Every finding on record at Aventura at Walton Hills

Based on record review, interview and review of the facility policy, the facility failed to timely develop care plans relative to elopement risk. This affected one resident (#77) of three residents reviewed for elopement. The facility census was 79. Findings include:Review of Resident #77's medical record revealed an admission date of 02/07/24 and diagnoses including anxiety, chronic kidney disease, type two diabetes, cognitive communication deficit, Parkinson's disease without dyskinesia and dementia without behavioral disturbance. Resident #77's daughter was listed as his legal guardian.Review of a wander-risk evaluation dated 10/29/25 revealed Resident #77 was a low risk for wandering.Review of an annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 was cognitively intact, did not wander and required partial to moderate assistance with ambulation using a wheelchair.Review of a wander-risk evaluation dated 01/29/26 and completed by Licensed Practical Nurse (LPN) #225 revealed Resident #77 was a moderate risk for wandering. The section under care plan probing what interventions are going to be care planned was left blank.Review of a discharge, return-anticipated MDS 3.0 assessment dated [DATE] revealed Resident #77 had okay memory, did not wander and required partial to moderate assistance for ambulation using a wheelchair.Review of a wander-risk evaluation dated 02/15/26 and completed by MDS/Registered Nurse (RN) #212 revealed Resident #77 was a high risk for wandering. The section under care plan probing what interventions are going to be care planned was left blank.Review of a progress note dated 02/15/26 at 3:00 P.M. and authored by RN #316 revealed the following information: Resident #77 pushed on exit door, activating door alarm. Staff member (not specified) immediately responded to alarm and found Resident #77 on his right side with wheelchair beside him. Fall was unwitnessed. Nurse completed head to toe assessment. Range of motion equal bilaterally. Neurological assessment initiated per protocol. Vital signs obtained. Resident alert and responsive. Resident denies pain or discomfort at this time. Staff members times four (not specified) assisted Resident #77 back into wheelchair. Resident #77 brought back to nursing station for closer monitoring.Review of a facility investigation regarding Resident #77's elopement on 02/15/26 revealed Resident #77 had exited out an emergency exit door off the 200 hall which was under construction and not occupied and had been outside less than five minutes. Resident #77 had been last seen five minutes prior at the nurses' station. The facility's alarm and egress doors had worked properly when pressed upon and staff responded immediately to the alarm and to Resident #77.Review of a care plan initiated 02/16/26 revealed Resident #77 had the potential for elopement and associated injury related to exit-seeking behavior. All listed interventions were initiated on 02/16/26.Interview on 03/04/26 at 11:44 A.M. with LPN #225 revealed nurses were responsible for completing wander-risk assessments and MDS/RN #212 did the care plans. When asked about the care plan interventions section of the wander-risk assessment, LPN #225 stated she'd never filled out that section and could not speak further to that part of the assessment.Interview on 03/04/26 at 1:07 P.M. with MDS/RN #212 revealed she care-planned elopement risk based on Interdisciplinary Team (IDT) discussions in addition to the risk identified on the resident's wander-risk assessment. MDS/RN #212 stated some residents could have a higher score on this assessment yet not be at risk for elopement. When asked about Resident #77 going from low to moderate risk per the wander-risk assessment dated [DATE], MDS/RN #212 stated we [the IDT] believed at the time Resident #77 was not an elopement risk but had more wandering behavior and she did not put a care plan in just for a resident wandering.Interview on 03/04/26 at 1:45 P.M. with the Administrator and the Director of Nursing (DON) revealed when Resident #77 started to self-propel around the facility in his wheelchair that is when he went from low to moderate wander-risk. The Administrator verified a care plan should have been put into place for Resident #77 when he started wandering in this manner and verified this was not done until after his elopement on 02/15/26.Review of the facility policy, Care Plans, Comprehensive-Person Centered, dated 2001 revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.This deficiency represents noncompliance investigated under Complaint Number 2791655.

Based on record review, interview and review of the facility policy, the facility failed to notify the guardian of Resident #77's elopement. This affected one resident (#77) of three residents reviewed for elopement. The facility census was 79.Findings include:Review of Resident #77's medical record revealed an admission date of 02/07/24 and diagnoses including anxiety, chronic kidney disease, type two diabetes, cognitive communication deficit, Parkinson's disease without dyskinesia and dementia without behavioral disturbance. Resident #77's daughter was listed as his legal guardian.Review of a discharge, return-anticipated Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77's memory was intact, he did not wander and required partial to moderate assistance for ambulation using a wheelchair.Review of a progress note dated 02/15/26 at 3:00 P.M. and authored by Registered Nurse (RN) #316 revealed the following information: Resident #77 pushed on exit door, activating door alarm. Staff member (not specified) immediately responded to alarm and found Resident #77 on his right side with wheelchair beside him. Fall was unwitnessed. Nurse completed head to toe assessment. Range of motion equal bilaterally. Neurological assessment initiated per protocol. Vital signs obtained. Resident alert and responsive. Resident denies pain or discomfort at this time. Staff members times four (not specified) assisted Resident #77 back into wheelchair. Resident #77 brought back to nursing station for closer monitoring. The progress note did not indicate Resident #77's guardian had been notified regarding his elopement.Review of a facility investigation regarding Resident #77's elopement on 02/15/26 revealed Resident #77 had exited out an emergency exit door off the 200 hall which was under construction and not occupied and had been outside less than five minutes. Resident #77 had been last seen at the nurses' station five minutes prior. The facility's alarm and egress doors had worked properly, and staff had responded immediately to the alarm and to Resident #77 who had been found lying on his right side on the ground with his wheelchair beside him.Review of a care plan initiated 02/16/26 revealed Resident #77 had the potential for elopement and associated injury related to exit-seeking behavior. All listed interventions were initiated on 02/16/26.Telephone interview on 03/04/26 at 12:50 P.M. with Resident #77's legal guardian revealed she had only been notified of Resident #77's fall on 02/15/26 and had not been aware he had gotten outside and eloped that date until the phone call with the surveyor. Resident #77's guardian denied Resident #77 having a history of exit seeking and indicated while he was able to answer yes and no questions, he was not really interviewable.Telephone interview was attempted with RN #316 on 03/04/26 at 1:01 P.M. but was not successful.During an interview on 03/04/26 at 1:45 P.M. the Administrator and the Director of Nursing (DON) were made aware Resident #77's medical record lacked evidence Resident #77's legal guardian was notified of his elopement on 02/15/26. The DON stated the incident report (part of risk documentation and not part of the medical record) contained evidence the family had been notified of the incident (not specified) and transfer to the hospital but acknowledged this did not ascertain to which incident the family was notified regarding, Resident #77's elopement or his fall this date.Review of the facility policy, Change in a Resident's Condition or Status, dated 2001, revealed unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident was involved in any accident or incident that results in an injury or there was a significant change in the resident's physical, mental or psychosocial status.This deficiency represents noncompliance investigated under Complaint Number 2791655.

Based on observation, staff interviews and facility policy review, the facility failed to ensure food items were stored in a safe and clean manner to prevent cross contamination, exposure to air, and failed to ensure the kitchen work areas were clean and free of debris and grease buildup. This had the potential to affect all residents who received food from the kitchen. The facility identified three residents (#4, #9 and #29) who received no food by mouth. The facility census was 75.Findings include:Observation of kitchen on 09/29/25 at 8:15 A.M. with Facility [NAME] #117 and Dietary Manager #110 revealed multiple items that were uncovered and exposed to air or pests. The thickener used to puree foods was open and uncovered and placed next to kitchen mixer which was observed to have fruit flies around the container. New coffee cups and Styrofoam food containers were being stored in a cardboard box on a shelf under the coffee machine which sustained liquid damage and splatter from spilled coffee. The shelf under the tray line had old, stained parchment paper which had clean plates on it to use for serving residents.Observation of the walls in the kitchen by the blender revealed a large amount of puree splatter and food debris.Inside the walk-in freezer revealed a large buildup of ice by the entrance as well as food items close to the freezer door. The freezer door was unable to close all the way due to the ice dam buildup around the door edges. Open shelving in the freezer did not have any liners to prevent food spillage or contamination to the shelving below. A large bag of hashbrowns, chicken tenders, and full box of pork patties were open, exposed to air and undated.In the walk-in refrigerator, a large grilled roast was on the bottom shelf with dirty parchment paper that contained old spillage from meat.In the dry storage area, a box of fettuccini dry noodles was open-to-air and undated. There were five bottles of Lime Away cleaner next to dry cereal boxes.The stove/grill area had a notable amount of grease buildup throughout and in the hood, and located on the wall next to the grill was a temperature regulator which was hanging off the wall with batteries and the motherboard exposed.Additionally, all the flooring throughout the kitchen area had marked staining, crumbs, and old debris.Interview with Dietary Manager #110 on 09/20/25 at 8:35 A.M. confirmed all findings in the kitchen. Facility [NAME] #117 did remove all open and unlabeled food items in freezer, and the exposed roast in the refrigerator as well as the contaminated coffee cups and Styrofoam bowls under the coffee maker. Dietary Manager #110 stated there should never be cleaning supplies stored next to food items and removed the Lime Away cleaners immediately from the dry storage area. Dietary Manager #110 also stated maintenance placed a work order on the freezer unit because the fan was not turning off and caused the ice dam to form around the door of the freezer. No work order was provided to surveyor regarding freezer fan/motor issue.Review of the facility policy titled, Kitchen Sanitary Policy, revised October 2008, revealed the food service area shall be maintained in a clean and sanitary manner and that areas shall be clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.

Based on observation, record review, interview and facility policy review, the facility failed to ensure the staff prepared food that was palatable with seasoning and had the ingredients to prepare the food according to the dietitian approved recipes. This affected 72 out of 75 residents who ate their meals in the facility. The facility identified three residents (#4, #9, #29) who received no food by mouth. The facility census was 75.Findings include:A review of Resident #38's clinical record revealed an admission date of 12/20/24 with diagnoses including type II diabetes mellitus, chronic respiratory failure, hearing loss, above the right knee amputation, major depression, diabetic peripheral angiopathy, anxiety, obesity, insomnia, obstructive sleep apnea, and chronic obstructive pulmonary disease.Resident #38's physician order dated 01/30/25 indicated a consistent carbohydrate/liberal diabetic diet, with regular consistency, and thin liquidsAn interview with Resident #38 at 2:40 P.M. revealed the food tasted bland and had no flavor and tended to repeat the same recipes over and over.A review of Resident #60's clinical record revealed an admission date of 10/07/21 with diagnoses including vascular dementia, atherosclerosis of extremity arteries, high blood pressure, hypertensive heart failure, asthma, anxiety, cerebral vascular disease (stroke) with hemiplegia and hemiparesis of left side, gastroesophageal reflux disease, high cholesterol and severe obesity.Resident #60s physician order dated 08/17/23 indicated a regular diet with regular consistency and thin liquids.An interview with Resident #60 on 09/29/25 at 11:00 A.M. revealed the hamburgers were tasteless, and the food was generally bland.A review of Resident #65's clinical record revealed an admission date of 07/07/25 with diagnoses including multiple sclerosis, paraplegia, morbid obesity, osteoporosis, vitamin D deficiency, constipation, depression, cataracts, cognitive communication deficit, gastroesophageal reflux disease, and lymphedema.A review of Resident #65's physician order dated 07/07/25 indicated a diet order for regular diet, regular consistency with thin liquids.An interview with Resident #65 on 09/29/25 at 10:55 A.M. revealed the food was often very bland with tough dry meat.An interview with [NAME] #125 on 11/25/25 at 4:15 P.M. revealed she did not have a recipe for the food items she prepared for the dinner meal including jerked chicken and rice and beans. [NAME] #125 stated she made the jerked chicken by coating the boneless chicken thighs with olive oil and coating the pieces of chicken with a mixture of jerk seasoning, garlic powder, a little thyme and ginger. [NAME] #125 stated she allowed the coated chicken to sit for a while. [NAME] #125 stated she prepared the white rice according to the cooking directions and added water, butter, salt and kidney beans. [NAME] #125 agreed she did not prepare the jerked chicken and rice/beans according to the recipe. An observation of [NAME] #125 on 11/25/25 at 4:20 P.M. revealed the dinner meal had been prepared according to the menu. The food items prepared included jerked chicken, rice and beans, macaroni or potato salad, apple sauce and Jello. At 4:50 P.M. the staff started to plate the food items. Several of the plates used to serve the food were chipped along the rim of the plate. The Jello and apple sauce were served in clear plastic disposable containers with a lid. A test tray was inspected and tasted. The rice and bean side dish was overcooked and had a bland flavor.A review of the recipe for the food items served during the meal revealed the rice and beans recipe included the following ingredients:10 pounds of rice1 cup garlic minced3 number 10 cans of kidney beans1/3 quart of water1/8 teaspoon salt2 cups of scallions/green onions2 tablespoons of black pepperThe directions indicated to prepare the rice according to the directions. Heat oil in a steamed-jacketed kettle or tilt skillet. Add onions and garlic and cook until transparent. Add beans, water and seasoning to vegetables. Bring to a boil, reduce heat and simmer until the beans are tender for 40 to 50 minutes. Most of the water should be evaporated when the beans are done. Stir the rice into the beans in a 12-inch by 10-inch by 4-inch pan. Garnish with sliced green onions.The recipe for preparing the jerked chicken included the following ingredients and cooking directions:18 pounds of chicken1 and 1/8 quart of lime juice2 and 1/4 quart of water23 and 2/3 teaspoons of allspice6 teaspoons of nutmeg12 teaspoons salt23 and 2/3 tablespoon vegetable oil12 teaspoons of brown sugar23 and 2/3 teaspoons of dry thyme leaves23 and 1/2 teaspoons of chopped fresh onions1 gallon of chopped green onions23 and 2/3 teaspoons of minced garlicThe directions included placing the boneless chicken thighs in a bowl and cover with lime juice and water, set aside. In a food processor, place allspice, nutmeg, salt, brown sugar, thyme, ginger, black pepper, and vegetable oil and blend well, then mix in onions and garlic until almost smooth. Pour most of the mixture (marinade) into the bowl with the chicken, reserving a small amount to use for basting while cooking, cover the chicken, and marinate in the refrigerator for at least two hours. Grill chicken, turning and basting frequently until the internal temperature reached 165 degrees Fahrenheit.An interview with Dietary Manager (DM) #110 on 11/25/25 at 5:23 P.M. revealed he had not ordered the ingredients needed to prepare the jerked chicken and rice and beans as indicated on the recipe including the lime juice and green onions. DM #110 verified the recipes were not available for the cooks to use to prepare the meals. DM #110 stated the recipes needed updated because the residents had voiced, they didn't like some of the ingredients used to prepare the jerked chicken and other foods. DM #125 stated the Jello and apple sauce should have been served in the small dinnerware bowls and not the disposable containers.A review of the undated facility policy and procedure titled Standardized Recipes indicated the policy was for the staff to use standardized recipes for the preparation of each menu food item. The procedure included the recipes to be readily available to the cooks and production staff. Staff should notify the Dietary Manager if they don't have a standardized recipe for a menu food item. The cook should notify the manager if they don't have the ingredients to make the menu food item. Standardized recipes are followed throughout the production process. If a menu substitution was necessary, the Dietary Manager would be notified to approve an alternate ingredient available or if a menu substitution would be necessary. The recipe file was maintained in the Dietary Manager's office and available to all cooks throughout their tour of duty.

Based on record review, observation and interview, the facility failed to ensure a clean and sanitary environment. This affected six residents (#08, #24, #39, #53, #65 and #82) of 11 residents reviewed for environment and had the potential to affect all the residents residing in the facility. The facility census was 75.Findings include:1. Interviews with residents on 09/29/25 between 10:30 A.M. and 2:45 P.M. revealed Resident #24 stated the hallways and residents' rooms are not kept clean. Resident #39 stated her room was not kept clean daily, and the furniture in her room was worn out, and the bedside table and over-the-bed table had chipped wood. Resident #65 stated the rooms were not cleaned daily, and the furniture was worn with chipped wood. Resident #82 stated her room was not cleaned or mopped daily, and the facility was generally dirty. Observations on 09/29/25 between 10:30 A.M. and 2:45 P.M. revealed the hallways in the facility had a buildup of dirt along the edges of the halls, had yellowed wax buildup with stains and dried liquids on several of the hallways. The floors were scuffed and dull throughout the facility hallways and residents' rooms. Several floor tiles in the hallways were cracked and/or missing. Resident #39's room had dirt and grime, food crumb buildup along the edges on the room, and furniture with chipped wood along edges of the wooden furniture including the bedside table and over-the-bed table. There was food debris on the floor in the room. Resident #53's room was very dirty with a mat on the floor next to the bed with black built-up grime, and sticky/dirty floors. Resident #65's room had furniture in poor condition with chipped wood along the edges, and the floors were yellow with built-up grime along the edges of the room. Resident #82's room had dried liquid stains, black scuffs and stained, scratched floors tiles. Observations noted on 11/24/25 between 10:00 A.M. and 11:00 A.M. revealed the residents' rooms had a clear line where the hallway cleaning ended and the residents' rooms' rooms' floors were yellow with scuffs, staining and in need of stripping and re-waxing. There were several rooms with holes in the walls and built-up of dirt and grime along the edges of the rooms and bathrooms floors. On 09/30/25 at 3:41 P.M. an interview with Regional Director of Operations (RDO) #233 revealed the facility had a mock survey in July 2025 which had identified there was a deficiency in floor care, tile repair, stripping and waxing, missing tiles and accountability. RDO #233 agreed that the facility was still in need of repair and deep cleaning. RDO #233 agreed that the facility was aware of the environmental concerns since April, 2025 and had failed to address those concerns in a timely manner. An interview with the Administrator on 11/24/25 at 2:15 P.M. agreed the facility was in need of deep cleaning including stripping and waxing the floors in all areas of the building. The Administrator stated the residents had been complaining for months regarding the cleanliness of the building. The Administrator stated she did not know why the previous administration had not addressed the environmental issues in the facility. An interview with Licensed Practical Nurse (LPN) #128 on 11/24 25 at 2:30 P.M. verified the handrails on the 100, 300 and 400 hallways were chipped, floors were scuffed with stains. The main lobby had yellow wax with some of the wax worn off in places with three tiles in need of repair, walls with black scuff marks and the door frames of the residents' rooms had chipped paint and floors needed stripped and waxed. An interview with Housekeeping Manager (HM) #171 on 11/25/25 at 2:16 P.M. verified the environment needed repair and deep cleaning. HM #171 agreed the facility had been neglected for a very long time. HM #171 stated when the staff attempted to strip the floors of the wax, they found seven to ten layers of wax had been applied without properly stripping the wax off the tile before applying a new coat of wax. This caused the dirt and grime build-up and would take a very long time to deep clean the floors in the facility. HM #171 agreed with the findings above. HM #171 stated the floors should be stripped of wax every six months to maintain cleanliness and appearance. A review of the facility policy titled Floors, revised 12/2009, indicated floors shall be maintained in a clean, safe, and sanitary manner.1. All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures.2. Floor cleaning procedures are maintained by the Environmental Services Director.3. Inquiries concerning floor care should be directed to the Director of Housekeeping Services.4. Mop heads shall be washed with a disinfectant and rinsed well after each use.5. Clean mop heads must be applied when changing areas of mopping and when used in isolation rooms. The facility policy and procedure titled Cleaning and Disinfection of Environmental Surfaces, dated 08/2021, indicated environmental surfaces will be cleaned and disinfected according to current centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) Blood borne Pathogens Standard. 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: a. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue (e.g., urinary catheters) or the vascular system (e.g., intravenous catheters) are considered critical items and must be sterile. b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. (Note: Some items that may come in contact with non-intact skin for a brief period of time (e.g., hydrotherapy tanks, bed side rails) are usually considered non-critical surfaces and are disinfected with intermediate-level disinfectants). c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors. (2) Most non-critical items can be decontaminated where they are used (as opposed to being transported to a central processing location). 2. Non-critical surfaces will be disinfected with an Environmental Protection Agency (EPA)-registered intermediate or low-level hospital disinfectants according to the label's safety precautions and use directions. a. Most EPA-registered hospital disinfectants have a label contact time of IO minutes. b. By law, all applicable label instructions on EPA-registered products must be followed.3. Devices that are used by staff but not in direct contact with residents (e.g., computer keyboards, PDAs, etc.) shall be cleaned and disinfected regularly (according to facility schedule) by the environmental services staff and as needed by the nursing staff. 4. Intermediate and low-level disinfectants for non-critical items include: a. Ethyl or isopropyl alcohol; b. Sodium hypochlorite (5.25-6.15% diluted l :500 or per manufacturer's instructions); c. Phenolic germicidal detergents; d. Iodophor germicidal detergents; and e. Quaternary ammonium germicidal detergents (low-level disinfection only).5. Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products including: a. Recommended use-dilution; b. Material compatibility; c. Storage; d. She1f-life; and e. Safe use and disposal.6. A one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes will be used in resident care areas where: a. uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt); or b. uncertainty exists about the presence of multidrug-resistant organisms on such surfaces. 7. Detergent and water will be used for cleaning surfaces in non-resident care areas ( e.g., administrative offices).8. High-level disinfectants/liquid chemical sterilant will not be used for disinfection of non-critical surfaces. 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. 12. Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently (e.g., floor mopping solutions will be replaced every three resident rooms, or changed no less often than at 60-minute intervals). 13. Mop heads and cleaning cloths will be decontaminated regularly (e.g., laundered and dried at least daily).14. Horizontal surfaces will be wet dusted regularly (e.g., daily, three times per week) using clean cloths moistened with an EPA-registered hospital disinfectant (or detergent). The disinfectant (or detergent) will be prepared as recommended by the manufacturer. 15. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated. Blood-contaminated items will be discarded in compliance with federal regulations (i.e., OSHA Bloodborne Pathogens Standard). 16. Procedures for the cleaning of mopheads are maintained by the Director of Housekeeping Services. 2. Record review revealed Resident #08 was admitted to the facility on [DATE]. Diagnoses include complete C1-C4 quadriplegia, patients non-compliance with other medical treatment and regimen due to unspecified reason, need for assistance with personal care and pressure ulcer of sacral region stage four. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #08 was dependent on staff for all activities of daily living. Record review of the care plans dated 10/29/25 revealed Resident #08 required assistance with dressing, bathing personal hygiene, transferring, toileting, changing position in bed and eating related to physical limitations of quadriplegia and wounds. Observation on 11/24/25 at 11:47 A.M. revealed dirt and debris on Resident #08's floor. Interview on 11/24/25 at 11:47 A.M. with Resident #08 revealed the floor needed swept and mopped. Interview with LPN #107 on 11/24/25 at 11:50 A.M. This deficiency represents noncompliance investigated under Master Complaint Number 2673324 and Complaint Number 2655011.

Based on observation, record review, interview and facility policy review, the facility failed to ensure staff followed infection control practices to prevent cross contamination of germs during Resident #42's incontinence care. This affected one resident (#42) out of three residents reviewed for bowel and bladder incontinence. The facility census was 75.Findings include: A review of Resident #42's clinical record revealed an admission date of 09/14/23 and re-admission date of 12/02/23 with diagnoses including breast cancer, lumbago with sciatica, depression, osteoarthritis of both knees, Alzheimer's disease, cervical spondylosis with myelopathy, right knee contracture, spinal fusion of lumbar region, atherosclerotic heart disease, high blood pressure, hearing loss, glaucoma with cataracts, high cholesterol, vitamin D deficiency, A review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #42 was always incontinent of bowel and bladder and was not on a toileting program.A review of Resident #42's plan of care dated 09/26/25 revealed Resident #42 would be assisted with bowel and bladder incontinence care and would remain free from complications related to urinary incontinence. Interventions included to assist Resident #42 to the toilet as needed.An observation on 11/27/25 at 9:33 A.M. of Hospice Certified Nursing Assistant (HCNA) #231 and Certified Nursing Assistant (CNA) #205 assist Resident #42 with incontinence care revealed a failure to maintain infection control standards during the procedure. HCNA #231 pushed Resident #42's call light button and CNA #205 responded to assist HCNA #231 with providing incontinence care for Resident #42. CNA #205 did not perform hand hygiene before/after assisting Resident #42 to the toilet or before exiting the room. Both staff assisted Resident #42 to the toilet, but she was unable to stand and pivot to use the toilet. Both staff assisted Resident #42 back in her wheelchair and pushed her to the bed and assisted her to bed to change her incontinence brief. HCNA #231 removed Resident #42's outer clothing and found she was wearing two incontinence briefs. HCNA #231 removed both incontinence briefs soiled with feces and then placed both briefs directly on the floor. HCNA #231 cleaned Resident #42's perineal area using two wash cloths and then placed the soiled washcloths on the floor next to the bed. HCNA #231 then assisted Resident #42 with donning a clean brief and pushed her call light. CNA #205 responded and assisted HCNA #231 with transferring Resident #42 back to her wheelchair and then exited the room. CNA #205 did not perform hand hygiene before or after assisting Resident #42 to transfer to her wheelchair.On 11/27/25 at 10:00 A.M. an interview with HCNA #231 and CNA #205 verified the above findings and agreed they didn't maintain infection control practices during Resident #42's incontinence care task.A review of the facility policy and procedure titled Handwashing/Hand Hygiene, revised 08/2015. indicated the following:1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.3. Hand-hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand-hygiene policies.4. Triclosan-containing soaps will not be used.5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility.6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:a. When hands are visibly soiled; andb. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:a. Before and after coming on duty;b. Before and after direct contact with residents;c. Before preparing or handling medications;d. Before performing any non-surgical invasive procedures;e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites);f. Before donning sterile gloves;g. Before handling clean or soiled dressings, gauze pads, etc.;h. Before moving from a contaminated body site to a clean body site during resident care;i. After contact with a resident's intact skin;j. After contact with blood or bodily fluids;k. After handling used dressings, contaminated equipment, etc.;l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;m. After removing gloves;n. Before and after entering isolation precaution settings;o. Before and after eating or handling food;p. Before and after assisting a resident with meals; andq. After personal use of the toilet or conducting your personal hygiene.8. Hand hygiene is the final step after removing and disposing of personal protective equipment.9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.10. Single-use disposable gloves should be used:a. Before aseptic procedures;b. When anticipating contact with blood or body fluids; andc. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.11. Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities and is prohibited among those caring for severely ill or immunocompromised residents. The Infection Preventionist maintains the right to request the removal of artificial fingernails at any time if he or she determines that they present an unusual infection control risk.

Based on observation, interview, record review and facility policy review, the facility failed to ensure dependent residents could reach their call lights. This affected one resident (#37) of eleven residents reviewed for environmental concerns. The facility census was 75.Findings include:Record review of Resident #37 revealed he was admitted to the facility 4/10/25 and had diagnoses including hemiplegia, major depressive disorder, and end stage renal disease. His Minimum Data Set (MDS) assessment dated [DATE] revealed he had mild or no cognitive impairment and he was dependent on staff assistance for chair-to-bed transfers and for mobility in his wheelchair.Observation of Resident #37 on 09/29/25 at 2:05 P.M. revealed he was in his room in a wheelchair in a reclined position with a Hoyer (mechanical lift) pad beneath him. The call light was tied to his bed rail and on the floor out of reach, roughly four feet from his wheelchair. Interview with Resident #37 at this time revealed he wanted assistance getting to bed but could not reach the call light.Interview with Certified Nurse Aide (CNA) #600 on 09/29/25 at 2:19 P.M. confirmed Resident #37's call light was out of reach.Record review of the call system policy dated 07/2025 revealed all residents were to have a means to call staff for assistance through a direct communication system.

Based on record review, interview and facility policy review, the facility failed to ensure the physician orders were implemented in a timely manner for Resident #38 and Resident #43. This affected two residents (#38 and #43) out of five residents reviewed for unnecessary medications. The facility census was 75.Findings include:1. A review of Resident #38's clinical record revealed an admission date of 12/20/24 with diagnoses including diabetes mellitus type II, neuropathy, chronic respiratory failure with hypoxia, hearing loss, above the knee amputation of the right knee, major depression disorder, diabetic angiopathy without gangrene, anxiety, asthma, epilepsy, and schizophrenia.A review of Resident #38's Medication Regimen Review form dated 05/19/25 revealed the pharmacist recommended the physician provide an order for a valproic acid level based on review of Resident #38's medication list. The most recent valproic acid level was obtained on 03/25/25. The Medication Regimen Review also indicated to increase the Lantus insulin dose to 30 units subcutaneously twice a day based on Resident #38's blood sugar level had routinely been greater than 250 milligrams (mg)/diluent. The physician agreed with the recommendations on 06/10/25. A review of Resident #38's laboratory results dated [DATE] to 11/27/25 revealed a valproic acid level had not been obtained.A review of Resident #38's physician orders dated 11/01/25 to 11/30/25 revealed to administer Lantus 25 units subcutaneously twice a day.A review of Resident #38's clinical record revealed no valproic level had been obtained, and the dosage of Lantus insulin had not been increased as ordered on 06/10/25.2. A review of Resident #43's clinical record revealed an admission date 07/31/24 and re-admission date 11/30/24 with diagnoses including cerebral infarction (stroke) with hemiparesis and hemiplegia affecting the left side, dysphagia (trouble swallowing), dysarthria (slurred speech), anxiety, insomnia, gastroesophageal reflux disease (GERD), high cholesterol, high blood pressure, chronic pain, mild cognitive impairment and depression.A review of Resident #43's Medication Regimen Review form dated 06/18/25 revealed the pharmacist recommended Colace, Ibuprofen, Cepacol, Flonase, ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3 milliliters (ml), and polyethylene glycol powder as needed medications be discontinued based on they had not been administered to Resident #43. The physician agreed with the recommendation.A review of Resident #43's Medication Administration Record (MAR) and physician orders dated 11/01/25 to 11/30/25 revealed the above listed medications were not discontinued and had not been administered to Resident #43.A review of Resident #43's Medication Regimen Review form dated 07/25/25 and 09/10/25 revealed the pharmacist had recommended to decrease the dosage of gabapentin based on the renal dose adjustment to 900 mg/day in two to three divided dosages instead of the 1600 mg/day dosage currently ordered. The physician agreed with the recommendation and ordered the dosage of gabapentin be decreased to 300 mg three times a day. Resident #43's Medication Regimen Review form dated 09/22/25 indicated the pharmacist had recommended to obtain a lipid panel routinely for Resident #43 based on his diagnosis of high cholesterol. The physician agreed with the recommendation and indicated to obtain a lipid panel twice a year and a liver function test once a year.A review of Resident #38's physician orders and MAR dated 07/25/25 to 09/10/25 revealed the dosage of the gabapentin medication remained to administer 400 mg orally four times a day (total 1600 mg/day) until 09/12/25. On 09/12/25 a physician order was entered to change the dosage of the gabapentin to 900 mg/day. On 09/24/25 an order was written to obtain a lipid panel and liver function test once a year.An interview with Administrator on 11/25/25 at 2:39 P.M. verified the above findings and agreed the staff failed to ensure the pharmacy recommendations and physician orders were implemented in a timely manner.A review of the facility's policy and procedure titled Physician Orders, revised 04/2012, revealed each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen at least once every 60 days. A current list of physician orders must be maintained in the clinical record of each resident. Physician orders must be maintained in chronological order.

Based on observation, record review, facility policy review and interview, the facility failed prevent Resident #58 from developing an in-house pressure ulcer and failed to ensure timely identification, proper treatment and interventions were initiated to promote healing. Additionally, the facility failed to ensure nursing staff completed accurate and comprehensive weekly skin assessments/checks as ordered. Actual Harm occurred on 12/04/24 when the facility failed to implement appropriate and effective interventions for Resident #58, who was at risk for developing pressure ulcers, was always incontinent of bladder, frequently incontinent of bowel, and required staff assistance for activities of daily living, to prevent the development of an in-house acquired unstageable (full-thickness tissue loss in which the base of the ulcer is covered by slough or and/or eschar making the depth/stage undetermined) pressure ulcer to the left buttocks. This affected one resident (#58) of three residents reviewed for pressure injuries/skin impairments. The facility identified five residents (#1, #17, #33, #58, and #63) with pressure ulcers. The facility census was 71. Findings include: Review of Resident #58's medical record revealed an admitted [DATE] with diagnoses including type II diabetes mellitus (DM), schizophrenia, pressure ulcer of left buttock and secondary Parkinsonism. Review of a plan of care initiated on 03/09/18 revealed Resident #58 had a potential for skin breakdown related to fragile skin and impaired mobility. Interventions included Braden Scale per protocol, complete skin assessment per protocol, encourage turning and repositioning, pressure reducing mattress to bed, and pressure releasing devices as indicated. Record review revealed no documented evidence staff encouraged or provided turning and repositioning of the resident. Review of Resident #58's medical record revealed a physician's order dated 05/03/24 for skin checks weekly every day shift every Monday. Review of Resident #58's weekly skin observations/assessments dated 11/11/24 and 11/13/24 revealed the resident had no skin issues. Review of Resident #58's weekly skin observation dated 11/19/24 revealed staff documented the resident had a skin abrasion to the left buttock that measured 3.0 centimeters (cm) by 3.0 cm and documented as N/A for stage. Review of a progress note dated 11/19/24 at 10:45 P.M. revealed Resident #58 had a 3.0 cm by 3.0 cm by 0 cm abrasion on left buttock. Resident #58 had complaints of left buttock pain and as needed (PRN) medications were administered. However, the record review revealed there was no documented evidence pain medication was administered on the medication administration record (MAR) on 11/19/24. The note revealed a treatment was applied. However, there was no documented evidence of what treatment was applied. Notifications were made to the physician, Director of Nursing (DON), and family. Review of the Braden Scale for Predicting Pressure Ulcers dated 11/20/24 revealed a score of 20.0 which indicated Resident #58 was risk for developing pressure ulcers. There was no documented Braden Scale completed before 11/19/24. Review of an interdisciplinary team (IDT) progress note dated 11/20/24 revealed Resident #58 had a reddened area to the left buttock. The left buttock skin was intact but noted to be non-blanchable. Notifications were made to the physician, DON, and family. The note indicated the wound physician was notified and would follow up with the resident on the next scheduled visit. An initial intervention included to pad and protect the left buttock. No additional interventions were noted to be implemented at that time. Review of physician orders and treatment administration records (TAR) revealed from 11/20/24 to 11/22/24 an order was in place to cleanse the resident's coccyx (although the wound was on the left buttock) with normal saline (NS) and apply a clean dry dressing (CDD) every night shift (HS). A new order was obtained on 11/24/24 to cleanse the left buttock/coccyx with NS, pat dry, cover with a CDD every night shift. This order remained in place from 11/24/24 until it was discontinued on 12/03/24. Review of Resident #58's weekly skin observation dated 11/25/24 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 12/02/24 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of a Wound Physician Note dated 12/04/24 (first visit by the wound physician) revealed Resident #58 had an unstageable pressure to the left buttock that measured 2.5 cm in length by 2.4 cm width with a depth that could not be determined (UTD). The wound bed tissue composition at the beginning of visit was 10% granulation, 10% slough, and 80% eschar. Minimal exudate and erythema were noted. A new treatment to use hydrogel gauze, cleanse wound with NS or sterile water, apply to the wound bed and cover with a dry clean dressing was noted in the progress note. Review of Resident #58's medical record revealed physician's orders dated 12/05/24 for Pro-Stat (protein supplement) two times a day (BID) give 30 milliliters (mL) for wound healing and an order for a pressure reducing cushion to the resident's wheelchair. Review of the care plan initiated 12/06/24 revealed Resident #58 had actual skin breakdown related to mobility deficit. Resident #58 had an unstageable deep tissue injury (DTI) (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear to the left buttock (12/03/24). Interventions initiated on 12/06/24 (following the identification of the pressure ulcer) included consulting a wound consultant and follow up as needed (PRN), encourage turning and repositioning every two hours while in bed, low air loss mattress, minimizing exposure to excessive moisture or stool, nutritional interventions as ordered, and wound care as ordered. The care plan was updated on 12/31/24 to reflect the pressure ulcer was a Stage III (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) pressure ulcer. Review of Resident #58's medical record revealed a physician's order dated 12/06/24 for a low air loss mattress. Review of Resident #58's weekly skin observation dated 12/09/24 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 12/16/24 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of the Wound Physician Note dated 12/18/24 revealed Resident #58 had a pressure injury on the left buttock that measured 2.5 cm by 2.4 cm by width UTD. The wound bed tissue composition was 10% granulation, 10% slough, and 80% eschar. Minimal exudate and erythema were noted. The treatment was to include 0.25% Dakin's moistened gauze every day and PRN. The healing status stated declined. Review of Resident #58's weekly skin observation dated 12/20/24 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 12/23/24 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #58 had intact cognition. She had no behaviors of rejection of care and had limitations to range of motion of the upper and lower extremities bilaterally. The assessment revealed the resident required supervision or touching assistance with toileting hygiene, showers, rolling left to right and transfers. She required partial to moderate assistance with lower body dressing and personal hygiene and was dependent on staff for putting on/taking off footwear. The assessment revealed the resident was always incontinent of bladder and frequently incontinent of bowel, was at risk for pressure ulcer development and had a Stage III pressure ulcer. Review of Resident #58's weekly skin observation dated 01/06/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 01/13/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 01/20/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 01/27/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 01/29/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 02/05/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 02/10/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 02/14/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 02/17/25 revealed the resident had a left buttock pressure; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 02/19/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 02/20/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 02/24/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 03/03/25 revealed the resident had a left buttock other, wound; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 03/10/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 03/17/25 revealed no skin issues were documented on the form. Record review revealed during this time period, the resident was being seen by the Wound Physician who did include measurements of the wound when the resident was seen. On 03/19/25 at 2:24 P.M. an interview with Regional Director of Clinical Operations (RDCO) #400 verified weekly skin observations were to be done every week, and the form was to be completed accurately to include the type of skin/pressure ulcer and the measurements of the pressure ulcer/wound. On 03/19/25 at 3:00 P.M. an interview with Wound Nurse (WN)/Assistant Director of Nursing (ADON) #205, who was new to the position, verified weekly skin observations were to be done every week by the nurses working the floor, despite the Wound Physician's weekly assessments, and the form was to be completed accurately to include the type of skin/pressure ulcer and the measurements. WN/ADON #205 verified weekly skin observations were not completed correctly for Resident #58. During the interview, she was also unable to provide a reason why some of the nurse's weekly skin observations showed no wounds when Resident #58 did in fact have a pressure ulcer to the left buttocks. In addition, during the interview WN/ADON #205 also revealed she would not expect an abrasion to turn into an unstageable pressure wound before additional interventions were implemented. No investigation was conducted by the facility to determine how the left buttock abrasion deteriorated from an abrasion to an unstageable pressure ulcer without staff knowledge before it became unstageable. WN/ADON #205 verified Resident #58's pressure ulcer to the left buttock was an in-house acquired unstageable pressure ulcer identified by the wound physician on 12/04/24. Observation on 03/20/25 at 12:47 P.M. of wound care revealed Licensed Practical Nurse (LPN) #211 performed hand hygiene, gathered supplies, donned personal protective equipment (PPE), knocked on door and entered. LPN #211 disinfected the over the bed tray and applied a barrier. Gloves were removed, hand hygiene performed, and new gloves applied. Resident #58 was in bed, and LPN #211 assisted in removing the resident's pants and brief. LPN #211 removed the resident's old dressing which had moderate dry drainage noted. An open area with some darkness was observed to the left buttock. LPN #211 cleansed with wound normal saline, patted the wound dry, applied collagen alginate with silver and covered with a dressing with date and initials. LPN #211 assisted Resident #58 with reapplying her brief and pants and assisted her to her chair. Infection control was maintained throughout the procedure, and Resident #58 tolerated with no complaints. LPN #211 doffed PPE before exiting the room. Review of the facility policy, Pressure Ulcer/Injury Risk Assessment, revised 07/2017, revealed the purpose of this procedure was to provide guidelines for the structures assessment and identification of residents at risk of developing pressure ulcers/injuries. The purpose of the risk assessment was to identify all risk factors and determine which could be modified, which could not, or which could be immediately addressed. Review of the facility policy, Pressure Ulcer/Injury Care and Management, revised 08/2022, revealed residents would receive care consistent with professional standards of practice, to prevent pressure ulcer/injury. Residents would receive necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. This deficiency represents non-compliance investigated under Master Complaint Number OH00163632.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure infection control measures were maintained during medications administration, which included hand washing/hand hygiene. This affected three residents (#4, #20, and #71) out of six residents observed for medication administration and had the potential to affect 16 additional residents (#3, #5, #10, #22, #23, #24, #28, #30, #31, #35, #39, #41, #44, #46, #66, and #67) on Licensed Practical Nurse (LPN) #215's assignment. The facility census was 71. Findings include: 1. Review of the medical record for Resident #4 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, type II diabetes mellitus, and vascular dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had intact cognition. Observation on 03/19/25 at 8:53 A.M. revealed LPN #215 began to prepare the medications for Resident #4 without performing hand hygiene. After placing all the medications in the medicine cup, she entered the resident's room and administered the medication to her. Upon leaving the room, LPN #215 did not perform hand hygiene and proceeded to prepare medications for the next resident (Resident #20). 2. Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, chronic kidney disease (CKD) stage 3b, history of COVID-19, and heart failure. Review of the quarterly MDS assessment dated [DATE] revealed Resident #20 had intact cognition. Observation on 03/19/25 at 8:55 A.M. revealed LPN #215 began to prepare the medications for Resident #20 without performing hand hygiene. One of the medications was Artificial Tears eye drops. After placing all the medications in the medicine cup, she entered the resident's room and administered the medication. She then put on gloves, without performing hand hygiene first, and administered Artificial Tears eye drops, one drop in each eye. After administering the eye drops, she removed her gloves and exited the room without performing hand hygiene and proceeded to the next resident (resident #71). 3. Review of the medical record for Resident #71 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with late onset, adult failure to thrive, dementia, and vitamin b12 deficiency anemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #71 had severely impaired cognition. Observation on 03/19/25 at 9:07 A.M. revealed LPN #215 began to prepare the medications for Resident #71 without performing hand hygiene. After placing all the medications in the medicine cup, she entered the resident's room and administered the medication. After exiting the room, she did not perform hand hygiene. Interview on 03/19/25 at 9:13 A.M. with LPN #215 verified she did not perform hand hygiene during medication administration before or after administering resident medications or before or after removing her gloves from administering eye drops. Interview on 03/19/25 at 12:41 P.M. with Regional Director of Clinical Operations (RDCO) #400 verified hand hygiene was to be performed before and after each medication pass and before and after donning/doffing gloves. Review of the undated facility policy, Infection Prevention and Control Program revealed hand hygiene protocol to include all staff shall wash their hands between resident contacts, and before and after performing resident care procedures. Review of the undated facility policy, Hand Hygiene Policy and Procedure revealed indications for handwashing to include before having direct contact with patients, and after removing gloves. Review of the facility policy, Administering Medications, revised December 2012, revealed staff shall follow established facility infection control procedures to include handwashing for the administration of medications. Review of the facility policy, Instillation of Eye Drops, revised January 2014, revealed to wash hands thoroughly and don gloves. After administering eye drops remove the gloves and wash hands thoroughly. This deficiency is an incidental finding identified during the complaint investigation and is a recite to the complaint survey completed 02/11/25.

Based on record review, interview and facility policy review, the facility failed to ensure care plans were individualized for Resident #33. This affected one resident (#33) out of three residents reviewed for care plans. The facility census was 71. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, neurogenic bowel, history of COVID-19, colostomy, and cannabis dependence. Review of Resident #33's care plan dated 10/23/24 revealed there was no care plan for the recent unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) acquired in house on 12/05/24. Interview on 03/25/25 at 2:33 P.M. with Regional Director of Clinical Operations (RDCO) #400 confirmed there was no care plan for the recent in house acquired unstageable pressure ulcer for Resident #33 and/or updated interventions. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive, person-centered care plan includes identified problem areas and measurable objectives and timeframes. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. This deficiency is an incidental finding identified during the complaint investigation.

Based on record review, interview and facility policy review, the facility failed to ensure weekly skin observations were accurately completed as ordered for Residents #33 and #72. This affected two residents (#33 and #72) out of three residents for wounds. The facility census was 71. Findings include: 1. Review of Resident #33's medical records revealed an admitted [DATE]. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, neurogenic bowel, history of COVID-19, colostomy, and cannabis dependence. Review of Resident #33's physician orders for March 2025 revealed an order to cleanse the right lateral ankle with normal saline (NS) or wound cleanser, pat dry, apply collagen to the wound and cover with boarder gauze every Monday, Wednesday, and Friday night shift and as needed (PRN). Review of Resident #33's Medication Administration Record (MAR) and Treatment Administrative Record (TAR) for October 10/23/24 revealed wound treatment was current for Stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to the right outer ankle and deep tissue injury (DTI) (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.) to the right heel. Review of the Braden Scale for predicting Pressure Ulcers dated 12/05/24 revealed Resident #33 was at low risk for pressure ulcers. Review of the care plan dated 10/23/24 revealed Resident #33 was actual/potential for skin integrity impairment related to immobility and obesity and listed on admission a Stage 3 pressure ulcer on the coccyx, healed on 11/05/24, and present on admission a Stage 3 pressure ulcer to the left ischium healed on 11/05/24. The care plan did not include the pressure ulcer to the right lateral ankle, or the pressure ulcer right heel. There were no interventions/revisions noted for the right lateral ankle or the right heel pressure ulcers. Review of the progress note for Resident #33 dated 12/05/24 at 1:03 P.M. revealed an open area was noted to the right outer ankle. First aid was initiated and the physician, nurse practitioner (NP), Director of Nursing (DON), and the wound nurse were notified. An order for Resident #33 to be referred to the wound physician was obtained. Review of the weekly skin observations for Resident #33 revealed for 11/15/24 he had no skin issues. The next weekly skin observation was not completed until 12/05/24 which had no skin issues noted. The weekly skin observations for 01/07/25 and 01/14/25 revealed the right heel pressure ulcer and the right lateral ankle pressure ulcers with no measurements. The weekly skin observations for 02/04/25, 02/07/25, 02/11/25, 02/14/25 revealed the right lateral ankle pressure with no measurements. There were no weekly skin observations documented for March 2025 for Resident #33. Interview on 03/19/25 at 2:24 P.M. with Regional Director of Clinical Operations (RDCO) #400 confirmed weekly skin observations were to be completed every week, and the form was to be completed accurately to include the type of skin/pressure ulcer and the measurements. RDCO #400 verified Resident #33 did not have weekly skin observations completed for some days, and some were done incorrectly. RDCO #400 verified no weekly skin observations were completed for March 2025. Interview on 03/19/24 at 3:00 P.M. with Wound Nurse (WN)/Assistant Director of Nursing (ADON) #205, who was new to the position, confirmed weekly skin observations were to be done every week, and the form was to be completed accurately to include the type of skin/pressure ulcer and the measurements. WN/ADON #205 verified Resident #33's weekly skin observations were not done correctly and/or were not done at all. WN/ADON #205 verified Resident #33 did not have any weekly skin observations for March 2025. 2. Review of Resident #72's closed medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included acute duodenal ulcer with hemorrhage, acute posthemorrhagic anemia, acute respiratory failure with hypoxia, morbid severe obesity, irritant contact dermatitis, and atrial fibrillation. Review of Resident #72's Braden Scale for predicting Pressure Ulcers risk dated 02/06/25 revealed she was at moderate risk for skin breakdown. Review of Resident #72's admission evaluation for skin dated 02/06/25 revealed she had no skin issues except bilateral lower extremity discoloration. Review of the admission progress note dated 02/06/25 at 6:45 P.M. authored by Licensed Practical Nurse (LPN) #221 revealed Resident #72 had no skin issues except bilateral discoloration to lower extremities. Review of the care plan dated 02/07/25 revealed Resident #72 was at risk for actual and potential skin integrity impairment related to immobility and incontinence. Interventions included applying barrier cream after incontinence, assessing pain before, during, and after treatments, encourage the resident to get out of bed to the wheelchair daily, encourage the resident to turn and change position every two hours, keep skin clean and dry, wound consultant and follow up PRN. Review of Resident #72's Minimum Data Set (MDS) modification of admission assessment dated [DATE] revealed the resident had intact cognition. Resident #72 was independent for bathing, required substantial assistance for oral hygiene, and was dependent on staff for toileting hygiene, showers, dressing, and personal hygiene. Resident #72 was occasionally incontinent for urine and always incontinent for bowels. Review of Resident #72's physician orders dated February 2025 revealed an order dated 02/06/25 for Nystatin external powder 100000 Unit/Gram (unit/gm) (treats fungal or yeast infections of the skin) topical apply to skin folds topically two times a day (BID) for excoriation. On 02/10/25 a new order was obtained for Nystatin external powder 100000 unit/gm topical apply to skin folds topically two times a day (BID) for excoriation for 14 days. Review of the MAR and TAR for February 2025 revealed Nystatin external powder was administered on 02/06/25 and discontinued on 02/10/25. Started back up on 02/10/25 until 02/24/25. Review of Resident #72's weekly skin observation assessment revealed only one skin assessment was completed on 02/14/25, which revealed no skin issues. Interview on 03/19/25 at 2:24 P.M. with RDCO #400 verified weekly skin observations were to be done every week on every resident, and the form was to be completed accurately to include the type of skin/pressure ulcer and the measurements. RDCO #400 verified Resident #72 only had one weekly skin assessment completed on 02/14/25. Interview on 03/20/25 at 3:00 P.M. with Wound Nurse/ADON #205 revealed the only weekly skin assessment completed for Resident #72 was on 02/14/25, and it did not identify any skin issues. WN/ADON #205 verified the weekly skin assessments were not completed as required and should be done on all residents every week. Wound Nurse/ADON #205 verified Resident #72 did not have a weekly skin assessments performed on 02/21/25, 02/28/25, and 03/07/25 before discharge. Review of the facility policy, Pressure Ulcer/Injury Care and Management, revised 08/2022, revealed weekly skin audits will be performed on all residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00163632.

Based on record review, observation and interview, the facility failed to ensure staff followed enhanced barrier precautions during catheter care. This affected one (Resident #15) of three residents reviewed for catheters. The facility census was 72. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body) and neuromuscular dysfunction of the bladder (condition where nervous system injury or disease affects the bladder). Review of the physician's orders for Resident #15 revealed an order dated 12/03/24 for catheter care every shift. He also had an order dated 01/13/25 for enhanced barrier precautions. Observation of catheter care to Resident #15 on 02/11/25 at 9:18 A.M. with Licensed Practical Nurse (LPN) #206 revealed he was on enhanced barrier precautions. There was a sign for enhanced barrier precautions on his door stating that all staff must wear gloves and gown when providing hygiene and care of urinary catheter. There was noted to be an isolation cart outside of his room by the door with gowns, gloves and masks. LPN #206 had a surgical mask on and went into his room. After setting up her supplies to provide suprapubic catheter care, she put gloves on and provided care. After the care was completed, LPN #206 verified she did not don a gown as instructed by the enhanced barrier precautions sign on the door. Review of the facility policy titled, Enhanced Barrier Precautions, updated March 28 (unknown year), revealed residents for which enhanced barrier precautions are indicated, enhanced barrier precautions are employed when performing care including providing hygiene, changing briefs, assisting with toileting and urinary catheter care. Personal protective equipment included gloves and gown. This deficiency represents non-compliance investigated under Complaint Number OH00161853.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure appropriate urinary catheter care had been performed. This affected one Resident (#11) of three observed for catheter care. The facility identified five residents with indwelling urinary catheters. The facility census was 71. Findings include: Review of Resident #11's medical records revealed an admitted [DATE]. Diagnoses included paraplegia and bladder dysfunction. Resident #11's record indicated he had a chronic, indwelling suprapubic (surgically created opening in the abdomen in which a urinary catheter is inserted into to allow for continuous bladder drainage) catheter present upon admission. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. Resident #11 was dependent on staff for toileting, and required maximum assistance with bathing and personal hygiene tasks. Resident #11 had a urinary catheter for elimination. Review of Resident #11's physician orders for December 2024 and January 2025 revealed to flush urinary catheter with 60 milliliters (mL) of normal saline for possible blockage every 24 hours as needed, anchor catheter tubing, and check catheter placement every shift. Review of Treatment Administration Record (TAR) for December 2024 and January 2025 revealed no documented urinary catheter flushes. TAR for December 2024 and January 2025 included daily documentation of foley (urinary catheter) anchor being in place. Observation on 01/13/25 at 9:10 A.M. revealed Resident #11's call light was activated and Certified Nursing Assistant (CNA) #310 answered the call light and stated Resident #11 needed cleaned up. Interview with Resident #11 at time of observation revealed his urinary catheter had been leaking and his bed was wet with urine. Resident #11 stated he had asked the evening shift nurse the night before to flush his catheter as it often became clogged and leaked. Resident #11 stated the nurse had not flushed it, nor had the nurse performed any care of his catheter site. Resident #11 stated the only thing the nurse had done for his catheter was to empty the urinary drainage bag. Observation with CNA #310 and #317 revealed Resident #11's catheter insertion was not covered. A soiled dressing was hanging from the catheter tubing. Thick, white mucus-like drainage was observed around the resident's uncovered urinary insertion site which had a slight foul odor. Resident #11's catheter tubing was observed to have large amounts of thick sediment throughout the tubing and into the collection bag. Resident #11 stated he routinely asked for his catheter to be flushed due to the sediment contained in the urinary catheter tubing. Interview on 01/13/25 at 9:42 A.M. with Licensed Practical Nurse (LPN) #237 revealed Resident #11 had a physician order to flush the catheter with 60 milliliters mL of normal saline as needed for blockages. LPN #237 stated she had not flushed Resident #11's catheter during her shift. LPN #237 stated she would change Resident #11's catheter and needed to obtain supplies. Observation on 01/13/25 at 10:11 A.M. revealed LPN #237 returned to Resident #11's room and stated she had informed the Nurse Practitioner (NP) of Resident #11's catheter and urine appearance and the NP had ordered for urinary labs to be collected. Observation of catheter care and changing with LPN #237 at time of interview confirmed the thick mucus around the insertion site as well and the large amounts of sediment in the tubing and collection bag. Further observation revealed a piece of tape around the tubing that was not anchored or secured to Resident #11's leg. LPN #237 confirmed there should have been an anchor placed on Resident #11's leg to prevent the tubing from moving or pulling. LPN #237 had changed Resident #11's urinary catheter and placed an anchor on his leg to secure the tubing. Review of the facility policy titled Urinary Catheter Care revised 09/14 revealed catheter irrigation may be ordered to prevent obstructions in residents at risk for obstructions. Ensure the catheter remains secured to reduce friction and movement at the insertion site. This deficiency represents non-compliance investigated under Complaint Number OH00161010.

Based on record review, interview, review of facility policy, and review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS), the facility failed to timely report an allegation of staff to resident verbal abuse to the State Agency as required. This affected one resident (Resident #72) of three residents reviewed for abuse. The facility census was 71. Findings include: Review of Resident #72's medical records revealed an admitted [DATE]. Diagnoses included Alzheimer's and failure to thrive. Review of MDS dated [DATE] revealed Resident #72 had impaired cognition. Resident #72 required maximum assistance with toileting, bathing, and personal hygiene tasks. Review of the ODH CALS website revealed an incident of alleged emotional/verbal abuse involving CNA #318's interactions with Resident #72 was reported to the State Agency on 01/13/25 at 12:08 P.M. Interview on 01/13/25 at 1:02 P.M. with Receptionist #278 revealed on 01/11/25 she had observed CNA #318 yelling at Resident #72. Receptionist #278 stated Resident #72 was near the nurse's station and was attempting to get CNA #318's attention by waving her hands. Receptionist #278 stated she had then heard CNA #318 yell leave me alone (residents name). Receptionist #278 stated she was unsure what to do and stated the following day on 01/12/25 she had written a statement about what occurred and had given it to Admissions Director (AD) #203. Receptionist #278 stated she had been asked about the situation on 01/13/25 by the Administrator and Director of Nursing (DON). Receptionist #278 stated that was not the first negative incident she had observed and reported between Resident #72 and CNA #318. Receptionist #278 stated she had not received any recent abuse training and was unsure what to do or who to report to when she first witnessed the incident between CNA #318 and Resident #72. Interview on 01/14/25 at 2:17 P.M. with Administrator and DON revealed they had been made aware of the incident that had occurred on 01/11/25 on the morning of 01/13/25. Administrator stated Receptionist #268 had provided a written statement to AD #203 on 01/12/25 and the statement given to him on 01/13/25. Administrator stated they had began a self-reported incident (SRI) on 01/13/25, however the allegation of staff to resident verbal abuse should have been reported on 01/11/25. Review of facility policy titled Abuse revised 04/20/23 revealed once a supervisor received the information they must notify the Administrator/Director of Nursing immediately and gather requested information. An investigation must be directed by the Administrator or designee immediately, and not later than, twenty four hours after the knowledge. This deficiency represents an incidental finding of non-compliance identified while investigating Master Complaint Number OH00161010 and Complaint Number OH00160958.

Based on observation, interview, and medical record review, the facility failed to ensure residents were treated in a respectful and dignified manner. This affected three residents (#31, #68, and #70) of six observed for dignified treatment. The facility census was 71. Findings include: 1. Review of Resident #31's medical records revealed an admitted [DATE]. Diagnoses included developmental disorder, bladder dysfunction and Parkinson. Review of MDS assessment dated [DATE] revealed Resident #31 had impaired cognition. Resident #31 required maximum assistance with toileting, bathing and personal hygiene. Resident #31 had a urinary catheter for elimination. Review of Resident #31's physician orders for January 2025 revealed to keep foley bag covered with privacy bag. Observations on 01/13/25 from 11:16 A.M. to 11:20 A.M. revealed Resident #31's urinary drainage bag was visible from the doorway and did not have privacy cover in place. Resident #31 was not interviewable. Interview with Certified Nurse Aide (CNA) #317 on 01/13/25 at 11:25 A.M. confirmed Resident #31's catheter bag was visible from the doorway and CNA #317 stated she was unsure if the facility had privacy bags as she had not seen privacy bags in use. 2. Review of Resident #68's medical records revealed an admitted [DATE]. Diagnoses included dementia. Review of MDS assessment dated [DATE] revealed Resident #68 had impaired cognition. Resident #68 required set up assistance with toileting, bathing and personal hygiene. Resident #68 had a urinary catheter for elimination. Review Resident #68's of physician orders for January 2025 revealed to keep foley bag covered with privacy bag. Observations on 01/13/25 from 11:16 A.M. to 11:20 A.M. revealed Resident #68's urinary drainage bag was visible from the doorway and did not have privacy cover in place. Resident #68 was not interviewable. Interview with CNA #317 on 01/13/25 at 11:25 A.M. confirmed Resident #68's catheter bag was visible from the doorway and CNA #317 stated she was unsure if the facility had privacy bags as she had not seen privacy bags in use. 3. Review of Resident #70's medical records revealed an admitted [DATE]. Diagnoses included stroke with left-sided weakness, aphasia (difficulty speaking), and dementia. Review of MDS dated [DATE] revealed Resident #70 had no cognition score as the resident was rarely understood. Resident #70 was dependent on staff for toileting, bathing, and personal hygiene tasks. Observation on 01/13/25 at 11:44 A.M. revealed CNA #313 was standing in the hallway outside of Resident #70's room, while Resident #70 was in a wheelchair. CNA #313 was observed to have been repeating the word NO! as Resident #70 attempted to push his wheelchair around CNA #313. Resident #70 had continued to attempt to push his wheelchair around CNA #313 and enter his room when CNA #313 stated go ahead and try to get in, I dare you in an intimidating and rude manner. Interview on 01/13/25 at 11:45 A.M. with CNA #313 revealed Resident #70's roommate had recently passed away and she was supposed to stand with the resident so he was unable to enter the room. CNA #313 was asked if anyone had explained the situation to Resident #70, and CNA #313 responded rudely, I don't know, they just told me to stand here with him. CNA #313 appeared frustrated with Resident #70, who continued to attempt to enter his room, until CNA #313 walked away at 11:50 A.M., leaving Resident #70 unattended in the hallway. Interview on 01/13/25 at 12:30 P.M. with Assistant Director of Nursing (ADON) revealed the ADON was informed of the prior interaction with CNA #313 and Resident #70. The ADON stated she would immediately inform the Director of Nursing (DON) and the Administrator of CNA #313's behavior towards Resident #70. Interview on 01/13/25 at 12:31 P.M. with the DON and Administrator confirmed they would begin an investigation into CNA #313's previous interactions with Resident #70. This deficiency represents non-compliance investigated under Complaint Number OH00161010 and OH00160958.

Based on record review, staff and family interview, and review of the facility policy, the facility failed to ensure residents and their responsible parties were included in the development and implementation of the plan of care. This affected one resident (Resident #11) of three residents reviewed for care planning. The facility census was 71. Finding include: Review of Resident #11's medical records revealed an admitted [DATE]. Diagnoses included paraplegia and bladder dysfunction. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. Telephone interview on 01/13/25 at 10:33 A.M. with Resident #11's Power of Attorney (POA) revealed she had attempted multiple times to arrange a care planning conference to discuss Resident #11's needs, however no care planning conference had ever been scheduled. Interview on 01/13/25 at 3:03 P.M. with Social Services Designee (SSD) #332 revealed care planning conferences were to be done upon admission and then on a quarterly basis. SSD #332 stated the care planning conferences were then documented in the resident's electronic medical records. Review of Resident #11's medical records revealed no documented care planning conference. Follow up interview on 01/14/25 at 1:49 P.M. with SSD #332 revealed she had spoken with Resident #11's POA, however she could not recall a time frame or what the discussion entailed. SSD #332 confirmed Resident #11's medical records had not included a documented care planning conference and SSD #332 was unable to provide documentation of a care planning conference being held. Review of the policy Comprehensive Person-Centered Care Plans revised 03/16/23 revealed a comprehensive, person-centered care plan is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to participate in the planning process, request meetings, and to participate in establishing the expected goals out outcomes. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. If the participation of the resident and his/her resident representative in developing the resident's plan of care is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. This deficiency represents non-compliance investigated under Complaint Number OH00161010.

Based on record review, interview, and review of facility policy, the facility failed to timely address resident and family concerns. This affected two residents (#11 and #67) of four residents reviewed for concerns. The facility census was 71. Findings include: Review of the facility's grievance log revealed no logged grievances for December 2024 or January 2025 to date. 1. Review of Resident #11's medical records revealed an admitted [DATE]. Diagnoses included paraplegia and bladder dysfunction. Resident #11's record indicated he had a chronic, indwelling suprapubic (surgically created opening in the abdomen in which a urinary catheter is inserted into to allow for continuous bladder drainage) catheter present upon admission. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. Resident #11 was dependent with toileting, and required maximum assistance with bathing and personal hygiene. Resident #11 had a urinary catheter for elimination. Review of Resident #11's physician orders for December 2024 and January 2025 revealed to flush urinary catheter with 60 milliliters (mL) of normal saline for possible blockage every twenty-four hours as needed. Review of Treatment Administration Record (TAR) for December 2024 and January 2025 revealed no documented urinary catheter flushes. Interview on 01/13/25 at 9:10 A.M. with Resident #11 revealed he had expressed concerns related to urinary catheter to the nursing staff. Resident #11 was asked if he had reported his concerns to the Director of Nursing (DON) and Resident #11 replied who's that? Telephone interview on 01/13/25 at 10:33 A.M. with Resident #11's Power of Attorney (POA) revealed she had attempted to contact the DON of multiple occasions to discuss his care. POA stated on 11/23/24 Resident #11 had called her to inform her that his catheter had been leaking and stated the nurse had not done anything about it. POA stated she had informed the nurse (name unknown) to have the DON call her the next day to discuss the concerns, however the DON nor any other facility staff had returned her call to discuss her concerns. Interview on 01/14/25 at 2:17 P.M. with Administrator and DON revealed they had spoken with Resident #11 and his family regarding their concerns related to his catheter. DON stated the SR had requested his catheter to be flushed more times that what had been ordered, and stated she had explained the physician's orders to Resident #11. Administrator stated he had spoken with the Resident #11's POA about Resident #11's catheter leaking and he and the DON would investigate the resident and family's concern. 2. Review of Resident #67's medical records revealed an admitted [DATE]. Diagnoses included right below the knee amputation and vision loss. Review of MDS dated [DATE] revealed Resident #67 had intact cognition. Resident #67 required maximum assistance with toileting, bathing and personal hygiene. Interview on 01/13/25 at 2:22 P.M. with Licensed Practical Nurse (LPN) #239 revealed she had been made aware Resident #67 had concerns related to being left in the bathroom for a long period of time on 01/12/25. LPN #239 stated she had sent a text message to the DON to inform of the situation and stated the DON told her she would address it on 01/13/25. LPN #239 stated she was not aware if the situation had been addressed. Interview on 01/14/25 at 8:28 A.M. with Resident #67 revealed on 01/12/25 she had been left in the bathroom for a long period of time. Resident #67 stated she had informed the nurse, who told her she would make a report about the incident, however Resident #67 was not aware if the situation had been handled and stated no one had spoken to her about it. Interview on 01/14/25 at 2:17 P.M. with the DON revealed the DON denied being aware of a concern with Resident #67 and stated she would investigate the situation with Resident #67's care. Review of the policy Resident and Family Concerns and Grievances Policy and Procedure dated 2024 revealed the purpose of the policy is to provide for the prompt resolution of medical and non-medical grievances. Residents or their family members, guardian, or representative may voice a grievance to the Facility staff in person, by telephone, or via written communication. The facility will keep a log of all grievances expressed either orally and/or in writing. The facility will follow up with resident or their family members, guardian, or representative within 72 hours of the filing of the grievance. The facility will provide the resident with a written Grievance Decision which shall include the date the grievance was received, a summary statement of the resident's grievance, steps taken to investigate the grievance, a summary of the pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken, and the date the written decision was issued. This deficiency represents non-compliance investigated under Complaint Number OH00161010.

Based on record review, Self-Reported Incident (SRI) review, police report review, policy review, and interview, the facility failed to prevent the exploitation of Resident #33 by an employee. This affected one (Resident #33) of three residents reviewed for abuse. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the non-dominant left side, dysphagia (difficulty swallowing), personality disorder, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/05/24, revealed Resident #33 had intact cognition and was independent for bed mobility, transfers, and eating. Review of the plan of care dated 11/22/24 revealed Resident #33 had problematic behavior characterized by inappropriate sexual behavior including making inappropriate remarks and attempting to touch other residents and staff. Review of SRI #254363 with a creation date of 11/22/24 revealed on 11/21/24 at around 12:00 P.M. there was an incident between Resident #33 and Kitchen Aide (KA) #206. KA #206 alleged that Resident #33 rode his wheelchair into the staff and started to grope her. Upon further investigation Resident #33 had KA #206's number on his phone and naked pictures of her. Upon interviewing Resident at 11:45 A.M. on 11/22/24, he said that he had given KA #206 $175 and KA #206 had made it clear that if he would give her $300 she would have sex with him. Resident #33 made it clear that there was no physical contact of any kind, and the money was sent to her by his brother and a friend. The allegation of sexual abuse, misappropriation was substantiated. Review of the facility's investigation initiated on 11/21/24 revealed KA #206 and Resident #33 exchanged personal text messages. The messages dated 10/19/24 through 10/26/24 revealed KA #206 and Resident #33 sending flirtatious texts to each other. KA #206 asked for money via cash app a couple of times. According to the text, Resident #33 sent KA #206 40.00 dollars. KA #206 replied I thought you were sending 100.00 dollars? KA #206 sent Resident #33 a naked picture of her genital area and stated that more pictures would come later. Further review of the investigation revealed Resident #33 involved his brother asking him to transfer money to KA #206. Review of the police report dated 11/22/24 revealed the caller requested to speak with an officer about a possible elder abuse from an employee. The employee was identified as KA #206 and the victim was identified as Resident #33. It was noted the employee was not on the scene. The report indicated Resident #33 had a stroke and was very difficult to understand. Resident #33 stated that KA #206 told him that for $300 KA #206 would give him sex. Resident #33 stated that he intended on having sex with KA #206 for money. Resident #33 gave KA #206 $100. Resident #33 stated that KA #206 sent him nude pictures of herself to his phone. Resident #33 said, KA #206 told him that she needed a real man and gave his money back. Resident #33 refused to make a written statement at that time. The offense listed on the police report indicated soliciting another for sexual activity for hire. Review of the Police Department Voluntary Statement dated 11/24/24 and written by the Director of Nursing (DON) revealed KA #206 came to her office and said that Resident #33 assaulted her with the wheelchair and was feeling on her. She was asked to calm down and write a statement. After KA #206 left the office Resident #33 was riding by the office and the DON called him into the office. Resident #33 stated he had KA #206's number in his phone. When asked how and why he had her phone number in his phone he told her they were in a relationship. When asked what he meant he said they were in a romantic relationship. He opened his phone and showed the DON where KA #206 sent nude photos of her body and asking and accepting money. The statement also indicated that on 11/22/24 Resident #33 told the Administrator that KA #206 told him that if he paid her $300 he could have sex with her. Interview on 12/04/24 at 10:37 A.M. with Resident #33 revealed he and KA #206 exchanged phone numbers and started talking because KA #206 wanted to find a real man. Resident #33 stated KA #206 asked him for money to have sex with him. KA #206 sent him a naked picture and wanted him to take care of her. They never had sex but were planning on having sex after he moved to an assisted living facility. Resident #33 stated the police took the pictures and texts from his phone. Interview on 12/04/24 at 1:10 P.M. with the DON revealed they had no idea KA #206 and Resident #33 were exchanging test messages until KA#206 reported Resident #33 ran into her with his wheelchair. When the DON talked to Resident #33 about the incident, Resident #33 indicated he and KA #206 were in a relationship. When asked why he felt they were in a relationship, Resident #33 indicated he had KA #206's phone number and KA #206 sent him naked pictures of herself. The DON indicated upon receipt of this information an SRI was submitted to the State agency, an investigation initiated and the police were contacted. The DON stated they wanted to terminate KA #206 immediately; however, the police wanted them to wait until they spoke with KA #206 at the facility on 11/25/24 when a meeting was scheduled to discuss disciplinary action. KA#206 did not show up for the 11/25/24 meeting. Interview on 12/04/24 at 1:26 P.M. with KA #206 revealed she was fired for the incident; it was in her past and she would not discuss the matter any further. Review of facility policy titled Abuse, dated 2023, revealed the facility would not take advantage of a resident for personal gain using manipulation, intimidation, threats, or coercion. This deficiency represents non-compliance investigated under Control Number OH00160143.

Based on record review and interview, the facility failed to ensure Resident #50's pressure ulcer wound care was completed as ordered. This finding affected one (Resident #50) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #50's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, generalized anxiety disorder and unspecified osteoarthritis. Review of Resident #50's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #50's Admission Nursing Evaluation form dated 08/05//24 revealed the resident had bruising to the right antecubital, right buttock and left buttock. Review of Resident #50's Wound Observation form dated 08/06/24 revealed the resident had bilateral buttocks dermatitis first acquired 08/05/24. The resident was discharged from wound care. Review of Resident #50's Braden Scale for Predicting Pressure Sore Risk form dated 08/12/24 revealed the resident was high risk for developing pressure ulcer wounds. Review of Resident #50's progress note dated 08/31/24 at 4:00 P.M. authored by Licensed Practical Nurse (LPN) #839 revealed while performing activities of daily living (ADL) care on the resident, the State tested Nursing Assistant (STNA) and daughter had observed three open areas on the buttocks. The area was cleansed with normal saline at this time. The nurse attempted to apply a border foam dressing and the resident's daughter denied. Hospice and the Director of Nursing (DON) were made aware. Review of Resident #50's progress note dated 08/31/24 at 6:30 P.M. authored by LPN #839 revealed the hospice nurse arrived with new orders to clean the area with normal saline, pat dry, apply a foam border dressing daily and as needed. Review of Resident #50's hospice Visit Summary form dated 08/31/24 authored by Hospice Registered Nurse (RN) #925 indicated three new open areas to the buttocks were identified and the wound nurse was to assess. New orders were provided to clean the area and apply a foam border dressing until the wound nurses assesses the resident. Review of Resident #50's medication administration records (MARS) and treatment administration records (TARS) from 08/31/24 to 09/16/24 did not reveal evidence wound care to the bilateral buttocks were ordered or completed on 09/01/24 and 09/02/24. Review of Resident #50's Wound Observation Evaluation form dated 09/03/24 revealed the resident had bilateral buttocks Kennedy ulcer (a dark, irregularly shaped sore that develops rapidly in the final stages of life) first identified 08/31/24 with full thickness with fat layer exposed and the documentation indicated 30% epithelial tissue, 50% granulation tissue and 20% slough. The treatment included to cleanse with normal saline or sterile water, cleanse with Dakins antibacterial cleanser solution, cover wound bed with oil emulsion dressing and then cover with a clean dry dressing. The wound measurements were 6.1 centimeters (cm) length by 15.3 cm width by 0.2 cm depth. Interviews on 09/17/24 at 8:08 A.M. with the DON and Assistant Director of Nursing (ADON) #805 confirmed Resident #50's medical record did not have evidence of bilateral buttocks pressure ulcer wound care was ordered accurately in the resident's electronic health record (EHR) or completed as ordered by hospice services on 09/01/24 and 09/02/24. The DON and ADON #805 confirmed the resident's bilateral pressure wounds were documented by hospice services as [NAME] Ulcers. Review of the undated Wound Care Management policy revealed the policy was to ensure that all residents were assessed on admission, quarterly and with a change in condition for the potential of skin breakdown and to ensure interventions were in place to maintain skin integrity. This deficiency represents non-compliance investigated under Complaint Numbers OH00157839 and OH00157857.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's policy and procedure, review of the facility's Coronavirus (Covid-19) timeline, review of daily resident census reports, observations, record review, and staff interview, the facility failed to perform adequate staff screening to properly identify, quarantine, and appropriately test residents with exposure to staff members who had tested positive for Covid-19. The facility failed to implement appropriate quarantine procedures and ensure staff used appropriate personal protective equipment (PPE) to prevent the spread of Covid-19 within the facility. This resulted in Immediate Jeopardy on [DATE] when the facility failed to identify a staff member with Covid-19 symptoms of loss of taste and smell indicated on the facility screening tool and permitted her to work with direct patient care until [DATE]. Her Covid-19 test was positive on [DATE]. The facility failed to ensure staff members discarded N95 and KN95 respirators after caring for Covid-19 positive residents, before leaving the Covid-19 unit, and donning a new N95 or KN95 respirator to care for non Covid-19 positive residents. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facilities failure to control the spread of Covid-19. The facility census was 57. The administrator was notified on [DATE] at 1:10 P.M. that an Immediate Jeopardy began on [DATE] when a staff member (Activity Director(AD) #63) notified the facility she was experiencing loss of taste and smell and was permitted to continue to work with direct resident contact until [DATE]. In addition, observations on [DATE] revealed staff members were not changing all personal protective equipment (PPE), particularly N95 and KN95 respirators when exiting resident rooms that had tested COVID-19 positive. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following correction actions: · All residents residing in the facility are impacted and currently are at their baseline and are without symptoms. · Residents likely to be impacted: all residents. Regional Director of Clinical Services, Registered Nurse (RN) #58, reviewed all resident records for current symptom screening, completed [DATE]. There were no negative findings. · On [DATE] at 4:30 PM: Staff and visitor screening tools from [DATE] to present were audited by the Director of Nursing (DON), Infection Preventionist (RN #57) and the Licensed Nursing Home Administrator (LNHA) to identify any positive screens not previously identified, completed on [DATE]. No other concerns were identified. · On [DATE] at 5:00 PM: a 30-day supply of PPE on hand, verified by Infection Preventionist, RN #57. · The DON and Infection Preventionist (RN #57) educated nursing staff regarding indicators for Covid-19 testing as well as practice of requesting from the physician Covid-19 testing with identification of symptoms, completed on [DATE]. · The DON and Infection Preventionist (RN #57) educated all staff regarding indications for PPE, isolation measures and donning/doffing of PPE. The education started on [DATE] and was completed on [DATE]. · The DON and Infection Preventionist (RN #57) educated all staff regarding performance of and indications for hand hygiene. The education started on [DATE] and was completed on [DATE]. · The DON and Infection Preventionist (RN #57) educated all staff regarding identification of Covid-19 symptoms. All staff were educated regarding restrictions to facility access related to Covid-19 symptoms. All staff were educated regarding Covid-19 symptom reporting requirements, completed on [DATE]. · All staff designated to perform staff and essential visitor screens were educated on performance, denial of access to facility with positive screen and competency performed. The education and competency were completed by Regional Director of Clinical Services (RN #58), the DON and Infection Preventionist (RN #57); started on [DATE] and completed on [DATE]. · Director of Policy Management (RN #73) updated staff on [DATE] on the Essential Visitor Screening Tool updated [DATE]. · The DON and Infection Preventionist (RN #57) initiated all staff competencies for donning/doffing PPE and Hand Hygiene which were completed [DATE]. · To monitor and maintain ongoing compliance the DON or Infection Preventionist (RN #57) will complete observations of five staff weekly times four weeks, then monthly times two months for donning/doffing PPE and hand hygiene to ensure staff have implemented effective and recommended infection control practices to decrease the spread of Covid-19 within the facility. · The DON or Infection Preventionist (RN #57) will review respiratory screeners (documentation of resident symptom screening) during clinical morning meeting five days a week times four weeks, then monthly times two months to ensure staff effectively respond to a resident with potential signs and symptoms of Covid-19. · The Licensed Nursing Home Administrator will compare the staff/essential visitor screening tool against the schedule five days a week times four weeks, then monthly times two months to verify that staff members or essential visitors expressing symptoms of Covid-19 are not permitted to work with direct resident care or gain access to the facility. · An as needed Quality Assurance and Performance Improvement (QAPI) meeting was completed on [DATE] with the Interdisciplinary Team (IDT), the Medical Director and the Regional Director of Clinical Services #58. · The results of the audits will be forwarded to the facility QAPI for further review and recommendations. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The Quality, Safety and Oversite Group (QSO) Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and Centers for Disease Control (CDC) so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of Covid-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). Observation and interview on [DATE] at 6:15 A.M. with State tested Nursing Assistant (STNA) #51 revealed she wore a white mask (KN95) and full PPE when she cared for residents with Covid-19. STNA #51 stated the white masks were good for a couple days and at the end of her shift she sprayed the mask with 91 percent (%) alcohol she kept with her and put the mask in a paper bag and left it in her car until she worked again. Observation on [DATE] at 6:55 A.M. revealed STNA #53 walking in the 100-West hallway (the Covid-19 unit) with a blue surgical mask on her face. Interview on [DATE] at 6:55 A.M. with STNA #53 revealed the blue surgical mask was worn while she was in the hallway of the Covid-19 unit, and the white KN95 was kept in her pocket until she entered resident rooms to give care. She stated she put the white mask on, took care of the resident then she would go to the bathroom, remove her PPE, take the white mask off and put it in her pocket until she needed to help another resident. Interview on [DATE] at 7:15 A.M. with RN #54 revealed she tested positive for Covid-19 on [DATE] and was off work until [DATE]. RN #54 stated she usually worked on the 100-West (the Covid-19 unit) and 300-West units and wore one KN95 mask every day when she came to work. She indicated she did not change it during her shift and discarded it when she left. Interview on [DATE] at 7:50 A.M. with Social Worker (SW) #57 revealed she was also an RN and the facility Infection Preventionist. SW #57 stated her office was in the 100-West hallway which was also the facility Covid-19 unit. SW #57 stated the National Guard tested facility staff on [DATE], and eight staff members tested positive for Covid-19. All staff denied symptoms on [DATE]. SW #57 further stated she tested positive for Covid-19 and was off work until [DATE]. Staff members were permitted a new KN95 or N95 mask every day. SW #57 further stated Health Department Official (HDO) #59 did not give the facility guidance on the use of PPE. Observation on [DATE] at 8:51 A.M. revealed STNA #72 wearing a KN95 mask entering resident room [ROOM NUMBER] on the Covid-19 unit. The STNA donned appropriate PPE and doffed it prior to leaving resident room. There was no observation of the STNA changing the KN95 mask after leaving the Covid-19 unit. Interview on [DATE] at 9:00 A.M. with STNA #72 revealed she wore one KN95 mask per day and did not change it until she left the facility when her shift was over. Observation and interview on [DATE] at 9:10 A.M. with STNA #60 revealed the facility stockroom was full of boxes of hand sanitizer, isolation gowns, N95 masks and KN95 masks, surgical masks and gloves. STNA #60 stated we do not have a shortage of PPE. Observation on [DATE] at 9:51 A.M. revealed LPN #56 entering resident room [ROOM NUMBER] on the Covid-19 unit wearing a KN95 mask and proper PPE. There was no observation the KN95 mask was removed prior to leaving the Covid-19 unit. Interview on [DATE] at 9:55 A.M. with LPN #56 revealed the KN95 mask was not removed after she left the Covid-19 unit. LPN #56 stated it was only changed if it became wet or dirty. Interview on [DATE] at 4:55 P.M. with LPN #56 revealed when she arrived for work each day she would fill out a screening tool and collect a surgical mask and a KN95 mask from the desk and proceed to her assigned area which was usually 100-West (the Covid-19 unit) and 300-West. She stated she passed medications and gave care to the residents in the 300-West unit first then proceeded to 100-West (COVID) unit. LPN #56 stated she donned gown, gloves, face shield, and had her KN95 mask and surgical mask on. LPN #56 stated when she finished giving care to the residents in the Covid-19 unit she doffed the gown and gloves and placed them in the red biohazard bin in the resident room, and wiped the face shield off with disinfecting wipes between residents. LPN #56 stated she changed her mask during the day if it was wet or dirty, otherwise she wears the same mask all day and discards it in the biohazard bin when she leaves for the day. Phone interview on [DATE] at 8:38 A.M. with Admissions Representative (AR) #64 revealed she worked about a week with symptoms including runny nose and sneezing. before the National Guard tested the facility staff on [DATE]. AR #64 did not notify administration because she did not think she had Covid-19 and did not mark any symptoms on the screening tool when she arrived for work each day. AR #64 received positive Covid-19 results on [DATE] and was off work from [DATE] until [DATE] when she was cleared to return by Regional Nurse #58. Phone interview on [DATE] at 8:47 A.M. and 4:52 P.M. with AD #63 revealed she lost her sense of taste and smell on [DATE] and continued to work until she received her positive Covid-19 test results from the facility on [DATE]. AD #63 further stated she did a lot of one on one activities with the residents. She indicated she would go in the resident rooms in the morning to pass out activities and give the residents a little one on one attention. Regional Nurse #58 cleared her to return to work on [DATE]. Review of the facility Employee/Medical Provider/Visitor/Surveyor Screening Tool on [DATE] revealed AD #63 marked new loss of taste and smell as symptoms of Covid-19 on [DATE], [DATE] and [DATE]. AD #63 tested positive for COVID-19 on [DATE]. Review of AD #63's Timecard Report revealed she worked [DATE] from 9:31 A.M. until 5:39 P.M. and returned to work [DATE] and worked from 9:34 A.M. until 5:16 P.M. Phone interview on [DATE] at 9:01 A.M. with LPN #65 revealed on Friday [DATE] she worked on 100-West (the Covid-19 unit) and 300-West and during her night shift she developed chills but did not notify anyone because she thought she was just cold. She did not work the weekend, but her symptoms got progressively worse, and she was tested for Covid-19 on [DATE]. LPN #65 received positive Covid-19 results on [DATE], her symptoms worsened, and she went to the emergency room and was admitted to the hospital on [DATE]. Interview on [DATE] at 9:53 A.M. with the Administrator revealed she developed a fever on [DATE] and went to the emergency room where she tested positive for Covid-19. The administrator said she returned to work [DATE]. Interview on [DATE] at 11:17 A.M. with the DON revealed Resident #201 expired on [DATE] positive for Covid-19; Resident#202 tested positive for Covid-19 on [DATE] and expired on [DATE]; Resident #200 and #203 tested positive on [DATE]. Review of electronic physician orders for Resident #200 and #203 revealed no orders for droplet precautions. Interview on [DATE] at 8:17 A.M. with Medical Doctor (MD) #66 revealed she was unaware of Covid-19 in the facility. MD #66 indicated she was told everything was fine and there was no Covid-19. The MD indicated the facility had one resident that had Covid-19 and was cured. MD #66 stated she would always ask if there was Covid-19 so she would be prepared with PPE. Interview on [DATE] at 2:34 P.M. with LPN #55 revealed she floated between the East and West wings in the facility. When she worked in the West wing, she started with the 300-unit which was non-Covid-19 and worked her way to the Covid-19 unit. At noon she again passed medications on the 300-unit and worked her way to the Covid-19 unit. LPN #55 stated she wore one KN95 each day she worked and did not change it. Interview on [DATE] at 2:50 P.M. with STNA #67 revealed she wore a new KN95 mask every day, and she did not change it while she worked. She indicated she discards the mask in the biohazard bin at the end of her shift. STNA #67 stated she sometimes worked on the Covid-19 unit. Interview on [DATE] at 3:26 P.M. with HDO #59 revealed she did not give guidance on the use of PPE or the Covid-19 screening tool that was used for the facility. HDO #59 further stated the line list received from the facility had a total of seven positive cases, four residents and three staff. She received a phone call from SW/Infection Preventionist/RN #57 on [DATE] stating the facility had more positive cases, but they were not on the line list as of [DATE]. Review of facility timeline for Covid-19 revealed 12 staff members tested positive for Covid-19, LPN #55 received positive test results on [DATE], the Administrator tested positive on [DATE], the DON, Dietary Aide (DA) #68, AR #64, AD #63, RN #54 and Maintenance Director #69 all received positive results on [DATE]. LPN #65 received positive Covid-19 test results on [DATE], STNA #70 received positive results on [DATE], and LPN #71 received positive results on [DATE]. Review of the facility policy titled, Transmission-Based Precaution Policy, revised, [DATE], revealed facility staff providing care for the resident will be notified by the facilities infection control coordinator and/or charge nurse regarding needed precautions based on infectious agent or condition. Review of the facility competency for Personal Protective Equipment (PPE) Donning and Doffing for Standard Precautions and Transmission Based Precautions under doffing revealed remove mask/respirator (respirator removed after exit room/closed door), grasp bottom, then top ties or elastics and remove, discard in waste container. Review of guidance from the CDC indicated, Perform expanded [MEDICAL CONDITION] testing of all residents in the nursing home if there is an outbreak in the facility (i.e., a new [DIAGNOSES REDACTED]-CoV-2 infection in any HCP or any nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident). A single new case of [DIAGNOSES REDACTED]-CoV-2 infection in any HCP or a nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with [DIAGNOSES REDACTED]-CoV-2 who can continue to spread the infection, even if they are asymptomatic. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC interventions (e.g., isolation, cohorting, use of personal protective equipment) to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. Review of CDC Guidance titled Preparing for Covid-19 in Nursing Homes, updated [DATE] revealed if HCP develop fever (Temperature above 100.0 degrees Fahrenheit) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. Have a plan for how to respond to HCP with COVID-19 who worked while ill (e.g., identifying and performing a risk assessment for exposed residents and co-workers). Review of National Institute for Occupational Safety and Health (NIOSH) Pandemic Planning, titled Recommended Guidance for Extended Use and Limited Re-Use of N95 Filtering Facepiece Respirators in Healthcare Settings, revealed discard N95 respirators following close contact with, or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions. This deficiency substantiates Complaint Number OH 003.

Based on record review and staff interview the facility failed to ensure Resident #54, who was cognitively impaired and required extensive assistance from two persons for transfers was transferred safely via a mechanical (Hoyer) lift to prevent a fall with injury. Actual Harm occurred on 12/12/19 when Resident #54 sustained a fall from the Hoyer lift resulting in a laceration to her head requiring transport to the emergency room . This affected one resident (#54) of one resident review for accidents. Findings Include: Record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 was severely cognitively impaired and required extensive assistance for activities of daily living including two person assistance for transfers. Review of the nurse's note authored by Licensed Practical Nurse (LPN) #50 dated 12/12/19 at 8:09 [NAME]M. revealed LPN #50 was notified by maintenance of an emergency in Resident #54's room. Upon arriving into Resident #54's room LPN #50 discovered Resident #54 laying supine (facing upward) on top of the Hoyer lifts legs. State tested Nursing Assistant (STNA) #120 explained to LPN #50 that while STNA #120 and another STNA were transferring the resident the hoyer lift malfunctioned and Resident #59 fell hitting her head on the Hoyer lift. Resident #54 was sent out to the hospital after assessment revealed a posterior (back) head wound. Review of the fall investigation, dated 12/12/19 revealed the hydraulic lift system of the Hoyer malfunctioned and subsequently caused the fall for Resident #54. Following the incident, a review a Lift Preventative Maintenance Inspection, dated 12/12/19 revealed under the section titled Shift Handle a visual/functional inspection of the lift used for Resident #54 revealed the lift needs cross; Support & Hardware. The lift was taken out of service as it was not in proper working order but failed to include information as to specifically why or how the lift malfunctioned as noted in the nursing progress note and investigation. The facility failed to identify the lift was not in proper working order prior to the the incident on 12/12/19 in which Resident #54 sustained an injury when she fell out of the lift during a staff assisted transfer. During the onsite survey, the facility failed to provide evidence of effective preventative maintenance to ensure the proper functioning of all lift devices to prevent resident falls with injury. Interview with the Director of Nursing on 12/17/19 at 2:05 P.M. verified the events of the fall and findings of the fall investigation as noted above.

Based on observation, record review and staff interview the facility failed to ensure the physician ordered treatments/dressings were completed for Resident #35's sacral pressure ulcer (tissue necrosis or death that typically develops when soft tissue is compressed between a bony prominence and an external surface for a long period of time). Actual harm occurred when Resident #35's Stage 2 sacral pressure ulcer (a partial thickness skin loss involving the epidermis and/or the dermis which is superficial and presents as an abrasion, blister, or a shallow crater) was not monitored and treated as ordered by the physician resulting in a decline to an unstageable pressure ulcer (a full thickness skin an tissue loss in which the extent of tissue damage cannot be confirmed because it is covered by slough and/or eschar). This affected one of three residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/24/17, 03/31/17, 04/13/17, 07/12/17 and 07/18/17, Resident #35 was assessed to be at risk for developing a pressure ulcer. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was alert, oriented and had no cognitive impairment. This assessment indicated his skin was intact. Review of the MDS assessment dated [DATE] revealed Resident #35 required extensive assistance of one to two staff for turning and repositioning in bed. Review of Resident #35's current Impaired Skin Integrity Care Plan included an intervention dated 07/06/17 for nursing staff to complete wound treatments per protocol and the physician orders. Review of Resident #35's Weekly Wound Assessment form dated 07/10/17 indicated Resident #35 developed a stage 2 pressure ulcer on the sacrum which measured 3 cm (centimeters) by 4 cm by 0.1 cm. The wound bed appeared red with scant serous (clear) drainage and had 100% granulation tissue (new healthy tissue indicating the ulcer is healing). Review of Resident #35's physician orders [REDACTED]. Review of Resident #35's Weekly Wound Assessment form dated 07/17/17 indicated the Stage 2 sacral pressure ulcer had declined and was larger at 4 cm by 5 cm, however no depth measurement was recorded. The wound bed appeared necrotic and had moderate serous drainage. The assessment indicated the pressure ulcer now had 100% necrotic or dead tissue covering the wound bed. Resident #35's physician orders [REDACTED]. Review of Resident #35's Weekly Wound Assessment form dated 07/21/17 indicated the stage 2 pressure ulcer progressed to an unstageable pressure ulcer and was now 4 cm by 5 cm. The depth was not measure since the base of the wound was not visible. The wound bed was completely covered with necrotic tissue and moderate serous drainage was recorded. Review of Resident #35's Weekly Wound Assessment form dated 07/31/17 indicated Resident #35's sacral ulcer was an unstageable pressure ulcer measuring 4 cm by 4 cm by 0.2 cm. The wound bed appeared pink and necrotic with moderate serous drainage. The ulcer bed was assessed to have 60% subcutaneous tissue visible and the other 40% was necrotic tissue. Review of Resident #35's Weekly Wound Assessment form dated 08/07/17 indicated Resident #35's unstageable sacral pressure ulcer measured 3 cm by 4 cm by 0.5 cm. The wound bed appeared reddened with moderate serous drainage. One hundred percent (100%) subcutaneous tissue was noted. Review of Resident #35's treatment administration record (TAR) from 07/11/17 to 07/31/17 revealed no evidence the daily sacral wound treatment was completed as ordered by the physician on 07/12/17, 07/13/17, 07/15/17, 07/16/17, 07/18/17, 07/20/17, 07/22/17, 07/23/17 and 07/26/17. Interview on 08/17/17 at 11:55 A.M. with Licensed Practical Nurse (LPN) #93 verified Resident #35's medical record did not contain evidence the sacral pressure ulcer care and treatment was completed from 07/12/17 to 07/16/17 (excluding 07/14/17). LPN #93 confirmed the physician order [REDACTED].M. with LPN #93 verified Resident #35's sacral pressure ulcer worsened and progressed to an unstageable ulcer very quickly.

Based on observation, staff and resident interview, record review and review of the facility's smoking policy, the facility failed to provide adequate supervision and interventions related to safe smoking for residents. This resulted in Immediate Jeopardy for three residents (Residents #109, #138 and #161). The potential for serious or likely harm occurred when State tested Nurse Aide (STNA) #2 failed to remove the oxygen nasal cannula from Resident #138's nose while it was still connected to an oxygen tank located on the resident's wheelchair and was providing her oxygen at a flow rate of three liters. STNA #2 handed Resident #138 a cigarette and lighter. STNA #2 then left Residents #109, #138 and #161 in the smoking courtyard unsupervised as she went to return the cigarette box to administration. Resident #138 was observed lighting Resident #109's cigarette before lighting her own. Resident #161 was standing behind Resident #138. During the lapse in supervision, Resident #138 was at risk for igniting the oxygen and herself while smoking and Resident #109 and Resident #161 were at risk for burns/injuries related to the close proximity to Resident #138. This affected three of ten residents identified by the facility as smokers. The facility census was 93. On 06/15/16 at 4:23 P.M., the Regional Administrator and the facility Administrator were notified that Immediate Jeopardy began on 06/15/16 at 2:03 P.M. when STNA #2 did not provide adequate supervision while Resident #138 used a lighter to ignite Resident #109's cigarette and then her own cigarette while wearing oxygen which was at a flow rate of three liters. The oxygen tank was attached to Resident #138's wheelchair. STNA #2 did not ensure Resident #161 and Resident #109's safety was maintained by providing adequate supervision and removing Resident #138's oxygen prior to handing the resident a lighter and cigarette. The Immediate Jeopardy was removed on 06/16/16 when the facility implemented the following corrective actions: · On 06/15/16 at 2:15 P.M., the Administrator began staff education with 55 staff on the current smoking policy and safe smoking practices. Staff educated included four activity staff (#20,#21, #22, #23); one Licensed Social Worker (LSW #9); four administrative staff (#24, #25, #26, #27); six dietary staff (#28, #29, #30, #31, #32, #33); three housekeeping staff (#34, #5, #36,); three maintenance personnel (#37, #38, #39); three laundry staff (#40,# 41, #42); 14 Licensed Practical Nurses (LPNs #43, #44, #45, #46, #47, #48, #49, #50,#51, #52, #53, #54, #55, #56,) five Registered Nurses (RNs #57, #58, #59, #60, #61) and 12 State tested Nursing Assistants (STNAs #62,#63, #64, #65, #66, #67, #68, #69 #70, 71, #72, #73) and re-educated Resident #138 on the facility smoking policy. Resident #138 signed the smoking contract again on 06/15/16 at 2:30 P.M. The Administrator indicated STNA #2 was counseled and re-educated on 06/15/16 at 2:10 P.M. of the dangers of oxygen and smoking and reviewed the smoking policy. · On 06/15/16 at 3:10 P.M., the Administrator addressed the immediacy of the concern by implementing twenty-four hour monitoring of the smoking courtyard until 06/20/16. · On 06/15/16 at 5:35 P.M., the Administrator posted a notice on all facility doors indicating family members and visitors were not permitted to give residents cigarettes or lighters. At the same time, LSW #9 re-educated all 10 residents (Residents #23, #54, #57, #105, #106, #109, #138, ##160, #161 and #162) who smoked on the current smoking policy and searched the resident rooms with their permission for cigarettes and lighters. Residents who smoke were required to sign a current smoking contract and an addendum was added on 06/15/16 that it was absolutely prohibited to allow anyone to smoke with oxygen. Residents #23, #54, #57, #105, #106, #109, #138, #160, #161 and #162 who smoke had their care plans updated to reflect the current smoking status. · On 06/15/16 at 6:30 P.M., an audit was initiated to monitor the smoking courtyard every smoke break (smoke break times 9:00 A.M., 11:00 A.M., 2:00 P.M., 4:00 P.M., 6:30 P.M., 9:30 P.M. and 11:00 P.M.) The Administrator indicated every single smoke break would be monitored with the audit tool to determine if residents with oxygen were smoking and making sure residents were throwing cigarette butts in the approved fire receptacle. The Administrator indicated an emergency quality assurance meeting was conducted on 06/15/16 at 6:30 P.M. with the medical director (participating by phone conference) regarding the smoking policy, audits, plan of correction and staff education. · On 06/16/16 at 6:15 A.M., the Administrator educated staff on the smoke break audit and began performing competency interviews with the staff about their knowledge of their smoking policy. The Administrator indicated the facility began auditing on 06/16/16 at 6:15 A.M. with fifteen audits completed. The Administrator revealed competency audits would be completed as follows: ten audits of staff competency per day for the first week and then five competencies per day for the next two weeks and then ten per week for a week. Thereafter, the facility would complete five staff competencies per week for 60 days. · Interviews on 06/16/16 from 7:50 A.M. to 8:10 A.M. with RN #62, Physical Therapy Assistant (PTA) #75, STNA #76, Laundry Staff #42, STNA #78 and STNA #77 indicated the staff was aware of the current smoking policy. Although the Immediate Jeopardy was removed on 06/16/16 the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was continuing to monitor and complete audits of residents who smoke. Findings include: Medical record review revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #109's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited memory impairment. Resident #109 required total dependence with two staff person physical assist for transfers. Resident #109 had a Smoking assessment dated [DATE]. The facility identified Resident #109 was the responsible party for decision making. Medical record review revealed Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #138's MDS assessment dated [DATE] indicated the resident was alert. Resident #138 required supervision with locomotion on and off the unit. Review of Resident #138's physician orders [REDACTED]. Review of Resident #138's Smoking assessment dated [DATE] indicated the resident must be supervised by staff, a volunteer or a family member at all times when smoking. The assessment indicated she was able to communicate why the oxygen must be shut off prior to lighting a cigarette. Medical record review revealed Resident #161 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #161's MDS assessment dated [DATE] indicated the resident exhibited intact cognition and was alert and oriented. On 06/15/16 at 1:58 P.M., STNA #2, Resident #109, Resident #138 and Resident #161 were observed in the lounge area (closest to the main entrance) that was connected to the smoking courtyard. STNA #2 was observed handing Resident #109 a cigarette from a locked case labeled cigarettes and the resident, using a motorized wheelchair, exited into the smoking courtyard located off of the lounge area. STNA #2 then handed Resident #138 a cigarette and a lighter. Resident #138 was wearing a nasal cannula which was connected to the oxygen tank located on the back of her wheelchair. The oxygen was on at three liters. Resident #138 and Resident #161 both exited into the smoking courtyard. STNA #2 was observed at 2:00 P.M. exiting the lounge area and entering into the main hallway near the front door. At 2:03 P.M., Resident #109's motorized wheelchair was in the courtyard facing the lounge door and Resident #138's wheelchair was slightly across from Resident #109's motorized wheelchair. Resident #161 was standing behind and slightly to the right of Resident #138. Resident #138 was observed leaning over to light Resident #109's cigarette before lighting her own. Resident #138's oxygen was on at three liters. Resident #161 was talking to both Resident #138 and Resident #109. Resident #138 was at risk for igniting the oxygen while smoking while Resident #109 and Resident #161 were at risk for burns related to the close proximity to Resident #138 while the resident was smoking with oxygen. On 06/15/16 at 2:06 P.M., the DON and LPN #6 came into the courtyard and verified was smoking with oxygen. The DON removed the oxygen and oxygen tubing from Resident #138's wheelchair. Following the removal of Resident #138's oxygen, STNA #2 removed the resident from the smoking courtyard and placed the resident in her room with one to one supervision. Interview on 06/15/16 at 2:17 P.M. with STNA #2 revealed she was assigned to monitor Resident #138 because the resident was terminally ill and weak. STNA #2 indicated she was informed by administration to monitor the residents smoking during the 2:00 P.M. smoke break when Resident #138 entered the courtyard to smoke. STNA #2 confirmed she was aware Resident #138 was wearing oxygen and verified she handed the resident a lighter and cigarette. STNA #2 also indicated Resident #138 was supposed to wait for her prior to smoking. STNA #2 indicated she had never been trained on the smoking policy and smoking safety. Review of STNA #2's employee file revealed the she was hired by the facility on 04/20/16 and was in-serviced on smoking safety and fire safety during her orientation. An interview on 06/15/16 at 3:30 P.M. was conducted with Resident #138. She verified she received the lighter and cigarette from STNA #2 prior to entering the courtyard to smoke. Resident #138 confirmed she leaned over to Resident #109 and lit his cigarette prior to lighting her own cigarette. Resident #138 said she forgot she was wearing her oxygen. Resident #138 indicated she had to remind STNA #2 earlier in the day during a smoke break to remove the oxygen tubing but forgot to remind her in the afternoon. During the interview on 06/15/16 at 3:46 P.M. with the Administrator, she indicated the smoking area would be monitored around the clock and staff would be educated on the smoking policy to address the immediacy of the issue. Interview on 06/15/16 at 4:31 P.M. with the Regional Administrator indicated Resident #138 was to have one to one supervision because she was a hospice patient and very weak with a tendency to fall. Resident #138 was assigned one to one supervision for safety. The Regional Administrator agreed STNA #2 should have only been assigned to monitor Resident #138 or the smoking courtyard but not both together. Further interview with the Regional Administrator indicated the incident was a lapse in STNA #2's judgement. Observation on 06/15/16 at 5:26 P.M. of the lounge area near the front lobby revealed Maintenance Staff #38 was sitting in the lounge area monitoring the smoking courtyard and a family member was in the courtyard smoking. Interview on 06/15/16 at 5:35 P.M. with the Administrator confirmed twenty-four hour monitoring of the smoking courtyard was implemented and a sign was posted on the facility front door to informing family members to not give residents cigarettes or lighters. The Administrator verified the facility was in the process of educating staff on the smoking policy. Further interview with the Administrator confirmed ten residents currently resided in the facility who smoked including Residents #23, #54, #57, #105, #106, #109, #138, #160, #161 and #162. The undated current facility Smoking Policy and Procedure that was in place at the time of the incident indicated all residents who smoke would have a Safe Smoking Evaluation form completed by the nursing staff and be asked to sign a Smoking Contract. The evaluation form would be completed with each readmission, quarterly, and with any significant change in the resident's condition and both the evaluation form and contract would be filed in the resident's medical record in the social service section. Residents may only smoke in the designated area at designated times and smoking materials would be retained and distributed by the facility staff during the designated smoking times. An addendum was added on 06/15/16 indicating it was absolutely prohibited to allow anyone to smoke with oxygen.

Based on record review and staff interview, the facility failed to ensure wound assessments and treatments were conducted timely for one of three sampled resident identified with pressure ulcers. Harm occurred when Resident #105 was identified with an in-facility developed pressure ulcer that was not assessed and there was no evidence of treatment for 30 days. Forty two days after the initial skin breakdown, Resident #105 had a consult with his primary care physician (PCP) who ordered him to be a direct admit to the hospital for treatment of [REDACTED]. This had the potential to affect the current five residents under treatment for [REDACTED]. Findings include: Resident #105, a [AGE] year old male, was admitted to the facility on [DATE]. Medical history included [MEDICAL CONDITION], depression, hypertension, [MEDICAL CONDITIONS], history of resolved pressure ulcers, and dysphagia. At the time of admission, Resident #105 was identified as a risk for altered skin integrity and a care plan was initiated on 12/27/12. Interventions included bi-weekly skin checks, administer treatments as ordered and monitor for effectiveness, inform family of any new area of skin breakdown, perimeter air mattress, pressure reducing cushion to tilt in space wheelchair, wedge cushion, and up for meals only. Review of the annual Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #105 was receiving treatment for [REDACTED]. The annual MDS dated [DATE] revealed Resident #105 was not receiving treatment for [REDACTED]. Review of the quarterly MDS dated [DATE], 11/11/15, 12/16/15, and 03/07/16 revealed Resident #105 was not receiving treatment for [REDACTED]. Review of the weekly shower sheet dated 03/04/16 revealed Resident #105 was identified to have an open area to his butt which was reported to the nurse, Licensed Practical Nurse (LPN) #202. Review of the telephone orders dated 03/04/16 revealed an order was implemented for a left buttocks wound (cleanse open area to left buttocks with normal saline, pat dry, apply [MEDICATION NAME] topically and cover with foam dressing daily and as needed). The order was written by LPN #202. Review of the clinical record did not identify a nurses note written for 03/04/16 identifying the wound, description or measurements, what order was being implemented, notification to Certified Nurse Practitioner (CNP) #220, PCP, dietician or the responsible party of a change in Resident #105's condition. Review of the treatment administration record (TAR) for March, 2016 did not identify an order for [REDACTED]. On 03/11/16 a nurses note revealed CNP #220 was contacted regarding a weight lost and an order was obtained to increase an antidepressant ([MEDICATION NAME]) which also is used to stimulate appetite. There was no mention of the new left buttocks wound to CNP #220 in the note. On 03/25/16 a nurses note written by LPN #200 revealed dressings dry and intact; wound to coccyx. Vital signs within range for this resident. Resident is disoriented, responsive and pleasant. Respirations unlabored; lung sound clear. No [MEDICAL CONDITION] noted with right and left pedal pulses present. Resident is a two person physical assist. On 04/01/16 a nurses note written LPN #208 revealed dressings dry and intact. Review of the shower sheets from 03/4/16 through 04/03/16 revealed various state tested nurse aides (STNAs) and various charge nurses were checking a box on the sheet indicating Resident #105 ' s skin was ' not intact ' . No details of new or old wound or locations were noted on these shower sheets. Several of the shower sheets were marked with multiple circles on the anatomical figure, indicating more than one area of the skin was compromised. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #105 was moderate risk, chair fast with limited mobility, excellent nutrition, and potential problem for friction and shearing. Review of the bi-weekly skin checks completed by nurses revealed nurses were to document if a resident has current skin issues and if they do, nurses were to document the site location with a description. If new skin issues were identified, nurses were to document the current site location with a description. Review of the bi-weekly skin checks from 03/10/16 through 04/12/16 revealed 12 assessments were completed. Two of the 12 assessments, one dated 03/10/16 and one dated 03/31/16, were completed by LPN #204. She identified a left buttocks wound in the text of the assessment, but did not describe the wound or document measurements of the wound. The remaining assessments did indicate yes resident had skin issues but the forms were void of any details, locations, descriptions, or measurements. On 04/03/16 a nurses note written by LPN #224 revealed an unidentified nursing assistant noted while providing care this shift, noticed open area to buttocks. Reported to LPN #224 who assessed a one centimeter by 0.5 centimeter to left buttocks and pus filled area to right buttocks. No further description was indicated. Both areas cleansed and dressed. The physician and family were contacted. On 04/03/16 a telephone order revealed the same treatment was being implemented to the right buttocks and left gluteal fold (clean with normal saline and apply foam dressing daily). On 04/04/16 a telephone order revealed a perimeter air mattress was being replaced with an air mattress and bolster to open the side of the bed. A treatment order was written for a left buttocks wound (clean the left buttocks wound with normal saline and apply foam dressing daily). A treatment order was also written for inner thigh abscess (clean with normal saline and apply foam dressing daily). On 04/04/16 at 5:10 P.M., a nurses note written by Registered Nurse (RN) #210 revealed a skin assessment to the left buttocks. A new pressure ulcer to the left buttocks measured 9.0 length by 6.5 width, unstageable. The note did not indicate centimeters or inches. A necrotic cap was noted on the wound. At 5:14 P.M., a nurses note written by RN #210 revealed new skin impairment of wound identified on 04/03/16. Purulent drainage; scant amount; wound bed appearance is pink; no odor; peri wound appearance is pink and wound status is unchanged. Right inner thigh abscess with two small drain holes draining thick purulent drainage. The physician was called. At 6:18 P.M., the physician called about the abscess to right inner thigh and ordered antibiotics twice a day for seven days (Doxyclycline 100 mg). The responsible party was informed of the new orders. A care plan was initiated on 04/04/16 for actual skin impairment to Resident #105's skin integrity that identified a left buttocks wound. A care plan was initiated on 04/08/16 for actual skin impairment to Resident #105's skin integrity that identified a right inner thigh abscess. On 04/06/16 a nurses note written by LPN 206 revealed the physician ordered three liters of intravenous (IV) hydration. Wounds to right buttocks and right inner thigh. Dressing changed and intact. Wound has some odor and some drainage. On 04/08/16 nurses notes written by LPN #200 revealed Resident #105 was stable, vital signs within range for this resident, no temperature, no pain, clear lung sounds, dressings dry and intact. On 04/09/16 at 7:05 P.M., nurses note written by LPN #214 revealed IV hydration was noted to be complete. At 11:54 P.M., the nurses note written by LPN #212 indicated Resident #105 had a surgical incision. On 04/12/16 at 12:26 P.M., a nurses noted written by LPN #200 revealed she contacted the responsible party to discuss Resident #105 not eating, pocketing food, losing weight, and possibly signing him up for hospice or getting a feeding tube. At 1:20 P.M., CNP #220 and Dietician #216 consulted with Resident #105 to assess his condition and wound. The note indicated there was no significant change in weight. Pureed diet continued. Dietician #216 recommended Vitamin C tablets and zinc tablets for the next 14 days. Protein supplements were also increased and pre-[MEDICATION NAME] levels drawn. On 04/13/16 at 11:33 A.M., the responsible party came into the facility and requested Resident #105 receive a feeding tube related to not eating and wounds. On 04/14/16 at 1:22 P.M., the PCP consulted with Resident #105 and ordered a direct admit to the hospital. A telephone order revealed Resident #105 was being admitted to the hospital to treat an infected wound, malnutrition, and dehydration. Review of the PCP's consults dated 01/04/16, 02/01/16, 03/07/16, and 04/04/16 did not identify any significant change in medical status. Review of lab work dated 03/01/16, 04/06/16, and 04/13/16 did not identify any significant medical changes in Resident #105's blood work analysis and each report had a note at the bottom indicating the physician was not implementing any new orders. On 04/19/16 at 2:40 P.M. a meeting was held with Regional Registered Nurse (RRN) #222. RRN #222 reported the facility identified a deficient practice on 04/04/16, involving Resident #105 who was identified to have an unstageable pressure ulcer and unable to determine when it may have occurred due to insufficient documentation. The facility was unable to find any wound tracking on Resident #105. RRN #222 indicated the director of nursing (DON) was assigned to conduct weekly wound rounds and measure, track, and assess wounds per protocol. The facility terminated the DON and an interim corporate nurse was acting as the DON. On 04/19/16 at 4:00 P.M., the newly appointed wound nurse, LPN #200, reported she was the nurse who assessed the wound on 04/03/16 with the former DON. LPN #200 indicated the former DON was to document, but didn't. LPN #200 indicated she attempted to have the wound physician consult with Resident #105 but the wound physician declined due to not being covered under Resident #105's insurance plan. At 5:10 P.M., LPN #200 confirmed she changed the style of air mattress because she felt the perimeter air mattress was part of the problem for the altered skin integrity for Resident #105. On 04/20/16 at 8:00 A.M., the interim DON was interviewed. She confirmed the progress notes did not reflect a note for 03/04/16 when the skin breakdown was first identified, and no evidence the PCP, CNP #220, Dietician #216, or the family was notified. On 04/20/16 at 12:15 P.M., LPN #202 was interviewed. LPN # 202 was identified as the nurse who wrote the treatment order on 03/04/16 for the left buttocks wound. LPN #202 stated I wrote a treatment order ([MEDICATION NAME]). We had it in stock. I would not have determined that but was directed to initiate ([MEDICATION NAME]) but I can't remember who told me to write the order. Something was being done for Resident #105. I'm not sure what. LPN #202 confirmed she was unable to locate any documentation to support treatments were implemented in March, 2016. On 04/20/16 at 4:15 P.M., RRN #222 verified the facility was unable to find a treatment record for March, 2016 for Resident #105, and confirmed no wound tracking was being completed for Resident #105. RRN #222 reviewed the nurses notes, the bi-weekly assessments, and TARS and verified the discrepancy and inconsistency in what was documented and what was missing, supporting the confusion and lack of knowledge regarding Resident #105's skin breakdown. Review of the wound management policy dated July, 2012 indicted treatments steps were to be initiated based on skin assessment findings. The facility never conducted that assessment on Resident #105 on 03/04/16 when the first left buttocks wound was identified. The wound was never described or measured. The policy indicated wound measurements were to be conducted initially and weekly. There was only one measurement dated 04/03/16, 30 days after the wound was first identified for Resident #105. No other assessments with measurements were documented to ensure the wound was being assessed for improvement, declining, if current treatment was appropriate or if a different treatment was required. Per the progress notes and telephone orders, the same type of treatment was being implemented for three different wounds, and one wound was identified as an abscess. Resident #105's wounds and treatments were not assessed by facility nurses for 30 days between 03/04/16 and 04/04/16. The facility wound physician did not consult with Resident #105 due to insurance conflict. CNP #220 consulted with Resident #105, 40 days after the left buttock was identified to have skin breakdown, followed by the PCP on 04/14/16. The progress notes and skin assessments were inaccurate or incomplete. Resident #105 was assessed to have a history of resolved pressure ulcers. However, documentation that was available did not present a significant change in medical status prior to the wound on 03/04/16 being discovered. Interventions were implemented after 04/04/16 when the facility identified the deficient practice. Thirty days passed and the facility was uncertain as to what skin breakdown Resident #105 had and what if anything was being done to resolve the skin breakdown that warranted a hospital admission to treat an infected wound for Resident #105. This deficiency substantiates Complaint Number OH 803.

Based on observation, interview and record review the facility failed to ensure the safe use of a mechanical lift for one resident. This resulted in actual harm to Resident #50 who was injured by the lift sustaining a head laceration and shoulder abrasions that required emergent hospital intervention. This affected one resident reviewed for the use of a mechanical. The facility identified 28 residents requiring the use of mechanical lifts. The facility failed to ensure fall interventions were in place for two residents ( Resident #12 and #99) identified to be at risk for falls. This affected two of four residents reviewed for falls. The facility census was 115. Findings include: 1. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) 3.0 dated 11/02/13 revealed Resident #50 was totally dependent on staff for bed mobility and transfers requiring two or more person physical assistance. Review of a facility investigation dated 10/03/13 revealed at 8:10 P.M. on that date a nurse entered Resident #50's room and observed the resident lying on his bed with the mechanical lift tilted on top of him. State tested Nurse Aide (STNA) #200 and #201 were with the resident. The nurse assisted the STNAs to remove the mechanical lift and get the resident up. Review of nurses notes dated 10/03/13 timed 8:15 P.M., revealed the nurse heard a noise in Resident #50's room and observed two STNAs (STNA #200 and #201) standing over the resident and the mechanical lift. The resident was yelling out and calling the STNAs names. The resident was bleeding from the top of his head. The nurse had the STNA apply pressure to the wound for 10 minutes. Review of the nursing assessment revealed revealed Resident #50 sustained a laceration to the top of his head that measured four centimeters (cm) in length and .5 cm in depth and was bleeding. Resident #50 sustained an abrasion to the left shoulder measuring 2.5 cm long and an abrasion to the right should measuring .5 cm in length. At 8:20 P.M. the physician was notified and an order was received to send the resident to the emergency room via a 911 call. Resident #50 was treated at the emergency room and received four staples to a head laceration. During an interview with Resident #50 on 01/23/14 at 9:30 A.M. he stated the staff hurt him with the mechanical lift. The resident stated he was mad and did not want to be lifted and they forced him. He stated the lift fell on him cutting his head open. Review of the witness statement from STNA #200, dated 10/03/13, revealed she asked STNA #201 to assist in obtaining a weight for Resident #50 using the mechanical lift. STNA #201 was providing incontinence care and Resident #50 was swearing and being combative. STNA #200 and #201 then put Resident #50 in the mechanical lift. Resident #50 continued yelling and started pulling on the lift which he pulled down on himself and the lift hit the top of his head. The nurse came in the room to help get the lift back up off the resident. Review of the witness statement from STNA #201, dated 10/03/13, revealed she and STNA #200 were weighing Resident #50 with the mechanical lift. When Resident #50 was in the air he was swinging and pulling on the lift. The lift fell backwards towards the resident and hit him on top of his head. STNA #201 applied pressure to the residents head and the nurse assisted the resident. Review of Resident #50's current behavior care plan revealed he was resistive to care with yelling out and crying. Interventions included to reassure the resident, leave and return in five to ten minutes and try again, if possible negotiate a time for care so the resident participates in the decision making process and return at the agreed time. On 01/23/14 at 9:40 A.M., interview with STNA #201 verified Resident #50 could get upset at times if you did not explain exactly what you were doing and proceed slowly. She indicated the resident spits, curses and yells at times saying they are hurting him but that at other times he is fine. She stated staff were supposed to leave him alone, tell the nurse and reapproach later. STNA #201 verified Resident #50 was already agitated and yelling prior to using the mechanical lift to attempt to get his weight but she and STNA #200 continued anyway. On 01/23/14 at 4:45 P.M., interview with STNA #203 revealed staff needed to talk through all care with Resident #50. She indicated if procedures were not explained, Resident #50 became easily agitated. She stated they had to be very patient and as long as Resident #50 understood what was being done he was okay. On 01/23/14 at 5:05 P.M. telephone interview with STNA #200 revealed Resident #50 could be combative at times during care. She indicated two staff were always in the room in case the resident got mad. STNA #200 verified Resident #50 was weighed in the mechanical lift. STNA #200 verified on 10/03/13 the resident was already agitated and yelling because STNA #201 was providing incontinence care. STNA #200 verified Resident #50 "was terrible that evening" and kept hitting her hand when attempting to lift him with the mechanical lift. STNA #200 verified she told the resident to put his right hand on the sway bar of the lift, the part that hooks to the pad. When the resident put his hand on the bar he started shaking it and the lift tilted and fell on the floor. STNA #200 stated as it fell it hit Resident #50 on the head. STNA #200 verified she locked the wheels to stabilize the lift but could not remember what position the legs were in while the resident was lifted in the air. STNA #200 verified both she and STNA #201 continued to get the resident in the mechanical lift despite him being agitated. On 01/24/14 at 1:00 P.M. STNA #201 was asked to demonstrate the use of the mechanical lift as it was performed with Resident #50. STNA #201 indicated the mechanical lift was pushed under the bed with the legs in the closed position. STNA #201 was standing on the right side of the bed and STNA #200 was operating the lift. STNA #201 indicated Resident #50 was only lifted a few inches off of the bed when the lift fell toward the head of the bed and the base (long arm) of lift landed on the resident's head. STNA #201 stated she was not instructed to open the legs of the lift for optimum stability. STNA #201 stated the shifter on the lift was always loose which allowed the legs to move around when residents were in the lift. STNA #201 verified frequently the wheels of the lift stick making it difficult to maneuver the lift. STNA #201 verified she called maintenance when that was observed but at times needed to utilize the lift before maintenance could fix it. STNA #201 verified they should have stopped care, stopped putting the resident in the mechanical lift, reported to the nurse and approach Resident #50 later, Review of the Owners Operator and Maintenance Manual for the mechanical lift revealed the legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. It indicated not to lock the rear casters (wheels) while lifting a resident because locking the rear casters could cause the lift to tip and endanger the resident and assistants. Review of the monthly lift maintenance inspection and test logs, from September 2013 through January 2014, did not list all the mechanical lifts in the facility. The log did not indicate any concerns were identified or any lifts needed maintenance despite STNA #201 indicating the lifts were frequently in ill repair. On 01/24/14 at 1:30 P.M.., interview with the administrator and the director of nursing (DON) verified Resident #50 was already agitated and STNA #200 and STNA #201 should not have lifted the resident when he was agitated. The DON verified Resident #50's behavior care plan indicated to leave the resident alone when agitated and reapproach later. The DON verified the investigation was not comprehensive and did not include important details that were obtained from the surveyor's interviews with STNA #200 and #201 that would have aided in educating the staff. The administrator verified the monthly lift maintenance inspection and test logs, from September, 2013 through January, 2014, did not indicate all of the mechanical lifts in the facility were inspected or tested . The administrator verified the logs did not indicate any concerns were identified or any lifts needed maintenance despite STNA #201 indicating the lifts were frequently in ill repair. 2. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the fall care plan initiated 07/26/13 revealed Resident #12 had poor safety awareness and general weakness. Interventions included to bring the resident to the common area when restless to monitor behavior, low bed with matt to floor and educate resident to use call light. On 01/23/14 at 2:15 P.M., Resident #12 was observed in bed with the call light on the floor. At 2:16 P.M., interview with STNA #219 verified the call light was on the floor and out of reach of the resident. On 01/24/14 at 12:45 P.M., Resident #12 was observed in bed. The bed was not in the lowest position and the floor matt was not next to the bed. The call light was out of reach, tangled in the grab bar and dangling toward the floor. Resident #12 was making attempts to get out of bed and then sat up at the edge of the bed. The surveyor located Licensed Practical Nurse (LPN) #220 down the hall and returned to Resident #12's room. LPN #220 verified the fall interventions were not in place including the low bed, the matt to the floor and the call light. 3. Resident # 99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #99's MDS dated [DATE] revealed the resident was a one person physical assist with bed mobility, transfers and toileting. Review of the nursing assistant care card revealed Resident #99 was a one person physical assistance with transfer to and from the wheelchair. Review of the fall care plan revealed Resident #99 had impaired mobility due to a head trauma from a motor vehicle accident. The intervention was to make sure the wheel chair was locked prior to self-transferring. Review of the nursing note dated 01/20/14 at 12:01 P.M., revealed Resident #99 was found laying on her left side on the floor beside the bed with the wheel chair at the end of the bed by the dresser unlocked. Resident #99 stated she was self-transferring from the bed to the wheelchair, the wheel chair moved and she lost her balance and fell on to the floor. The immediate intervention was to re-educate the resident to make sure the wheelchair was locked prior to transferring. On 01/24/14 at 9:10 A.M., interview with Resident #99 verified she fell on the previous Tuesday. Resident #99 verified she waited a long time for someone to answer the call light and no one came so Resident #99 attempted to self-transfer. Resident #99 verified she did not have use of her right side. Resident #99 stated she was trying to transfer herself from the wheelchair into bed. On 01/24/14 at 2:35 P.M., interview with the administrator revealed Resident #99 was not suppose to self-transfer and needed one person physical assist for bed mobility and transfers. On 01/24/14 at 4:00 P.M., interview with the DON verified Resident #99 was a one person physical assist for transfers and verified the plan of care did not address transfer needs. The DON verified the MDS, nursing assistant care card and plan of care did not indicate the same care needs. The DON indicated the facility could not stop the resident from self-transferring so they educated her to ensure the wheels on the wheelchair were locked. The DON verified Resident #99 had left sided hemiparesis from a CVA. This deficiency substantiates Complaint Number OH 358.