and not because of the wheel coming off the gurney. Interview on 02/20/26 at 10:35 A.M. with Agency CNA #719 revealed on 01/11/26 she and LPN #692 had transferred Resident #77 out of his bed with a mechanical lift to the shower gurney. She had locked all the wheels on the shower gurney prior to transfer, and she did not notice anything wrong with the wheels to the shower gurney. She pushed the shower gurney from his room to the shower room with him lying on top of the gurney without any issue. She felt the wheels had functioned appropriately. When she was in the shower room, she was the only one there and kept both side rails up and locked all wheels as she prepared him for his shower. She did not notice anything wrong with the wheels when she re-locked them. The side rail on the left side was stationary and unable to come down. She proceeded to tuck the mechanical lift sling and incontinence brief under him on the side she was on and then rolled him away from her towards the stationary side rail. She verified she had rolled him away from her as she stated, yes rolled him away from me see you do not understand that is how you have to roll someone to get the stuff out from underneath them. She stated he was in the center of the gurney the whole time including while rolling him. While he was lying in the center, she turned around to put the incontinence brief in the garbage, set the mechanical lift sling down and as she was turned around, suddenly he fell off the gurney because the wheel fell off the end of the shower gurney. She stated that he then fell over the stationary side rail on the gurney onto the floor as she felt the side rail on that gurney was too short. She immediately got the nurse and stated that she never moved the gurney from the position that it was in when he fell. Review of the undated Operation Instructions for the shower gurney model used in the incident involving Resident #77 and Agency CNA #719 revealed the shower beds were equipped with four locking casters to be used during transfers and for when wanting to remain stationary. When a mechanical lift to transfer a resident in and out of the shower gurney was used, the manufacturer recommended keeping the side rails up and always locked. The instructions under precautions stated to never leave an at-risk user unattended on the bed, and that exaggerated user movement in any direction or rolling to the edge may cause the gurney to tip. The instructions stated, Do not roll user away from you unless there is a partner caregiver on the other side. The operation instructions indicated to check the pipe and fittings for hairline fractures monthly, check all junctures to make sure the pipe and fittings do not pull apart, and clean and lubricate casters monthly. Interview on 02/20/26 at 11:46 A.M. with the DON verified per the Operation Instructions for the shower gurney model used in incident involving Resident #77 and Agency CNA #719, the instructions stated, Do not roll user away from you unless there is a partner caregiver on the other side. She verified per the investigation, Agency CNA #719 reported she had rolled Resident #77 away from her when taking out the incontinence brief and mechanical lift sling and that she was the only staff member in the shower room. The DON confirmed staff were to not to roll residents on a shower gurney away from them during care unless they had another staff member on the other side.Interview on 02/23/26 at 1:58 P.M. with PCP/MD #723 revealed he was aware of the incident but was unable to know for a fact if it was caused by the wheel coming off the gurney or by the aide rolling the resident too far off the bed. He stated Resident #77 was very rigid requiring dependence of staff for all his care. It depended on the day if Resident #77 was cognitively intact or not as sometimes he was coherent and sometimes he was not. He was unable to provide any other details regarding the incident. Review of facility policy titled, Accidents and Incidents, last revised 05/22/24, revealed all accidents or incidents involving residents were investigated and reported to the administrator. The facility was to be in compliance with current rules and regulations governing accidents and/or incidents. Review of facility undated policy titled, Shower/Tub Bath, revealed the purpose of the procedure was to promote cleanliness, provide comfort and observe the condition of the residents' skin. The policy indicated to handle residents as gently as possible and not to rush the procedure. The procedure specified to never leave the resident unattended in the tub or shower and use the emergency call signal to summon assistance. There was nothing in the policy regarding ensuring staff did not roll residents away from them on a gurney unless there was another caregiver on the other side. The deficient practice was corrected on 01/27/26 when the facility implemented the following corrective actions: On 01/11/26, the Administrator and DON halted all gurney showers until MD #676 inspected and evaluated the equipment. There were no abnormal findings. On 01/11/26, the DON notified the staffing agency and requested the agency place Agency CNA #719 on the do not return (DNR) to the facility list. On 01/12/26, MD #676 implemented and conducted an audit of shower equipment that lubricated the wheels if needed, inspected the PVC tubing for hairline cracks and damage, checked all junctures to make sure pipe and fittings did not pull apart and checked tightness of fasteners. This audit was conducted by MD #676 daily for seven days, weekly for five weeks and then returned to the previous shower beds/chairs monthly maintenance and safety checklist. On 01/12/26, the Administrator, DON, ADON/RN #601, and MD #676 completed a re-enactment of the incident for an investigation of the root cause of the incident. On 01/12/26, a risk management meeting was held with Administrator, DON, ADON/RN #601, MD #676, Unit Manager/RN #602, Unit Manager/LPN #680, LPN #681, and MDS/RN #600 to discuss the incident, root cause, and interventions.On 01/12/26, the Administrator and DON met with Resident #77's granddaughter to review the investigation/re-enactment. On 01/13/26, MD #676 ordered new shower gurneys. On 01/15/26, the DON reviewed the facility investigation with PCP/MD #723.On 01/15/26, the Administrator updated Resident #77's daughter on the investigation.On 01/16/26, the Administrator and DON reviewed the facility policies including Accidents and Incidents last revised 05/22/24, and Shower/Tub Bath undated. On 01/20/26, the Administrator updated Resident #77's daughter to discuss Resident #77's return to the facility and interventions to be implemented. On 01/21/26, a Physical Therapy (PT) evaluation was completed by PT #729 and Occupational Therapy (OT) evaluation was completed by OT #728 for Resident #77.On 01/21/26, Unit Manager/LPN #680 changed Resident #77 to be a two-person gurney shower on weekdays.On 01/21/26, a risk management meeting was held with Administrator, DON, ADON/RN #601, MD #676, Unit Manager/RN #602, Unit Manager/LPN #680, LPN #681, and MDS/RN #600 to discuss the incident, interventions, changing gurney showers to weekdays with some exclusions, and discussed an upcoming staff in-service meeting scheduled 01/27/26. On 01/21/26, the Unit Manager/RN #602, Unit Manager/LPN #680 and LPN #681 updated the facility shower schedule to change all gurney showers with some exclusions to weekdays.On 01/26/26, ADON #601 updated the interview data sheets/incident/accident reports to provide more details to assist in finding the root cause of an incident.On 01/27/26 and on 01/29/26, an in-service with all nurses and CNAs was conducted by DON and ADON/RN #601 to review fall policy, bathing policy, safety including not rolling a resident away from staff only towards staff unless another staff member was on the other side, have a second staff member assist with gurney showers when needed, updated interview data sheets/incident/accident reports, change in shower schedules, and reporting any maintenance issues including on gurneys. On 01/29/26, MD #676 ordered new shower chairs.On 02/13/26, Interdisciplinary Team Meeting was held with Resident #77's daughter and granddaughter to discuss overall care.On 02/17/26, a risk management meeting was held with Administrator, DON, ADON #601, MD #676, Unit Manager/RN #602, Unit Manager/LPN #680, LPN #681, and MDS/RN #600 to discuss any feedback from in-service and review of all current interventions. On 02/20/26, the Administrator updated PCP/MD #723. This deficiency represents non-compliance investigated under Complaint Number 2730416.

Based on record review and interview, the facility failed to ensure Resident #115's guardian was informed and gave consent for Resident #115 to be discharged from the facility. This affected one resident ( Resident # 115) of the three residents reviewed for discharge. The facility census was 114. Findings include: Review of the medical record revealed Resident #115 was admitted to the facility on [DATE] and discharged from the facility on 08/12/24. Guardian #392 was listed as the responsible party guardian and emergency contact #1. Resident #115's mother was the emergency contact #2. Medical diagnoses included pulmonary edema, Asperger's syndrome, diabetes, bipolar, hypertension, glaucoma, dependence on renal dialysis, depression, and anemia. Review of the Minimum Data Set ( MDS) 3.0 Discharge Return Not Anticipated assessment dated [DATE] revealed discharge was unplanned to home. Resident #115 had moderate impairment for decision making. Resident #115 displayed physical behaviors. Resident #115 needed set up for eating. Maximum assistance was needed for oral hygiene. Moderate assistance was needed for toilet hygiene, bathing and dressing. Resident #115 needed moderate assistance to roll left and right in bed, sit on the side of the bed, lie back in bed , stand and transfer from bed. Moderate assistance was needed to walk ten feet. Resident #115 received hemodialysis. Review of the Health Status Note dated 08/12/24 at 2:41 P.M. written by Licensed Practical Nurse (LPN) #344 , revealed Resident #115's mother stated she wanted to take Resident #115 home. The physician was notified. This note stated Residents guardian [NAME] was also notified of residents discharge from the facility. Review of the document titled Probate Court of Ashtabula County Letters of Guardianship, dated 08/07/23, revealed Catholic Charities of Ashtabula County shall be appointed Guardian of Resident #115, an incompetent and the duties of the Guardian shall be discharged by the appointed agent Guardian #392. As Guardian, powers were person only for an indefinite time period. The document was signed by the Probate Judge. Review of medical record Discharge Summary dated 08/12/24 revealed Resident #115 was discharged from the facility to home and Resident #115's mother signed the Discharge Summary along with LPN #344. Interview with Healthcare Compliance Investigator( HCI) #391 on 11/04/24 at 8:34 A.M. revealed the facility allowed Resident #115 and his mother to sign themselves out because of behaviors Resident #115 was displaying. The legal guardian was not notified until after Resident #115 was discharged from the facility. This was not a planned discharge. The guardian wanted Resident #115 to remain in the facility. HCI #391 also stated the mother missed some health appointments while Resident #115 was home. Interview on 11/04/24 at 12:20 P.M. with Social Service Director ( SSD) #375 revealed Resident #115's discharge was considered an impromptu discharge. SSD #375 verified the facility did not have the legal guardianship paperwork in the medical record so they were not aware of it. SSD #375 stated during the next care conference social work would bring up no guardianship paperwork was in the chart. SSD #375 also stated the social worker did not set up skilled care for home because Resident #115's mom was to be the caregiver. Interview on 11/04/24 at 12:30 P.M. with Unit Manager Licensed Practical Nurse ( LPN) #344 revealed she called the physician to notify the physician of Resident #115's request to leave the facility. LPN #344 stated she did not call the guardian because there was no paperwork in the chart during Resident #115's discharge. LPN #344 stated she called the guardian when Resident #115 left. LPN #344 stated Resident #115 did not make safe decisions. LPN #344 stated the facility still discharged the resident despite the guardian not approving of the discharge. Interview on 11/04/24 at 12:40 P.M. with the Director of Nursing ( DON) revealed a text message was sent on 08/12/24 at 12:05 P.M. to physician regarding Resident #115 wanting a discharge home. The DON was unable to provide a text message to the guardian and could not verifying the guardian was notified by text or phone call on 08/12/24. The DON stated Resident #115 created an uproar with staff in the facility. Interview with Guardian #392 on 11/04/24 at 1:22 P.M. revealed she did speak with the nurse staff on Saturday 08/10/24 regarding Resident #115's behaviors and Resident #115 wanted to be discharged . Guardian #392 told the facility she did not agree with Resident #115's discharge to home. Guardian #392 stated she was notified on 08/12/24 during an unannounced visit at 2:00 P.M. to the facility to check on Resident #115. Guardian #392 stated she did not sign in because this was an unannounced visit. Guardian #392 stated the facility did not notify her prior to Resident #115's discharge and the guardian paper work should have been sent in with the hospital paperwork on admission. The Guardian #392 stated the facility did not call her on 08/12/24 prior to Resident #115 discharge because she had no missed calls or voice messages from the facility. Guardian #392 stated the facility did not prepare Resident #115 for a safe discharge. The Guardian stated Resident #115 had been placed at another facility and passed away in October 2024 due to complications from COVID-19 related pneumonia. Review of the facility policy titled, Notice of Transfer and/or Discharge, dated April 2011, revealed a resident or representative sponsor would be given 30 days notice of impending transfer or discharge from a facility except if the transfer was necessary for the resident welfare and the resident needs could not be met in the facility. Consent of Notice: the resident or representative sponsor would be provided the following information, the reason for discharge, the effective date, the location. This deficiency represents non-compliance investigated under Complaint Number OH00159196

Based on observation and interview the facility failed to ensure all meals were served at an appetizing temperature. This had the potential to affect 108 residents at the facility. The facility identified one resident (#30) as receiving no food from the kitchen. The facility census was 109. Findings include: On 08/30/23 at 11:34 A.M. observation of temperatures taken on the tray line revealed the roast turkey measured an internal temperature of 170 degrees Fahrenheit (F). The Brussel sprouts measured an internal temperature of 148 degrees F, and the scalloped corn measured an internal temperature of 160 degrees F. On 08/30/23 at 12:04 P.M. the food cart with the test tray left the kitchen. On 08/30/23 at 12:06 P.M. the cart was on the unit. On 08/30/23 at 12:07 P.M. two staff members started passing the food trays. On 08/30/23 at 12:26 P.M. all resident trays had been passed and the food on the test tray was evaluated. Review of the test tray with Assistant Dietary Manager (ADM) #759 revealed the tray consisted of roast turkey, Brussel sprouts, and scalloped corn. The turkey measured an internal temperature of 118 degrees F. The Brussel sprouts measured an internal temperature of 118 degrees F, and the scalloped corn measured an internal temperature of 112 degrees F. Interview on 08/30/23 at 12:29 P.M. ADM #759 verified the temperature findings of the test tray.

Based on observation, closed record review, facility policy and procedure review and interview the facility failed to provide adequate interventions to prevent a fall with injury for Resident #114. Actual Harm occurred on 10/14/22 when Resident #114, who was severely cognitively impaired and at high risk for falls sustained an unwitnessed fall from an electronic lift recliner chair in his room. The resident was found face down on the ground with his electronic lift recliner chair in the forward position with a large amount of blood coming from a laceration to his left eyebrow and a loss of consciousness. Resident #114 was subsequently transferred to the hospital and then to another long-term acute care hospital after being diagnosed with a traumatic brain injury. This affected one resident (#114) of three residents reviewed for falls. The facility census was 108. Findings include: Review of the closed medical record for Resident #114 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #114 had diagnoses including urinary tract infection, pressure ulcer of right buttocks, and psychosis not due a substance or known physiological condition. Review of fall risk assessments dated 01/28/22, 02/09/22, 03/19/22, 07/20/22, 09/24/22, and 09/30/22 revealed Resident #114 was at a high risk for falling. Review of care plan dated 01/31/22 and updated 07/28/22 for Resident #114 revealed he was at a high risk for falls due to impaired mobility and cognition. Interventions included to keep his call light within reach and have him nonslip socks while out of bed. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #114 had severe cognitive impairment. The assessment revealed Resident #114 required extensive two-person physical assistance for bed mobility and toileting; total dependence of two-persons for transfers; extensive one-person physical assistance for dressing and personal hygiene; and limited one-person physical assistance for eating. Resident #114 was always incontinent of urine and bowel. Review of physician's progress note, dated 10/13/22 for Resident #114 revealed the resident was alert and oriented times person and place. The note revealed the resident was mildly anxious, dysphoric, and somatic. Review of nursing progress note, dated 10/14/22 for Resident #114 revealed the nurse was in the hallway and she hear a loud noise. She went to the room and found Resident #114's electronic lift recliner chair all the way forward and Resident #114 on the floor face first. Resident #114 was unconscious for about one minute. The resident had to be turned on his back due to the amount of blood due to a laceration to his left eyebrow. The resident was alert and oriented times person and place and did not recall falling. Resident #114 was transferred to the hospital. Review of a nursing progress note, dated 11/28/22 revealed Resident #114 was not returning to the facility from the long-term acute care hospital he had been in and was going to another facility. On 12/07/22 an initial tour was conducted which noted electronic lift recliner chairs were observed in each room for resident's on the rehabilitation unit. Interviews on 12/07/22 from 9:21 A.M. to 1:35 P.M. with Licensed Practical Nurse (LPN) #551 and #593 and State tested Nursing Assistants (STNA) #524, #547, and #572 revealed most of the rooms on the rehabilitation unit have electronic left recliner chairs in their rooms. They reported residents were educated on admission about safe usage. The staff also reported if a resident was confused, they would not put the resident in the chairs or they would tuck the remote in the pouch on the side of the chair out of the residents' reach. They also confirmed if they moved the remote, the resident would have their call buttons in reach. Interview on 12/07/22 at 2:29 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #500 revealed after investigating Resident #114's fall they were not sure how the resident hit the remote on the electronic lift chair to move his chair into the forward position and fall out of it. They reported he could have sat on it or was pushing the buttons thinking it was the call light. The also confirmed Resident #114 was confused and had good and bad days. The staff verified there were no interventions in place for safe electronic lift recliner chair use. Review of facility policy falls - clinical protocol, revised October 2010 revealed as part of the initial assessment, the physician would help identify individuals with a history of falls and risk factors for subsequent falling. Each resident would have a fall risk indicator; it would be located in the plan of care. The resident specific tasks would include safety checks. This deficiency represents non-compliance investigated under Complaint Number OH00137601.

Based on interview and review of staffing agency contracts, the facility failed to ensure all staff did not have a finding entered into the State of Ohio's Nurse Aide Registry prior to providing direct care. This had the potential to affect all 110 residents residing in the facility. Findings include: Interview with the Administrator on 10/12/22 at 7:00 A.M. indicated the facility had contracts with six staffing agencies. He indicated he assumed each agency did the required pre-screening of all of their staff. He also indicated Licensed Practical Nurse (LPN) #752 was the owner of Staffing agency #900. The facility provided documentation identifying the four agencies and the nursing staff sent to work in the facility in the last 30 days. Staffing agency #900 used one nurse, LPN #752 routinely. Staffing agency #901 sent two nurses to work at the facility (LPNs #802 and #803). Staffing agency #902 sent 10 LPNs (#807 through #816). Staffing agency #903 sent three LPNs (#804, #805, and #806). Interview with LPN #752, representing Staffing agency #900, on 10/12/22 at 4:51 P.M. confirmed he provided direct care at the facility through contracted Staffing agency #900. LPN #752 indicated he was the only nurse at the agency along with aides. LPN #752 indicated all employees had criminal background checks, health screening and verification their licenses or registrations were current. LPN #752 verified he was not checked against the State of Ohio's Nurse Aide Registry for findings against non-aides. Further interview with LPN #752 on 10/12/22 at 5:26 P.M. indicated he was not aware the agency had to do that specific screening. LPN #752 indicated he would begin doing that immediately. He was informed after review of the contract that the contract indicated the agency would follow all state and federal laws. Interview with Staffing agency #901's representative on 10/13/22 at 2:41 P.M. indicated they did a thorough screening of staff before on-boarding them. The representative reported only checking nurse aides against the State of Ohio Nurse Aide Registry and did not know checking non-aides against the registry was required. Interview with Staffing agency #902's representative on 10/13/22 at 2:52 P.M. revealed the representative was not sure if the agency checked non-nurses against the State of Ohio's Nurse Aide Registry. He indicated to speak with another representative who was called and a message was left. An attempt was made to speak Staffing agency #903's representative on 10/13/22 at 3:00 P.M. and a message was left and no return call was received. Review of each agency's contract with the facility lacked indication the agency would check non-aides against the State of Ohio's Nurse Aide Registry.

Based on observation, record review and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #94. Actual Harm occurred on 10/29/19 when Resident #94, who was quadriplegic and required extensive assistance to total dependence on staff for activity of daily living care, including bed mobility and transfers developed an unstageable/Stage IV (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) pressure ulcer to the coccyx. This affected one resident (#94) of two residents reviewed for pressure ulcers. The facility identified eight current residents with pressure ulcers. Findings include: Record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #94's care plan initiated 04/10/19 revealed a care focus for total assistance with bed mobility, bowel stimulation for bowel movement daily and risk of impaired skin integrity due to impaired mobility, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Interventions noted the resident required skin inspection with hands on care and observation for redness and open areas, barrier cream per physician order, pressure reducing cushion in wheelchair, air mattress in bed, and to turn and reposition every two hours and as needed. Review of Resident #94's physician's orders [REDACTED]. Review of the [MEDICAL CONDITION] Bowel Management instruction sheet indicated to perform a mini enema along the side of the wall of the rectum/bowel while resident was in bed, then after ten minutes and using one lubricated finger digitally stimulate using a circle along the wall of the bowel for 30 seconds until stool appeared, and repeat the process up to four times. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/16/19 revealed Resident #94 had no pressure ulcers. Review of Resident #94's shower sheets for (MONTH) 2019 indicated no skin changes to the coccyx area were identified during the shower that occurred on 10/26/19. Review of Resident #94's progress notes revealed an entry dated 10/24/19 which indicated the resident had no significant weight changes, he was eating meals well and his estimated nutritional needs were being met. On 10/29/2019 at 6:12 [NAME]M. a nursing progress note revealed a new Stage IV pressure area was found on the resident's coccyx during bowel care. Review of the wound assessment, dated 10/29/19 revealed Resident #94 had an unstageable pressure ulcer to the coccyx that measured 3.1 centimeter (cm) in length by 1.2 cm width with 70 percent (%) slough. The assessment revealed the resident had no sensation to the area. Review of quarterly Braden Scale, dated 11/02/19 revealed Resident #94 was at moderate risk for developing pressure ulcers due to the resident being chair fast, having impaired sensory, limited mobility, adequate protein and requiring moderate to maximum assistance in moving. Review of the MDS 3.0 assessment, dated 11/08/19 revealed Resident #94 had no cognitive impairment, required extensive assistance from two staff for bed mobility and was totally dependent on staff for personal hygiene, transfers, dressing, toileting and bathing. The assessment revealed the resident was always incontinent of bowel and had one unstageable wound not coded as present upon entry into the facility. Observation on 12/03/19 at 10:17 [NAME]M. revealed Resident #94 was seated in a specialized wheelchair and was reclined at 46 degrees. Interview with the resident at the time of the observation confirmed the degree of the wheelchair and confirmed the resident currently had a pressure ulcer to the coccyx area. The resident revealed he had little if any feeling in the area and staff changed the dressing daily on night shift after he received bowel stimulation by the nurse and was cleaned up afterward by the state tested nursing assistant (STNA) staff. Observation on 12/04/19 at 12:50 P.M. revealed Resident #94 was fully reclined in a specialized wheelchair at this time. Additional observations on 12/04/19 at 2:20 P.M., 12/04/19 at 4:45 P.M., 12/05/19 at 8:41 [NAME]M. and 12/05/19 at 10:45 [NAME]M. revealed Resident #94 was sitting in up in the specialized wheelchair. Interview on 12/04/19 at 9:56 [NAME]M. with Licensed Practical Nurse (LPN) #612 verified Resident #94's wound was initially discovered while in the facility on 10/29/19 as a Stage IV pressure ulcer. Interview on 12/04/19 at 2:29 P.M. with LPN #613 verified the resident was assessed to have a Stage IV pressure ulcer the morning of 10/29/19 and then it was changed to an unstageable pressure ulcer because the wound bed was covered in slough. She verified Resident #94 received [MEDICAL CONDITION] stimulation of bowel from the night shift nurses and bowel incontinence care thereafter since admission. She further indicated Resident #94 preferred to stay in the chair and indicated the resident could tilt himself. However, there was no evidence the facility had implemented any interventions to assess the effectiveness of the resident's tilting ability/frequency or included any information in the plan of care related to the resident or staff responsibility for position changes. Interview on 12/04/19 at 3:15 P.M. with STNA #615 revealed Resident #94 stayed up in the chair most of the time. Interview on 12/04/19 at 5:57 P.M. with Registered Nurse (RN) #606 and review of the resident's plan of care revealed Resident #94 received [MEDICAL CONDITION] stimulation of the bowel which should include a skin inspection. She further indicated if [MEDICAL CONDITION] stimulation of the bowel was conducted then the entire area would need checked for skin breakdown with the incontinence care thereafter. RN #606 further verified Resident #94's preference to stay up in the wheelchair which was not reflected in the care plan as well as a lack of evidence of monitoring or assessing the effectiveness of tilting frequency in the chair. Interview on 12/04/19 at 6:12 P.M. with LPN #616 verified Resident #94 stayed up in his chair most of the day unless he asked to lay down, he received bowel protocol every night, and the pressure reducing cushion he had was built into his wheelchair. She further indicated she believed Resident #94 tilted himself in the wheelchair and was not monitored by staff related to position changes in the wheelchair. Interview on 12/04/19 at 6:27 P.M. with LPN #613 revealed staff did not monitor the resident for position changes in the wheelchair but staff would lay him down if he asked. Interview on 12/05/19 at 2:19 P.M. with STNA #614 revealed Resident #94 spent most of the day up in his chair. The STNA revealed she did not assist with repositioning in the chair, tilting the chair or reminding the resident to change the tilt of the chair. Interview on 12/05/19 at 12:29 P.M. with the Director of Nursing verified Resident #94's pressure ulcer was facility acquired and discovered on 10/29/19 as a Stage IV until reassessed later that same day as unstageable due to the presence of slough tissue. She further verified [MEDICAL CONDITION] bowel stimulation was provided to Resident #94 every night and was a lengthy procedure, the resident was not able to feel in that area, and he was compliant with nutritional interventions. She also confirmed with these factors staff should be more hypervigilant to ensure skin checks were thorough and completed to find early signs of skin breakdown.

Based on observation, record review and interview the facility failed to accurately code alarms on the Minimum Data Set (MDS) 3.0 assessment for Resident #29, Resident #63, Resident #96 and Resident #99. This affected four residents (#29, #63, #96 and #99) of four residents reviewed for alarms. Findings include: 1. Record review for Resident #99 revealed an admission to the facility on [DATE]. Resident #99's current [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] revealed that Resident #99 was a high risk of falls. Review of the physician's orders [REDACTED]. A care plan relative to fall risk revealed individualized interventions for falls including: motion sensor beside bed, a motion sensor to bathroom door, and a self release alarmed seatbelt to wheelchair. The MDS 3.0 assessment, dated 11/08/19 revealed Resident #99 had a with a brief interview mental status (BIMS) score of of 99 indicating resident was unable to complete the assessment due to severe cognitive impairment. There was no reference to the use of alarms. Review of Resident #99's MDS 3.0 assessments, dated 10/11/19 and 11/08/19 under Section P-0200 Alarms, revealed the MDS indicated that (A) a bed alarm was not used, (B) a chair alarm was not used, (C ) a floor mat alarm was not used and (D) motion senor alarm were not used. Interview with MDS Coordinator RN #606 at 3:36 P.M. revealed the MDS section verified Section P indicated that a bed alarm (marked 0) was not used, a chair Alarm (marked 0) was not used, a floor mat alarm (marked 0) not used, and a motion senor alarm (marked 0) was not used. 2. Record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MDS 3.0 dated 09/20/19 revealed the resident was moderately cognitively impaired, required extensive assist of two staff for transfers and toileting, used a wheelchair for mobility, had no falls, and had no use of physical restraints or alarms. Review of the care plan, dated 10/01/19 included a care area for falls with interventions including a chair alarm (01/07/19) and a PBA (04/12/19). Observations of Resident #29 on 12/03/19 at 10:56 [NAME]M. and 12/05/19 at 9:44 [NAME]M. revealed the resident was seated in a wheelchair with the PBA and chair alarms in place. Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, the alarm use should be reflected on the MDS assessment. Interview on 12/04/19 at 3:34 P.M. with Registered Nurse (RN) #606 verified Resident #29 had a chair alarm and PBA in place but the alarm section of the MDS for Resident #29 was not accurate to reflect the use of the alarming devices. RN #606 revealed this may have been overlooked. Review of the Alarm policy, dated 01/11/13 revealed alarms were utilized for the purpose of safety, providing an audible notification to the staff of a resident's need for assistance or an audible reminder to the resident of their need receive or request assistance from staff. Need for alarm intervention and type of alarm was determined by or through the Fall Risk Assessment, the Admission assessment, a post fall assessment, the interdisciplinary team and/or the interdisciplinary team and/or the resident's physician. 3. Record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the MDS 3.0 assessment, dated 11/08/19 revealed the MDS did not reflect the use of alarms. Review of the care plan, dated 11/18/19 included a care area for risk of falls with interventions including a chair alarm and motion sensor to bedside. Observation and interview on 12/02/19 at 9:10 [NAME]M. with State tested Nursing Assistant (STNA) #608 verified Resident #96 had a motion sensor and chair alarm to help prevent falls. Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, the alarm(s) should be reflected on the MDS assessment. Interview on 12/04/19 at 03:34 P.M. with Registered Nurse (RN) #606 verified the alarm section of the MDS for Resident #96 was not complete and the use of alarms might have been overlooked. 4. Record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 06/09/19 included a care area of high risk for falls related to risks including immobility and dementia. The care plan was revised on 08/20/19 to initiate a chair tender alarm and again on 09/24/19 to initiate an alarming floor mat per doctor's order. physician's orders [REDACTED]. Review of the MDS 3.0 assessment dated [DATE] indicated chair and bed alarms were coded as not used for the resident. Observations of Resident #63 on 12/03/19 at 11:58 [NAME]M. and 12/04/19 at 2:14 P.M. revealed the resident was seated in her wheelchair with the chair tender in place. Observations of Resident #63 on 12/03/19 at 1:48 P.M., 12/04/19 at 8:48 [NAME]M. and 12/04/19 at 12:41 P.M. revealed an alarm floor mat in place under the left side of the bed while resident was sitting in a nearby reclining chair. Interview on 12/04/19 at 2:30 P.M. with Licensed Practical Nurse #613 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed. Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, that alarm should be reflected on the MDS. Interview on 12/04/19 at 3:15 P.M. with State tested Nursing Assistant (STNA) #615 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed. Interview on 12/05/19 at 11:22 [NAME]M. with STNA #614 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed.

Based on observation, record review and interview the facility failed to maintain adequate infection control practices during the administration of medication for Resident #62 and during meal services to prevent the spread of infection. This affected one resident (#62) of six residents observed during medication administration and six residents (#10, #27, #63, #73, #85 and #87) of ten residents observed for meal service. Findings include: 1. During medication observation on 12/03/19 at 7:19 [NAME]M. Licensed Practical Nurse LPN #610 entered Resident #62's room to obtain a glucometer reading. LPN #610 entered the resident's room, washed her hands, applied gloves and then completed the blood sugar testing. After completing the test, the LPN discarded the items in the appropriate container, removed her gloves and then returned to the medication cart without first performing any hand washing or hand hygiene. The LPN then cleaned the glucometer with a sanitizing wipe and obtained the resident's [MEDICATION NAME] KwikPen from the medication drawer and prepared it for administration. LPN #610 then entered Resident #62's room, applied gloves, administered the insulin, discarded the needle into the designated container, removed her gloves and returned to the medication cart without performing any hand hygiene/washing. Interview with LPN #610 on 12/03/19 at 7:38 [NAME]M. verified she did not perform handwashing after removing her gloves. Review of facility policy titled Handwashing/Hand Hygiene, revised (MONTH) 2010 revealed employees must wash their hands or use an alcohol-based hand rub after removing gloves. 2. Observation on 12/02/19 at 12:08 P.M. of meal tray service with State tested Nursing Assistant (STNA) #609 revealed STNA #609 obtained a meal tray and a clean clothing protector, then delivered it to Resident #10. STNA #609 adjusted Resident #10's bed position using the bed remote, then adjusted the overbed tray table, set-up the resident's meal tray by opening containers and lids, cut the resident's food using a fork and knife, and then re-adjusted the overbed tray table before leaving Resident #10's room. STNA #609 then entered Resident #63's room to assist the resident with another staff member without washing her hands. Interview on 12/02/19 at 12:28 P.M. with STNA #609 verified the above observation. Observation on 12/03/19 at 12:04 P.M. of meal tray service with STNA #609 revealed STNA #609 obtained a meal tray and a clean clothing protector from the meal cart and delivered the tray to Resident #85. STNA #609 adjusted the overbed tray table, pushed it toward Resident #85, applied the clothing protector onto Resident #85, cut the resident ' s food and opened condiments before returning to the meal cart. STNA #609 returned and opened the meal cart without first washing her hands, obtained another tray and delivered the tray to Resident #73. STNA #609 returned to the meal cart, obtained a meal tray and a clean clothing protector and delivered it to Resident #27. STNA #609 adjusted the overbed tray table, pushed it toward Resident #27, applied the clothing protector onto Resident #27, removed lids and opened condiments, then turned on the overbed light before leaving the room. STNA #609 then returned to the meal cart and picked up a used clothing protector and placed it into the soiled barrel in the soiled utility room. Without washing her hands, STNA #609 then provided assistance to Resident #87. Interview on 12/03/19 at 12:25 P.M. with STNA #609 verified the above observation. On 12/04/19 at 12:25 P.M. with Director of Nursing revealed the facility policy was to wash hands or use hand sanitizer after touching resident's personal effects which included resident furniture. Review of facility policy titled Assisting the Resident with In-Room Meals, revised (MONTH) 2011, revealed it was not necessary to wash hands between each resident tray; however, if there was contact with soiled dishes, clothing or the residents' personal effects, the employee must wash their hands before serving food to the next resident.

Based on record review and interview the facility failed to ensure Resident #49 was free from misappropriation of money. This affected one resident (#49) of three residents reviewed for misappropriation. Findings include: Review of the medical record for Resident #49 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the form titled, Resident Personal Funds revealed Resident #49 signed on 03/22/17 that she authorized the facility to manage her personal money while she was a resident at the facility. Review of a facility self-reported incident (SRI), tracking number 1 revealed an incident involving misappropriation for Resident #49 was discovered on 09/08/19. The SRI revealed on 09/02/19 State tested Nursing Assistant (STNA) #600 asked Resident #49 if she would like to have her coin purse locked up rather than leave her money in her room. Resident #49 agreed and STNA #600 took Resident #49's coin purse that contained $38.00 to Licensed Practical Nurse (LPN) #601. STNA #600 and LPN #601 verified the coin purse contained $38.00 and LPN #601 locked the coin purse inside the B wing medication cart inside the narcotic drawer. On 09/08/19 Resident #49 had asked for her money back and the coin purse was returned with $2.00 inside. Resident #49 reported she had money missing. A witness statement per LPN #602 dated 09/08/19 revealed Resident #49 came to her and requested her change purse from the medication cart. LPN #602 opened the narcotic drawer and retrieved the change purse. LPN #602 revealed Resident #49 stated she had $52.00 dollars in the change purse. LPN #602 opened the change purse and there were two one-dollar bills and some change wrappers in the purse. Resident #49 was given her change purse and the incident was reported to Registered Nurse (RN) #603. Review of police report dated 09/10/19 at 10:50 [NAME]M. for theft revealed Police Officer #604 responded to the facility. Assistant Director of Nursing (ADON) #605 revealed Resident #49 stated she was missing approximately $50.00. The police report stated the money was in Resident #49's possession until LPN #601 took the money for safekeeping and locked the money inside the medication cart. He revealed the cart was only assessable by the nurses at the facility. He was advised this was sometimes done to keep resident's money safe. He revealed the exact date when the money went missing was unknown and was advised almost a dozen nurses had access to the medication cart from the time the money was put into the cart and the time the money was located missing; therefore, was unable to investigate. A witness statement per Resident #49 dated 09/10/19 revealed STNA #600 found the coin purse and asked Resident #49 if she wanted her coin purse with her money locked up with the nurse. Resident #49 agreed and then checked on 09/08/19 to see if she had enough money to get lunch and the nurse gave her the coin purse and there was money missing. A witness statement per STNA #600 dated 09/10/19 revealed she gave LPN #601 Resident #49's coin purse that contained $38.00 dollars. She revealed she counted the money in front of LPN #601 and LPN #601 put the purse and money inside the medication cart. A witness statement per LPN #601 dated 09/15/19 revealed STNA #600 brought her Resident #49's coin purse and LPN #601 and STNA #600 counted the money inside the coin purse and there was $38.00 dollars. LPN #601 wrote on a piece of tape the resident's name and $38.00 dollars and placed the tape on the coin purse. LPN #601 placed the coin purse inside the B wing medication cart inside the narcotic drawer. Interview on 12/03/19 at 2:49 P.M. with LPN #602 verified Resident #49 had asked for her change purse with money out of the narcotic drawer on 09/08/19. She verified the change purse contained $2.00 dollars inside. She verified they did not have accounting records of Resident #49's money as they did not count her money in the narcotic drawer shift to shift. Interview on 12/03/19 at 3:06 P.M. STNA #600 verified on 09/02/19 Resident #49 agreed to not keep her change purse with money in her room. She verified she gave LPN #601 the change purse and they counted the money together and Resident #49 had $38.00 dollars inside the change purse. She verified LPN #601 placed the change purse with the money in the medication cart inside the narcotic drawer. Interview on 12/04/19 at 1:48 P.M. with the Administrator verified Resident #49 had personal money missing from the medication cart inside the narcotic drawer. She verified she had a personal funds account at the facility and revealed Resident #49's personal money should not have been maintained in the narcotic drawer instead should have been put into her personal account. Review of facility policy titled Abuse, Neglect, Misappropriation of Resident's Property and Injury of Unknown Source, dated 10/17/17 revealed misappropriation was defined as deliberate, depriving, defrauding, or otherwise obtaining the real or personal property of a resident. Review of facility policy titled Protection and Management of Resident Funds, dated 03/01/19 revealed if a resident presented written authorization, the facility shall hold, safeguard and manage and account for the resident's personal funds deposited with the facility.

Based on observation, record review and interview the facility failed to ensure Resident #62, who had a [DIAGNOSES REDACTED]. This affected one resident (#62) of six residents observed for medication administration. Findings include: Review of the medical record for Resident #62 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident had a physician's orders [REDACTED]. The order included to rotate sites, use arms not abdomen for injection. During medication administration observation on 12/03/19 at 7:42 [NAME]M., Licensed Practical Nurse (LPN) #610 entered Resident #62's room with the prepared [MEDICATION NAME] Kwikpen and exposed the resident's abdomen which revealed two small blue, red, and purple colored bruises to the right upper quadrant. Resident #62 inquired of LPN #610 why she was getting bruises and LPN #610 responded she believed it was from her insulin shots but she would check. LPN #610 then wiped an area of Resident #62's abdomen in the left upper quadrant of the abdomen and proceeded to inject six units of [MEDICATION NAME] using the Kwikpen. Interview on 12/03/19 at 3:27 P.M. with Resident #62 and LPN #610 confirmed Resident #62 had three bruises on the abdomen. LPN #610 verified two bruises coincided with previous insulin injections on the abdominal right upper quadrant and the third was new from the insulin injection she gave that morning. Interview on 12/03/19 at 3:49 P.M. with the Director of Nursing verified Resident #62 had a physician's orders [REDACTED]. She further confirmed Resident #62 received insulin injections in the abdomen on multiple occasions from 09/19/19 to 12/03/19. Review of Medication Administration Records for (MONTH) through (MONTH) 2019 revealed Resident #62 received the [MEDICATION NAME]injection in the abdomen on 09/19/19 at 9:15 P.M., 09/20/10 at 7:23 [NAME]M. and at 8:23 P.M., on 09/21/19 at 7:46 [NAME]M. and at 8:08 P.M., on 09/22/19 at 7:56 [NAME]M. and at 8:06 P.M., on 09/23/19 at 7:14 [NAME]M. and at 9:15 P.M., on 09/24/19 at 7:12 [NAME]M. and at 8:01 P.M., on 09/25/19 at 7:47 [NAME]M. and at 8:33 P.M., on 09/26/10 at 7:19 [NAME]M. and at 8:25 P.M., on 09/27/10 at 7:34 [NAME]M. and at 8:51 P.M., on 09/28/19 at 8:41 P.M., on 09/29/19 at 7:33 [NAME]M. and at 8:07 P.M., on 09/30/19 at 6:49 [NAME]M. and at 8:07 P.M., on 10/01/19 at 7:13 [NAME]M. and at 8:55 P.M., on 10/02/19 at 7:06 [NAME]M. and at 08:18 P.M., on 10/03/19 at 7:25 [NAME]M. and at 8:08 P.M., on 10/04/19 at 9:21 [NAME]M. and at 8:09 P.M., on 10/05/19 at 7:04 [NAME]M. and at 8:09 P.M., on 10/06/19 at 7:11 [NAME]M. and at 8:35 P.M., on 10/07/19 at 7:35 [NAME]M. and at 8:43 P.M., on 10/08/19 at 7:08 [NAME]M. and at 8:35 P.M., on 10/09/19 at 7:20 [NAME]M. and at 8:58 P.M., on 10/10/19 at 7:11 [NAME]M. and at 8:08 P.M., on 10/11/19 at 7:27 [NAME]M. and at 8:11 P.M., on 10/12/19 at 8:45 [NAME]M. and at 8:04 P.M., on 10/13/19 at 7:25 [NAME]M. and at 8:03 P.M., on 10/14/19 at 8:49 [NAME]M. and at 8:31 P.M., on 10/15/19 at 7:59 [NAME]M. and at 8:05 P.M., on 10/16/19 at 11:19 [NAME]M. and at 8:42 P.M., on 10/17/19 at 7:20 [NAME]M. and at 8:04 P.M., on 10/18/19 at 8:02 [NAME]M. and at 8:29 P.M., on 10/19/19 at 9:02 [NAME]M. and at 8:54 P.M., on 10/20/19 at 9:27 [NAME]M. and at 8:07 P.M., on 10/21/19 at 8:51 [NAME]M., on 10/22/19 at 8:55 [NAME]M. and at 9:04 P.M., on 10/23/19 at 7:22 [NAME]M. and at 8:17 P.M., on 10/24/19 at 8:52 [NAME]M. and at 8:19 P.M., on 10/25/19 at 7:36 [NAME]M. and at 10:45 P.M., on 10/26/19 at 7:48 [NAME]M. and at 8:05 P.M., on 10/27/19 at 7:04 [NAME]M. and at 10:31 P.M., on 10/28/19 at 9:59 [NAME]M. and at 8:26 P.M., on 10/29/19 at 10:25 [NAME]M. and at 8:13 P.M., on 10/30/19 at 7:31 [NAME]M. and at 10:44 P.M., on 10/31/19 at 8:46 [NAME]M and at 8:04 P.M., on 11/01/19 at 7:46 [NAME]M. and at 8:07 P.M., on 11/02/19 at 9:33 [NAME]M. and at 8:20 P.M., on 11/03/19 at 7:58 [NAME]M. and at 8:27 P.M., on 11/04/19 at 8:44 [NAME]M. and at 8:38 P.M., on 11/05/19 at 8:52 [NAME]M. and at 9:24 P.M., on 11/06/19 at 7:40 [NAME]M. and at 8:11 P.M., on 11/07/19 at 9:39 [NAME]M. and at 8:30 P.M., on 11/08/19 at 10:33 [NAME]M. and at 9:12 P.M., on 11/09/19 at 7:12 [NAME]M. and at 8:50 P.M., on 11/10/19 at 7:29 [NAME]M., on 11/11/19 at 7:37 [NAME]M. and at 8:28 P.M., on 11/12/19 at 9:42 [NAME]M. and at 9:22 P.M., on 11/13/19 at 7:00 [NAME]M. and at 8:41 P.M., on 11/14/19 at 7:19 [NAME]M. and at 8:11 P.M., on 11/15/19 at 7:39 [NAME]M. and at 8:52 P.M., on 11/16/19 at 7:27 [NAME]M. and at 8:28 P.M., on 11/17/19 at 9:38 [NAME]M. and at 8:06 P.M., on 11/18/19 at 9:00 [NAME]M. and at 9:06 P.M., on 11/19/19 at 7:39 [NAME]M. and at 9:36 P.M., on 11/20/19 at 10:50 [NAME]M. and at 8:12 P.M., on 11/21/19 at 9:29 [NAME]M. and at 8:00 P.M., on 11/22/19 at 7:03 [NAME]M. and at 8:14 P.M., on 11/23/19 at 8:50 [NAME]M. and at 9:00 P.M., on 11/24/19 at 9:27 [NAME]M. and at 8:34 P.M., on 11/25/19 at 7:10 [NAME]M. and at 8:15 P.M., on 11/26/19 at 9:48 [NAME]M. and at 8:17 P.M., on 11/27/19 at 7:16 [NAME]M and at 9:02 P.M., on 11/28/19 at 7:29 P.M. and at 8:18 P.M., on 11/29/19 at 7:20 [NAME]M. and at 8:04 P.M., on 11/30/19 at 7:57 [NAME]M. and at 8:33 P.M., on 12/01/19 at 7:41 [NAME]M. and 8:12 P.M., and on 12/02/19 at 7:31 [NAME]M and 8:09 P.M. Review of facility undated policy titled Medication Administration revealed medications must be administered in accordance with the orders.

Based on observation, record review and interview the facility failed to ensure medications were administered to Resident #59 via gastrostomy tube to decrease the risk of stomach upset/gastrointestinal disturbance. This affected one resident (#59) six residents observed for medication administration. Findings include: Review of the medical record for Resident #59 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During medication administration observation on 12/03/19 at 9:38 [NAME]M., Licensed Practical Nurse (LPN) #610 prepared the Potassium chloride solution 10% 7.5 ml into a medication administration cup. Observation of the Potassium Chloride medication label revealed a note that stated, must dilute before using. Interview at the time of the observation with LPN #610 revealed she would dilute the medication prior to administering in the gastrostomy tube. LPN #610 prepared five additional medications for administration, entered Resident #59's room, washed hands, applied gloves, disconnected the resident's tube feeding, removed gloves, washed hands, applied new gloves, checked gastrostomy tube placement, then added 15 to 30 ml water to each medication for dilution except for the Potassium chloride. Interview with LPN #610 at the time of the observation confirmed no additional water was added to the Potassium chloride liquid for dilution prior to the administration. LPN #610 then used gravity technique and a piston syringe barrel dated 12/03/19, flushed the gastrostomy tube with 200 ml water, followed by each medication with 30 ml of water flush in between and once for a final flush. Upon completion, LPN #610 disposed of the supplies in the appropriate containers, removed gloves and washed hands. Interview on 12/04/19 at 9:07 [NAME]M. with Pharmacy Consultant #611 revealed liquid potassium was recommended to be diluted with four to six ounces of water when a dilution amount was not specified in the order. He further indicated if administered with less than four ounces of water dilute, a risk existed for stomach upset or gastrointestinal disturbance.

Based on medical record review, review of hospital records, interview with facility staff, review of laboratory testing results, review of the facility policy titled Anticoagulation Clinical Protocol and review of the Nursing Drug Handbook, 38th Edition, the facility failed to ensure adequate monitoring was completed for one resident (Resident #6) who received the oral anticoagulant (blood thinning) medication, [MEDICATION NAME]. This resulted in Immediate Jeopardy when the blood clotting time was not monitored. Actual Harm occurred to Resident #6 on 08/28/18 when the resident was transported to the local emergency room with upper extremity bruising and bleeding evidenced by blood in the urine (indicators of possible increased bleeding due to the [MEDICATION NAME] medication) and was admitted to the hospital with [REDACTED]. The resident's International Normalized Ratio (INR) level (blood testing used to monitor therapeutic levels of the medication [MEDICATION NAME]) was significantly elevated with a level over 9 on that date. This affected one of eleven residents reviewed the facility identified as receiving anticoagulant medication. The facility census was 116. On 10/17/18 at 4:12 P.M., the Administrator, Regional Consultant #40, Assistant Director of Nursing (ADON) and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/20/18 when the facility failed to obtain laboratory (INR) testing to monitor Resident #6's [MEDICATION NAME] level. The lack of monitoring resulted in the resident being transferred to the emergency room and admitted to the hospital on [DATE] with bruising and hematuria (blood in urine) with hospital [DIAGNOSES REDACTED]. Resident #6 subsequently received fresh frozen plasma (FFP) and Vitamin K in an attempt to reverse the effects of the [MEDICATION NAME] medication. The Immediate Jeopardy was removed on 10/19/18 when the facility implemented the following corrective actions: · On 08/27/18 at 3:01 P.M. Registered Nurse (RN) #10 identified bruises on Resident #6's arms and notified the physician who ordered an INR and complete blood count lab work to be drawn on 08/27/18. · Laboratory testing results, dated 08/28/18 at 8:30 A.M. revealed Resident #6's INR level was over 9. The physician was notified, and an order was obtained to administer five milligrams (mg) of Vitamin K intramuscularly. Blood was subsequently identified in Resident #6's urine at 9:15 A.M. The facility reported the bloody urine symptom to the physician at 9:15 A.M. who ordered Resident #6 to the hospital for evaluation. At 9:30 A.M. emergency medical services (EMS) was called and at 9:56 A.M. Resident #6 was taken to the hospital emergency room . · A review of a facility investigation revealed Licensed Practical Nurse (LPN) #14 failed to document on the [MEDICATION NAME] log that PT/INR testing for Resident #6 was due on 08/20/18. Review of employee disciplinary action, dated 09/15/18 revealed LPN #14 was issued a three-day working suspension on 09/21/18, 09/22/18 and 09/23/18 for not ordering the PT/INR for Resident #6 on 08/20/18. · An emergency meeting of the Quality Assurance committee consisting of the administrator, DON, ADON and management consultants was held on 08/28/18 to direct the following corrective action related to the incident with Resident #6: Ongoing and frequent communication with the hospital and family regarding resident condition. Completion of preliminary audits on all units regarding [MEDICATION NAME] logs and the completion of those logs. · On 08/29/18 [MEDICATION NAME] log audits were completed for the eleven residents receiving [MEDICATION NAME] (Resident #6, #11, #19, #23, #27, #58, #65, #74, #83, #85, and #99) and were set for weekly audit through 12/31/18. The audits were completed by the unit managers, RN #620, RN #621 and RN #622. · On 08/29/18 body audits were completed/reviewed for the remaining ten residents, Resident #11, #19, #23, #27, #58, #65, #74, #83, #85, and #99 receiving [MEDICATION NAME] and found no negative for bleeding or bruising. The body audits were completed by the DON. · On 08/29/18 a plan was implemented for [MEDICATION NAME] log audits to be checked by the DON bi-weekly through 06/30/19. · Staff education regarding the use of anticoagulants, the [MEDICATION NAME] monitoring log and entering lab orders into Point Click Care electronic records was conducted on 09/15/18 for LPN and RN staff by the ADON. There were six LPNs and three RNs as of 09/15/18 who had not received the education. Those six LPNs and three RNs received the education on 10/18/18 by the ADON. Staff education was provided on 10/19/18 by the ADON for eight agency LPNs and any agency nurses who did not receive the education on 10/19/18 were put onto a Do Not Return list. · On 10/19/18 at 12:30 P.M. the DON provided a plan for all new agency staff to receive mandatory training on the same topic (related to the use of anticoagulants) from the ADON before working in the facility. A plan for any newly hired nurses to receive the training as part of the orientation program by the ADON was also implemented. · Nursing staff interviews were conducted on 10/19/18 from 9:06 A.M. to 9:24 A.M. with LPN #615, LPN #617, LPN #618 and LPN #619 who were employed by the facility. All LPN's interviewed verified recent education on anticoagulants including [MEDICATION NAME], using the monitoring tool to track PT/INR levels, [MEDICATION NAME] orders and lab orders and how to input lab orders into the electronic records system. Although the Immediate Jeopardy was removed on 10/19/18 the facility remained out of compliance at Severity Level 2 (no actual harm with potential for minimal harm that is not Immediate Jeopardy) as the facility remained in the process of implementing their corrective action plan. Findings include: Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and required extensive assistance from staff for bed mobility, transfers, toileting and hygiene. Record review revealed Resident #6 was unable to make her own financial and health care decisions without input from her son who was identified to be her responsible party. Record review revealed a plan of care, initiated on 07/03/18 and revised on 07/30/18 indicating the resident was on anticoagulant therapy. The goal developed was for the resident to be free from discomfort and adverse reactions related to anticoagulant use. Interventions included to monitor for side effects and effectiveness once a shift and labs as ordered, report abnormal lab results to physician. Review of the physician's orders revealed an order, dated 07/02/18 for the anticoagulant (blood thinning) medication, [MEDICATION NAME] ([MEDICATION NAME] Sodium) two milligrams (mg) once a day every Sunday, Tuesday, Thursday and Saturday for [MEDICAL CONDITION]. On 07/02/18 an additional [MEDICATION NAME] order was written for a four mg [MEDICATION NAME] once a day every Monday, Wednesday and Friday for [MEDICAL CONDITION]. The orders were discontinued on 07/16/18 and new orders were obtained. Review of the physician's orders revealed a new order, dated 07/16/18 for [MEDICATION NAME] four mg once a day on Sunday, Monday, Wednesday, Thursday and Saturday. On 07/16/18 a second order for [MEDICATION NAME] was noted for two mg once a day on Tuesday and Friday. Both of those orders were discontinued on 07/30/18 and a new order was written for [MEDICATION NAME] five mg by mouth one time a day for anticoagulant therapy. Review of the laboratory testing results revealed the resident's [MEDICATION NAME] was monitored by checking a [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) value. The resident's PT/INR were obtained on 07/06/18, 07/09/18, 07/16/18, 07/23/18, 07/30/18, 08/06/18 and 08/13/18 with changes made to the [MEDICATION NAME] dosage as noted above. The 08/13/18 laboratory testing revealed the resident's PT was 29.6 and INR was 2.9 (within normal limits for the resident) with an order to maintain the same dose and recheck values in one week. However, there was no evidence of any subsequent PT/INR lab values obtained by the facility until 08/28/18 after the resident was assessed with [REDACTED]. Review of the PT/INR Tracking Form for Resident #6 revealed that on 08/13/18 the facility was to draw another PT/INR in one week, however the next draw was not done until 08/28/18 after the resident had shown symptoms of bruising. Review of the nursing progress notes written by RN #10 on 08/27/18 at 3:01 P.M. revealed Resident #6 had three dark bruises on her right and left arm. RN #10 notified the physician and the physician ordered laboratory testing for an INR and complete blood count (CBC) lab work to be done on 08/27/18. The nursing progress notes written by LPN #11 on 08/28/18 at 2:47 A.M. revealed Resident #6 had bruises to the underside of both upper arms and the bruising was dark purple/red in color. Review of the nursing progress notes written by LPN #12 on 08/28/18 at 9:58 A.M. revealed that lab called the facility at 8:30 A.M. to report an elevated PT 88.8 and INR over 9. The physician was notified with new orders to give Vitamin K five mg intramuscular, hold the [MEDICATION NAME], recheck on Thursday. Vitamin K was given at 9:00 A.M. and at 9:15 A.M. Resident #6 urinated a large amount of hematuria (blood in urine). The physician then gave a new order to send Resident #6 to the emergency room . EMS (911) was called at 9:30 A.M. and arrived at 9:56 A.M. to transport Resident #6 to the hospital. Review of the Medication Administration Record [REDACTED]. Review of the nursing progress notes dated 08/28/18 at 3:24 P.M. by LPN #12 revealed Resident #6 was admitted to the hospital due to an elevated INR. The nursing progress notes written by RN #13 on 08/30/18 at 8:00 P.M. revealed Resident #6 returned to the facility on [DATE] at approximately 8:00 P.M. A nursing progress note written by LPN #14 on 08/31/18 at 1:37 P.M. revealed Resident #6 was not to be on [MEDICATION NAME] for four to six weeks upon re-admission. Review of the hospital discharge summary indicated Resident #6 was admitted on [DATE] due to significant, elevated INR over 9, and spontaneous bleeding with hematoma to arms and hematuria. Resident #6 was given several units of fresh frozen plasma and Vitamin K. Resident #6 had a computed tomography (CT) scan that showed a retroperitoneal bleed with a perinephric bleed. The discharge summary also recommended that before any [MEDICATION NAME] could be resumed for Resident #6 there would need to be a repeat CT scan. An interview was conducted on 10/17/18 at 7:36 P.M. with RN #10 who verified Resident #6 had dark bruises on both arms on 08/27/18 with no other signs of bleeding. RN #10 indicated she reported the findings to the physician who ordered a PT/INR and CBC to be done on 08/27/18. An interview was conducted on 10/17/18 at 7:48 P.M. with LPN #11 who verified Resident #6 had dark bruises on both arms on 08/28/18 with no other signs of bleeding. An interview was conducted on 10/18/18 at 8:24 P.M. with the DON who revealed the follow-up CT scan on Resident #6 was performed per hospital recommendations on 10/03/18 and found to be improved. Review of the CT scan report of the abdomen and pelvis with intravenous contrast completed on 10/03/18 for Resident #6 revealed bleeding was resolved. A review of physician orders, dated 10/17/18 and 10/18/18 revealed a PT/INR was drawn on 10/17/18 with result of 13.7 and 1.1, the doctor was notified and gave an order to begin [MEDICATION NAME] 2.5 mg once a day to start on 10/18/18. Per review of the MAR, the first dose was scheduled to begin on 10/18/18 at 5:00 P.M. An interview was conducted on 10/18/18 at 10:01 A.M. with the DON and ADON. The DON identified LPN #14 as the LPN who failed to enter the order for the PT/INR check to be done on 08/20/18. The DON and ADON explained that discipline was carried out per the progressive discipline policy of the facility. Review of the facility policy titled, Anticoagulation Clinical Protocol, dated 10/2010, revealed the physician would order appropriate laboratory testing to monitor anticoagulant therapy and potential complications and the staff should use a monitoring tool to follow trends in anticoagulant dosage and response. Review of the Nursing Drug Handbook, 38th Edition revealed [MEDICATION NAME] was an anticoagulant and used as treatment of [REDACTED]. The handbook indicated the medication should be used with caution and the most serious risk of therapy was hemorrhage. The dosage was adjusted according to the INR results and elderly tended to require lower dosages to produce a therapeutic level of anticoagulation. Under black box warning it indicated to regularly inspect patient for bleeding gums, bruises on arms or legs, nosebleeds, melena (dark and sticky stools), tarry stool, hematuria and hematemesis.

Based on observation, record review and interview the facility failed to ensure adequate assistance was provided to Resident #64 and Resident #74 to prevent falls. Actual harm occurred on 05/03/18 at 11:15 A.M. when Resident #64, assessed as requiring supervision with bathing, was left unattended by State tested Nurse Aide (STNA) #626 in the shower room and fell to the floor while reaching for his clothing. The resident sustained [REDACTED]. The resident also reported difficulty with using his arm following the incident. Actual harm occurred on 06/11/18 when Resident #74, assessed as requiring two staff for bed mobility and toileting, rolled out of bed sustaining a facial contusion and emergent hospital visit, while being provided care by only one STNA. This affected two residents (Resident #64 and #74) of four residents reviewed for falls. Findings include: 1. Record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. A plan of care was initiated on 01/26/15 and revised on 02/21/18 and identified Resident #64 was at risk for falls. A fall risk assessment completed on 02/08/18 revealed Resident #64 was at risk for falls. The fall interventions included bed locked and in low position during transfers, fall risk assessment and safety checks per policy, and nonskid strips to the floor on the right side of the bed. Review of the Minimum Data Assessment (MDS) 3.0 assessment, dated 02/09/18 revealed the resident was alert and oriented with no cognitive impairment and required the extensive assistance of one person for bed mobility, transfers, dressing, and toileting. Resident #64 required supervision and set up for both hygiene and bathing. Review of the nursing progress note, dated 05/03/18 at 3:23 P.M. revealed the nurse found Resident #64 on his knees holding onto his wheelchair. Resident #64 had a skin tear on the left forearm and small cut on his right second toe. The nursing progress note indicated STNA #626 told the nurse the resident had been left alone in the shower room (prior to being found on his knees on the floor). Review of an incident report revealed Resident #64 sustained a fall on 05/03/18. The incident report indicated Resident #64 was left alone in the shower room, fell on to his knees and hands while reaching for his clothing, was bleeding from his left arm and had cut his second toe on his right foot. As part of the investigation, STNA #626 provided a statement indicating she did leave Resident #64 alone in the shower. Following the incident, STNA #626 was in-serviced on not leaving residents alone in the shower room. Review of the MDS 3.0 assessment, dated 05/07/18 revealed Resident #64 was cognitively intact, required one person assistance for bed mobility, transfers and dressing. For personal hygiene Resident #64 was assessed to require set up and supervision. Review of the nursing progress notes from 05/09/18 through 06/05/18 revealed on 05/09/18 Resident #64 began complaining of pain and swelling in his left elbow region. The physician was notified and started him on the steroid medication, [MEDICATION NAME] 50 milligrams (mg) at bedtime. On 05/14/18 the pain and swelling increased, the physician was notified and came to see Resident #64. The physician expressed concern the arm was infected and planned for him to see an orthopedic physician the next morning. On 05/15/18 Resident #64 was started on the antibiotic [MEDICATION NAME] for a left elbow infection. On 05/16/18 nursing notes revealed that pain and redness was spreading in the left elbow region so his primary care physician at the facility wanted him evaluated at the hospital. Resident #64 was admitted to the hospital on [DATE] and had surgery during the stay for a [DIAGNOSES REDACTED]. He returned to the facility on [DATE] and was placed in contact isolation for the [MEDICAL CONDITION] (MRSA) in his elbow being treated with two antibiotics [MEDICATION NAME] and Bactrim DS. Resident #64 remained in contact isolation until 06/05/18. An interview was conducted on 10/15/18 at 4:04 P.M. with Resident #64 who revealed STNA #626 was assisting him in the shower, finished washing his back and told him she had to step out. Resident #64 said he was left on the shower bench with no towel and his dry clothing were on his wheelchair at least two to three feet out of reach. After ten to fifteen minutes had gone by he stated he was cold and reached for his clothing. He stated he managed to get his shorts on and when he reached a second time for his shirt he fell to the floor landing on his left forearm, which was cut during the fall. Resident #64 said that he was left handed and never had problems using his left arm until the fall on 05/03/18. Resident #64 explained that he had to go to the hospital because the cut he sustained on his left forearm got infected and he had to have surgery due to an infection and pain. He said his arm has not worked the same since the accident. An interview was conducted on 10/17/18 at 5:50 P.M. with the director of nursing who verified Resident #64 fell in the shower room and sustained an injury to his left arm as a result of STNA #626 leaving him unattended. The facility policy titled Shower/tub bath policy, dated 10/2010, revealed employees were to stay with residents throughout the bath and never leave the resident unattended in the bath or shower. 2. Record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #74's MDS 3.0 assessment, dated 03/18/18 revealed the resident required extensive assistance from two staff for bed mobility and toileting. Record review revealed Resident #74 sustained a fall on 06/11/18 when STNA #705 was providing bowel incontinence care. The post-fall investigation revealed one witness statement had been made concerning the event (done by STNA #705), which revealed STNA #705 rolled the resident in bed onto their side. Resident #74 rolled over the side of the bed when STNA #705 turned away to get a washcloth from the table. The investigation contained no other witness statements. Resident #74 received a contusion (bruise) to the face and was sent to the emergency room . On 10/17/18 at 6:51 P.M. interview with the Director of Nursing (DON) revealed she was involved in the post-fall investigation for Resident #74. The DON verified only one STNA was present in the resident's room and providing care at the time of the fall. The DON verified the resident was assessed to require two staff for bed mobility.

Based on observation, record review and interview the facility failed to ensure comprehensive nutritional assessments were completed and/or timely and adequate nutritional interventions were implemented to prevent weight loss. This affected six residents (Resident #269, #46, #57, #10, #79 and #70) of six residents reviewed for weight loss. Findings include: 1. Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was ventilator dependent and received nutrition/hydration via a gastrostomy tube. Review of the admission nursing assessment identified Resident #70 was admitted with a weight of 166 pounds. The resident's height was six feet. Review of the 14-day Minimum Data Set (MDS) 3.0 assessment, dated 09/24/18 revealed the resident had intact cognition. Rejection of care had not been exhibited. The resident was dependent for eating. The assessment indicated the resident had a weight of 145 pounds and had no or unknown weight loss on a feeding tube. Review of the 30-day Minimum Data Set (MDS) 3.0 assessment which was in progress and dated 10/08/18 revealed the resident had intact cognition. Rejection of care had not been exhibited. The resident was dependent for eating. The assessment indicated the resident had a weight of 138 pounds and had no or unknown weight loss on a feeding tube. Review of the nutrition risk assessments dated 09/19/18, 08/16/18 and 06/06/18 revealed the resident was at low risk for nutritional deficits. The amount of calories, protein and fluids the tube feeding was supplying was documented. However, none of the completed assessments reflected what Resident #70's calorie, protein, fluid or other nutritional needs were calculated to be to ensure his needs were being met via the enteral tube feedings. Review of the plan of care revealed the resident was at risk for weight loss due to the multiple [DIAGNOSES REDACTED]. Interventions included obtain weight per doctor's order, notify the doctor and the dietitian of significant changes, monitor intake, tolerance, residuals and record. Dietitian to evaluate and make tube feeding, flush and supplement change recommendations. Review of nutrition notes from 06/11/18, 06/22/18 and 6/23/2018 revealed Resident #70 was complaining of feeling full and uncomfortable and frequently asked to have the tube feeding shut off. An intermittent tube feed schedule was attempted. However, the resident was not agreeable to that tube feed schedule. The resident wanted the tube feeding held during the night. A more concentrated tube feeding formula was tried. Reducing the tube feeding rate was tried. A third tube feeding formula was then started and continued. Weight loss was noted for the resident in each of the notes. Review of the Weekly Weight Meeting Notes from 06/15/18 through 10/02/18 revealed Resident #70 was discussed weekly. However, there was no evidence of any new nutritional interventions after 08/17/18 despite Resident #70's weight loss that was identified. Observation on 10/15/18 at 1:19 P.M. revealed the Resident #70 was receiving tube feeding at the ordered rate. The head of the bed was at elevated. The resident appeared cachectic. Interview by phone on 10/17/18 at 10:31 A.M. with registered dietitian, licensed dietitian (RD, LD) #625 revealed Resident #70 had not tolerated several different tube feedings at different rates and schedules. The RD LD indicated the tube feeding was the most well tolerated but the resident occasionally had nursing turn it off. When the resident was in hospital his weight went up, which was possibly because the tube feeding wasn't being turned off. There was no evidence the facility determined why the resident was continuing to lose weight or why he was not tolerating the tube feedings that were being ordered. On 10/18/18 at 2:32 P.M. RD, LD #625 confirmed the resident's nutritional needs had not been calculated to ensure the enteral feeding ordered was meeting his needs prior to 10/17/18. Review of weights revealed on 06/06/18 Resident #70 weighed 166.0 pounds. On 10/17/2018 Resident #70 weighed 136.8 pounds which reflected a total weight loss of 29.2 pounds or 18% from 06/06/18 to 10/17/18 (a four month period of time) for a resident who received all of his nutrition/hydration via gastrostomy tube. 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nutritional care plan was initiated on 02/07/18 indicating that Resident #10 was at risk for impaired nutrition, weight loss and impaired hydration. Interventions included nutritional supplements would be provided per physician orders. A significant change Minimum Data Set (MDS) 3.0 assessment, dated 05/13/18 was completed for Resident #10 after she suffered a left [MEDICAL CONDITION] following a fall on 04/28/18. Resident #10 was on a regular diet and as of 05/24/18 and was to receive Med Pass 2.0, a nutritional supplement, twice a day, amount unspecified in the orders. The MDS 3.0 assessment, dated 10/02/18 indicated Resident #10 was severely impaired cognitively and was dependent on staff for activities of daily living including meal tray set up and supervision for eating. Section K of this MDS indicated that Resident #10 was 63 inches tall, weighed 138 pounds and did not reflect a significant weight loss or gain in the last one or six months. Observation conducted on 10/16/18 at 5:11 P.M., 5:17 P.M. and 5:25 P.M. revealed Resident #10 sitting upright in her bed with her dinner tray in front of her. She was able to feed herself with some difficulty due to her hand tremors. There were no staff providing supervision during the meal. She had eaten her meat but left 75% of her meal uneaten. Review of the monthly vitals section which included height and weight indicated on 04/01/18 Resident #10's weight was 159 pounds. On 07/04/18, Resident #10's weight was 142 pounds. On 09/02/18, Resident #10's weight was 138 pounds and on 10/02/18 Resident #10's weight was 135 pounds. From 04/01/18 to 10/02/18 Resident #10 lost 24 pounds which was a 15% weight loss in six months. According to the MDS, any weight loss of 10% or more in six months should be coded for a significant weight loss on the MDS. The 10/02/18 MDS indicated a weight of 138 pounds but was not coded as a significant weight loss in one or six months. The signature section indicated Dietary Manager (DM) #628 completed this section of the MDS on 10/04/18. An interview was conducted on 10/17/18 at 1:12 P.M. with DM #628 who verified she used the 09/02/18 weight of 138 pounds for the MDS assessment completed on 10/02/18. DM #628 said it should have been 135 pounds, and verified it did not capture the 15% weight loss in six months for Resident #10. She explained she was responsible for completing all of the nutritional assessments except for the goals and interventions sections which are completed by Dietitian #625. The nutritional assessments for Resident #10 completed on 02/05/18, 05/13/18, 07/03/18 and 10/02/18 contained no information related to Resident #10's calorie, protein or fluid needs. The nutritional assessment completed on 10/02/18 indicated a weight of 138 pounds and the goals and interventions section completed by Dietitian #625 also indicated there had been no significant weight loss and no new nutritional recommendations were made. An interview was conducted on 10/17/18 at 12:08 P.M. with Dietitian #625. She verified she completed the last two parts of the nutritional assessments, the goals and interventions sections. Dietitian #625 verified these nutritional assessments did not contain an assessment of calorie, protein or fluid needs and did not indicate Resident #10 was high nutritional risk. Dietitian #625 verified Resident #10's calorie, protein and fluid needs would increase after her [MEDICAL CONDITION]. Dietitian #625 explained that on 05/24/18 she recommended Resident #10 have the Med Pass 2.0 supplement twice a day due to a decline in her meal intakes. She said she assumed the specific amount of 120 milliliters twice a day would be put onto the Medication Administration Record [REDACTED]. An interview was conducted on 10/17/18 at 10:51 A.M. with Licensed Practical Nurse (LPN) #617. She explained that whenever a resident was ordered Med Pass 2.0 a specific amount to be given was specified in the physician order [REDACTED]. LPN #617 verified Resident #10's MAR indicated [REDACTED]. LPN #10 said nursing staff should have clarified the order to specify the amount. She said she gave Resident #10 whatever amount she would consume, which was usually four ounces but not always. She said sometimes she drank less or more. LPN #617 said there was no way to tell exactly how much Resident #10 consumed of the Med Pass supplement. Review of the MARs from (MONTH) (YEAR) through (MONTH) (YEAR) revealed there was no documentation of the amount of Med Pass supplement consumed by Resident #10. Review of the policy titled, Medical Nutritional Supplements, revised 11/05/09 indicated the facility would provide a designated amount of supplement during the routine medications passes. Review of the policy titled Nutritional Assessment, revised (MONTH) 2011 indicated the dietitian would document an estimate of calorie, protein, nutrient and fluid needs of each resident on the nutritional assessment and whether the resident's current intake was adequate to meet his or her nutritional needs. The policy also indicated the multidisciplinary team shall identify upon a change in condition the resident at increased risk for impaired nutrition and an increased need for calories and/or protein. 3. In addition, the nutrition risk assessments for four additional residents, Resident #269, Resident #46, Resident #57, and Resident #79 reviewed for weight loss revealed none had an estimate of their calorie, protein, nutrient and fluid needs. On 10/18/18 at 2:32 P.M., Dietitian #625 confirmed the resident nutritional needs had not been calculated and placed on record for the above residents until her progress note dated 10/17/18 which was following a discussion of the need for such information to be available. Review of the policy, Nutritional Assessment revised 12/2011, revealed the dietitian would document an estimate of calorie, protein, nutrient and fluid needs of each resident and whether the resident's current intake was adequate to meet his or her nutritional needs. The policy also indicated the multidisciplinary team shall identify upon a change in condition the resident at increased risk for impaired nutrition and an increased need for calories and/or protein.