Every finding on record at Bellbrook Health and Rehab

Based on medical record review, resident representative interview, staff interviews, and policy review, the facility failed to ensure a resident's continuous positive airway pressure (CPAP) was administered according to physician orders. This affected one (#40) of three residents reviewed for respiratory cares and services. The facility census was 36.Findings include:Review of the medical record for Resident #40 revealed an admission date of 04/17/26. Diagnoses included chronic obstructive pulmonary disease, asthma, and atrial fibrillation. Resident #40 discharged to another skilled nursing facility on 04/20/26. Review of an admission Data Collection evaluation, dated 04/17/26, revealed Resident #40 was cognitively intact. Resident #40 had oxygen at six liters per nasal canula and bilevel positive airway pressure (BiPAP) at home settings.Review of Resident #40's hospital discharge orders dated 04/17/26 revealed an order to continue CPAP as directed. The orders indicated Resident #40 discharged from the hospital on [DATE] at 6:01 P.M.Review of Resident #40's physician orders revealed an order dated 04/18/26 to apply home CPAP with six to ten liters of oxygen bleed in (process of adding supplement oxygen into another device's airflow every evening shift. Review of Resident #40's Treatment Administration Record (TAR) revealed the CPAP was applied on 04/18/26 and 04/19/26. There was no documentation in medical record to support Resident #40's CPAP was administered on 04/17/26.Interview on 04/29/26 at 1:28 P.M. with Regional Nurse #261 confirmed the medical record for Resident #40 revealed discharge orders on 04/17/26 for CPAP per home settings. Regional Nurse #261 confirmed the medical record did not contain documentation to support CPAP was administered as ordered or that the nurse notified the physician if the CPAP was not available for use on 04/17/26. Interview on 04/29/26 at 1:48 P.M. with Licensed Practical Nurse (LPN) #271 stated she was Resident #40's admitting nurse on 04/17/26 and confirmed Resident #40 had an order for home CPAP machine to be administered every evening. LPN #271 stated Resident #40's family went home to get the CPAP machine to bring back to the facility on [DATE]. LPN #271 stated the family had not returned by the time she finished her shift at 7:00 P.M.Interview on 04/29/26 at 1:55 P.M. with LPN #266 confirmed she was Resident #40's nurse on the evening of 04/17/26. LPN #266 confirmed Resident #40 did receive oxygen on 04/17/26 but could not recall if Resident #40's family had brought the home CPAP machine in that evening (04/17/26) for Resident #40's use. Interview on 04/292/6 at 2:50 P.M. with Resident #40's representative stated the family had brought the CPAP machine into the facility on the evening of 04/17/26 and the nurse and Respiratory Therapist were made aware. Resident #40's representative stated Resident #40 had called her in the morning on 04/18/26 and informed her that staff had not administered the CPAP machine. Review of the facility policy titled CPAP/BiPAP support, revised March 2015 revealed the purpose was to provide spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. The policy stated to review the physician orders to determine the oxygen concentration and flow, and the positive end-expiratory pressure (PEEP) pressure for the machine.This deficiency represents non-compliance investigated under Complaint Numbers 2997711 and 2990105.

Based on medical record review, resident representative interview, staff interviews, and policy review, the facility failed to notify the physician of a resident's pressure ulcer upon admission and failed to obtain treatment orders to treat it. This affected one (#40) of three residents reviewed for pressure ulcers. The facility census was 36.Findings include:Review of the medical record for Resident #40 revealed an admission date of 04/17/26. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation. Resident #40 discharged to another skilled nursing facility on 04/20/26. Review of an admission Data Collection evaluation, dated 04/17/26, revealed Resident #40 was cognitively intact and required staff assistance with bed mobility, transfers, toilet hygiene, and bathing. The evaluation revealed Resident #40 admitted with pressure ulcer to coccyx which measured five centimeters (cm) in length by 1.0 cm in width with less than 0.1 cm depth. Review of the physician order on 04/17/26 revealed an order for a low air loss mattress. From 04/17/26 to 04/20/26, there was no documentation to support the physician was notified of Resident #40's pressure ulcer or treatment orders were obtained. Interview on 04/29/26 at 1:48 P.M. with Licensed Practical Nurse (LPN) #271 stated she was Resident #40's admitting nurse on 04/17/26. LPN #271 confirmed Resident #40 had a pressure ulcer present upon admission to the facility and she did not notify the physician of the pressure ulcer to obtain treatment orders. LPN #271 stated she applied barrier cream to Resident #40's coccyx upon admission. Interview on 04/29/26 at 2:00 P.M. with Registered Nurse (RN) #235 stated she was the nurse who assisted Resident #40 with discharge to another skilled nursing facility on 04/20/26. RN #235 stated she assisted the certified nursing aide (CNA) with incontinence care for Resident #40 prior to discharge and stated she had not noticed any skin breakdown on his coccyx at that time. RN #235 confirmed she had only assisted the CNA with turning Resident #40 during incontinence care and had not completed a skin assessment prior to discharge. Interview on 04/29/26 at 2:50 P.M. with Resident #40's representative stated Resident #40 was admitted to the facility on [DATE] with a pressure ulcer to bottom which he developed while hospitalized . Resident #40's representative stated she was not notified of any treatment orders for Resident #40's pressure ulcer while at the facility. Resident #40's representative stated the pressure ulcer was still present upon his admission to the other skilled nursing facility on 04/20/26. Review of the facility policy titled Pressure ulcers/skin breakdown- Clinical protocol revised April 2018 revealed the staff, and practitioner would examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorption, etc.) and applications of topical agents.This deficiency represents non-compliance investigated under Complaint Number 2978515.

Based on medical record review, review of an incident report, review of the hospital records, and staff interview, the facility failed to maintain an accurate and adequately comprehensive medical record. This affected one (Resident #15) out of six (#15, #36, #39, #01, #23, and #45) residents reviewed for accurate and complete medical records. The facility census was 41.Findings include:Review of the medical record for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension. Further review of Resident #15's medical record revealed the resident was assessed as having moderately impaired cognition as of their most recent Minimum Data Set (MDS) assessment dated [DATE].Review of a facility incident report dated 02/17/26, an outside hospital history and physical note dated 02/17/26, and a Situation, Background, Assessment and Recommendation (SBAR) nursing communication note dated 02/17/26 revealed Resident #15 was administered a sublingual nitroglycerin tablet on 02/17/26 while experiencing chest pain at the facility.Interview on 03/12/26 at 12:40 P.M. with Certified Nursing Assistant (CNA) #30 revealed they witnessed Resident #15 being administered a medication under their tongue in response to complaints of chest pain prior to leaving the facility via ambulance. Review of progress notes contained in Resident #15's medical record revealed no mention of a sublingual medication being administered, or any reference of nitroglycerin being administered to the resident by facility staff on 02/17/26.Review of Resident #15's Medication Administration Record (MAR) for February 2026 revealed no mention of Resident #15 having received sublingual nitroglycerin on 02/17/26.Interview on 03/12/26 at 3:51 P.M. with Director of Nursing (DON) #167 verified that besides mention of medication given to resident without order as written on the incident report dated 02/17/26, there was no available facility produced documentation to identify that Resident #15 received sublingual nitroglycerin.This deficiency represents an incidental finding of noncompliance identified while investigating Complaint Number 2791092.

Based on medical record review, observation, staff interview, review of the Ohio Administrative Code (OAC), and policy review, the facility failed to ensure controlled substances were disposed of properly. This affected one (Resident #15) out of 33 residents with controlled substance medication orders. There were eight (#01, #02, #08, #10, #30, #31, #35, and #41) residents who were identified by the facility with no orders for controlled substances. The facility census was 41.Findings include:Review of the medical record for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension. Further review of Resident #15's medical record revealed the resident was assessed as having moderately impaired cognition as of their most recent Minimum Data Set (MDS) assessment dated [DATE].Observation on 03/12/26 at approximately 9:55 A.M. revealed Licensed Practical Nurse (LPN) #155 pulled one medication from a locked drawer that was contained in the medication cart while preparing medications for Resident #15. Further observation at this time revealed the medication was one 150 milligram (MG) capsule of pregabalin (a medication to treat neuropathic pain). LPN #155 was observed signing this medication out in a binder labeled for tracking the dispensing of narcotics prior to opening the capsule and pouring the drug into a medication cup for Resident #15.Observations on 03/12/26 at 10:00 A.M. and 10:15 A.M. revealed Resident #15 refused their pregabalin along with all other medications offered at that time for their morning medication pass.Observation on 03/12/26 at 10:20 A.M. revealed the facility had no waste/disposal solution to safely and properly discard the pregabalin powder, or any other controlled substances in the facility. At this time, no facility staff could locate any solution designated for safely discarding the controlled substances.Interview on 03/12/26 at 10:24 A.M. with the Director of Nursing (DON) #167 revealed the Regional Director of Operations would have to drive to another facility to obtain a container of liquid solution for the disposal of medications and bring it back to the facility so that the medication could be properly discarded. Further interview at this time revealed DON #167 recommended LPN #155 dispose of the pregabalin along with all of Resident #15's other refused medications by flushing the drugs down the toilet.Observation on 03/12/26 at 10:28 A.M. revealed LPN #155 went into an empty, unassigned resident room and flushed the controlled substance down the toilet while they were not accompanied by any other facility staff to verify the medication was properly disposed of.During a follow-up interview on 03/12/26 at 3:28 P.M. the DON #167 revealed a nurse that is discarding medications that are considered controlled substances should be accompanied by another nurse to witness the safe disposal of controlled substances. Further interview with DON #167 at this time verified there should be two nurses present at the time of discarding the medication, to ensure controlled substances are safely disposed of.Review of the facility policy titled Discarding and Destroying Medications, revised November of 2022 revealed medications that cannot be returned to the dispensing pharmacy, such as medications refused by the resident, are disposed of in accordance with federal, state, and local regulations governing management of controlled substances.Review of the Ohio Administrative Code (OAC 4729:5-3-01, effective 07/01/24) regarding the disposal of controlled substances revealed that if a long term care facility uses a method of destruction pursuant to the Code of Federal Regulations (CFR 1317, 09/25/23), the controlled substances transferred to their waste method must be completed by the director of nursing and witnessed by a nurse licensed in accordance with Chapter 4723 of the Ohio Revised Code.This deficiency represents an incidental finding of noncompliance identified while investigating Complaint Number 2791092.

Based on medical record review, staff interview, review of the hospital record, review of the incident report, review of the incident/accident log, and policy review, the facility failed to ensure residents were free of significant medication errors. This affected two (Resident #15 and #36) out of six (#15, #36, #01, #39, #23, and #45) residents reviewed for medication administration. The facility census was 41.Findings include:1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension. Further review of Resident #15's medical record revealed the resident was assessed as having moderately impaired cognition according to the most recent Minimum Data Set (MDS) assessment dated [DATE].Review of a progress and Situation, Background, Assessment, and Recommendation (SBAR) note dated 02/17/26 contained in Resident #15's medical record revealed Resident #15 experienced severe chest pain rated nine out of ten (9/10) on 02/17/26 at 9:40 A.M. and was sent out from the facility to the emergency department. Further review of the note revealed notification of the resident's condition was given to the resident's Primary Care Clinician (Nurse Practitioner #175) on 02/17/26 at 9:48 A.M. Additional review of this note revealed no mention of any medications administered in response to Resident #15's reported chest pain symptoms on the morning of 02/17/26.Review of an incident report prepared by the Director of Nursing (DON) #171 dated 02/17/26 at 10:00 A.M. revealed the following: Resident complaint of chest pain 9/10. Vital signs taken, The Nurse Practitioner (NP) was called, medication given to the resident without an order. Sent to emergency room (ER) for evaluation. Further review of the report revealed the resident identified on the report was Resident #15. Additional review of the incident report revealed immediate action steps were documented as calling the Nurse Practitioner and sending Resident #15 to the emergency room. Review of an outside hospital history and physical note dated 02/17/26 revealed Resident #15 was admitted for hospital treatment via the emergency department on 02/17/26 after presenting with complaints of chest pain. Further review of the history and physical note revealed the following: Patient states that he was given a dose of sublingual nitroglycerin prior to coming to the ED.Interview on 03/12/26 at 10:42 A.M. with Nurse Practitioner #175 revealed that to their best knowledge, Resident #15 was given sublingual nitroglycerin without an order on the morning of 02/17/26. Further interview revealed the Nurse Practitioner was called by facility staff after the incident occurred, asking the Nurse Practitioner to place the order for the medication after the medication had already been administered. Nurse Practitioner #175 stated they did not place an order for Resident #15 to receive sublingual nitroglycerin, and they were not going to place an order for sublingual nitroglycerin on 02/17/26 as they had not received an appropriate assessment that indicated the need for the medication to be administered, given the resident's reported status and health history.Interview on 03/12/26 at 12:34 P.M. with the DON #171 revealed they were aware of Resident #15 being administered sublingual nitroglycerin without an order in place on 02/17/26. Further interview revealed DON #171 did not directly witness facility staff administer the medication to Resident #15, though the DON #171 was in the facility that morning and went to the resident's room after the emergency medical squad had already arrived. DON #171 recalled receiving a telephone report from Nurse Practitioner #175 that Resident #15 had been administered sublingual nitroglycerin without an order prior to leaving the facility for the emergency department. DON #171 stated that when they were trying to investigate the incident, no facility nurse that was on duty the morning of 02/17/26 would admit to administering Resident #15 the nitroglycerin without an order.Interview on 03/12/26 at 12:40 P.M. with Certified Nursing Assistant (CNA) #30 revealed they were in the room with Resident #15 on the morning of 02/17/26 while the resident was experiencing chest pain. Further interview at this time revealed CNA #30 witnessed Resident #15 being administered a medication under their tongue by Licensed Practical Nurse (LPN) #188 in response to the chest pain the resident was describing.Review of Resident #15's physician orders as reflected on the medication administration record (MAR) for February 2026 revealed no record of an order for sublingual nitroglycerin.2. Review of the medical record for Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, diffuse traumatic brain injury with loss of consciousness, essential hypertension, and anxiety amongst other diagnoses. Further review of Resident #36's medical record revealed a more recent diagnosis of sepsis due to methicillin resistant staphylococcus aureus (MRSA) dated 01/22/26. Additional review of Resident #36's medical record revealed the resident was assessed as having moderate cognitive impairment as of their comprehensive MDS assessment completed on 01/28/26.Review of the facility Incident and Accident Log for January 2026 revealed one medication error was recorded on 01/28/26, involving Resident #36. Further review of the incident log revealed documented findings that the wrong antibiotic had been administered to Resident #36 at approximately 10:30 A.M. on 01/28/26.Review of an incident report dated 01/28/26 revealed Resident #36 had been subjected to a medication error incident when they were given intravenous (IV) ceftriaxone instead of IV cefepime as ordered, and the infusion of the incorrect antibiotic ran for approximately five to ten minutes before the antibiotic was stopped. Further review of the incident report revealed a trainee nurse had obtained the wrong antibiotic from the medication refrigerator and started the medication, after having verified the resident's name, medication and dose with another nurse that was training them.Review of the Medication Administration Record (MAR) for the month of January 2026 revealed Resident #36 had an active order for the IV antibiotic cefepime, and there was no order for the IV antibiotic ceftriaxone.Interview on 03/12/26 at 3:51 P.M. with DON #167 verified a medication error involving Resident #36 occurred on 01/28/26 when the resident was administered the wrong antibiotic.Review of the facility policy titled Administering Medications, revised April 2019 revealed medications are administered in accordance with prescriber orders.This deficiency represents non-compliance investigated under Complaint Number 2791092.

Based on medical record review, review of the Self-Reported Incidents (SRI), staff interview, and policy review, the facility failed to timely report an allegation of verbal abuse. This affected one (#23) out of three residents reviewed for abuse. The facility census was 41.Findings include:Review of the medical record for Resident #23 revealed an admission date of 02/02/26. Diagnoses included bipolar disorder current episode manic without psychotic features moderate, anxiety disorder, hypothyroidism, mixed hyperlipidemia, major depressive disorder single episode severe without psychotic features, and hypertension.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Resident #23 was assessed to require supervision for toileting, bathing, dressing, and transfer, set up assistance for oral and personal hygiene, and was independent for eating and bed mobility.Review of the provider visit note dated 02/16/26 revealed Resident #23 reported an incident with a staff member, where they became angry with the resident, which involved yelling and the use of profanity towards the resident. The note was signed by Former Nurse Practitioner (FNP) #175.Review of the electronic system for SRIs from 02/16/26 to 03/11/26 revealed there were no alleged incidents involving Resident #23 that had been reported by the facility.Interview on 03/11/26 at 5:29 P.M. with the Administrator revealed she was not informed of any allegations of abuse involving the staff member, identified as Licensed Practical Nurse (LPN) #94, and Resident #23. The Administrator stated she would have reported the allegation and initiated an investigation if she had been made aware of the concern.Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed the facility would investigate and report any allegations within timeframes required by federal requirements.This deficiency represents non-compliance investigated under Complaint Number 2791092.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure areas of the facility were in good repair. This had the potential to affect all 34 residents residing in the facility. Findings include:Observation of the facility's outdoor courtyard on 01/13/26 at 11:59 A.M. revealed a square raised planter box that was filled with soil had a corner that was broken and coming apart. The broken corner had exposed rusty nails. A small inoperable portable heater was on the concrete next to the planter box. A wooden fence enclosing the courtyard was loose and was falling toward the courtyard. A bag of sand was holding a section of the fence up. A wooden picnic table was covered in peeling paint, and the wood appeared to be deteriorating.Interview and observation with the Administrator on 01/14/26 at 9:03 A.M. confirmed the courtyard had a planter box that was broken, coming apart and had exposed rusty nails, there was portable heater sitting in the courtyard, and the wooden fence was loose and falling toward the courtyard. The Administrator confirmed residents have access to the courtyard. Review of the facility's policy titled Homelike Environment dated February 2021 revealed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment.This deficiency represents non-compliance investigated under Complaint Numbers 2566940 and 2581568.

Based on observations, interviews, record review, and policy review. the facility failed to secure and store medications appropriately. This affected one of two medication carts observed and the facility identified there were four medication carts. This affected Resident #11 and had the potential to affect 13 residents whose medications were stored in the 300-hall medication cart. The facility census was 34.Findings include: 1. Observation on 01/12/26 from 10:39 A.M. to 10:45 A.M. revealed Licensed Practical Nurse (LPN) #141 walked away from medication cart for the 300-hall and rounded the 200-hall corner, and the medication cart was unlocked. The medication cart was not in sight of LPN #141. Interview on 01/12/26 at 10:45 A.M. with LPN #141 confirmed the medication cart was unlocked when he walked away and out of sight. Observation and interview on 01/13/26 at 10:49 A.M. of the medication cart for the 300-hall with LPN #152 revealed the following findings: There were five white pills out of packing in the second drawer. The third drawer had a pink sticky substance in middle part of the drawer and eight bottles of medications had the pinky substance on them. There were two single pills, one beige and one white pill, out of packaging in the third drawer. There was one capsule out of packaging in the bottom drawer. 2. Review of medical record for Resident #11 revealed admission date of 08/23/22. Diagnoses included dementia without behaviors. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident had impaired cognition. Observation on 01/12/26 at 10:55 A.M. in Resident #11's room revealed he was laying in bed with his bedside table on his left side. There was a medication cup present on the bedside table within his reach. Interview and observation on 01/12/26 at 10:59 A.M. with Regional Clinical Nurse (RCN) #174 verified there was unattended medication on the bedside table in Resident #11's room. RCN #174 picked up the medication cup and asked Resident #11 about them. Resident #11 informed her the nurse had left the medication on the bedside table earlier in the morning. RCN #174 verified there were six pills in the medication cup and removed them from the room. Review of the policy titled Medication Labeling and Storage dated 2001 revealed the facility stores all medications and biologicals in locked compartments under proper temperatures, humidity and light controls. Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Compartments containing medications and biologicals are locked when not in use. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observations, staff interviews and facility policy review, the facility failed to ensure frozen foods were stored at appropriate temperatures. This has the ability to affect all residents except 11 residents (#1, #2, #3, #4, #6, #7, #19, #21, #23, #27, and #43) who did not receive food from the kitchen. The facility census was 34.Finding include:Interview and observations on 01/12/26 from 8:50 A.M. to 8:52 A.M. with Dietary Manager (DM) #127 revealed the kitchen's freezer had quit working the previous afternoon. He shared a repair company was called and the part which went out was under warranty and a new one was ordered. He acknowledged the food remained in the freezer and he stated the plan was to keep the food in the freezer with the door closed to help maintain temperature. The walk-in freezer's temperature was 28 degrees Fahrenheit and there was food stored in boxes on the shelves which included hamburger patties, bulk, french fries and vegetables which were in various states of thawing. DM #127 verified the food in the freezer was no longer frozen.The facility identified Residents #1, #2, #3, #4, #6, #7, #19, #21, #23, #27, and #43 had physician orders to be nothing by mouth.Review of the facility policy titled Food and Storage dated 2001 revealed frozen foods are maintained to keep the food frozen solid.

Based on record review, staff interviews, and observations, the facility failed to maintain an accurate medical record. This affected one resident (Resident #12) of 13 residents reviewed for accuracy of medical records. The facility census was 34.Findings include:Review of the medical record for Resident #12 revealed an admission date of 05/09/25.Review of a progress note dated 12/08/25 revealed the interdisciplinary team (IDT) met on that date to discuss an incident that occurred involved Resident #12 on 11/10/25. The team determined the resident had poor safety awareness and he was unaware of his transfer limitations. There were no progress notes in the chart on or around 11/10/25 describing the incident. Review of the active physician orders for 01/12/26 revealed a physician order dated 11/12/25 for a fall mat was to be placed to the left side of the Resident #12's bed when he is in bed, and its placement should be verified every day on each shift.Review of the treatment administration record (TAR) for November 2025, December 2025, and January 2026 revealed nursing staff documented the fall mat was in place at bedside for all shifts. On 01/14/26, Registered Nurse (RN) #165 signed the record confirming the fall mat was placed at Resident #12's bedside.Observations on 01/12/26 at 10:28 A.M. and 01/14/26 at 8:44 A.M. and 11:15 A.M. of Resident #12's room revealed there was no fall mat on either side of his bed while Resident #12 was lying in bed.Interview on 01/14/26 at 11:34 A.M. with RN #165 confirmed there was no fall mat placed at Resident #12's bedside. RN #165 then obtained a fall mat and placed it at the resident's bedside.Interview on 01/14/26 at 1:00 P.M. with the Director of Nursing (DON) revealed the IDT team met on 12/15/25 and determined that the fall mat was no longer an appropriate intervention and confirmed the order should have been discontinued on 12/15/25.Interview on 01/14/26 at 2:50 P.M. with Regional Clinical Nurse (RCN) #174 clarified the incident that occurred on 11/10/25 was a fall. RCN #174 confirmed a new order was received from the facility nurse practitioner for a fall mat to be placed to the left side of Resident #12's bed as an intervention to reduce the likelihood of injury from falls. RCN #174 confirmed the intervention was removed following the IDT meeting on 12/15/25 but the order remained active.

Based on observation, resident and staff interviews, record review and policy review, the facility failed to provide residents privacy for telephone calls. This affected one (Resident #50) of 17 residents reviewed for telephone calls. The facility census was 34.Findings include:Review of the medical record for Resident #50 revealed an admission date of 01/08/26. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, post-traumatic stress disorder, and depression.The admission Data Collection form dated 01/09/26 revealed Resident #50 was alert and oriented times four.Observation and interview on 01/12/26 at 10:57 A.M. revealed Resident #50 was at the 300-Hall nursing station. Resident #50 was utilizing a walker, using the desk telephone for personal call with multiple residents in the hallway. Business Office Manager (BOM) #102 stated the residents were usually given the cordless telephone from the front desk but Resident #50 was using the regular desk telephone at this time.Observation and interview on 01/13/26 at 10:22 A.M. with Licensed Practical Nurse (LPN) #152 revealed Resident #50 came up to the 300-Hall nursing station desk and asked if she could call her father. LPN #152 then handed her the desk telephone. LPN #152 stated that was the only telephone Resident #50 has to use; there was no private telephone. Resident #50 was talking on the telephone with another resident sitting in a wheelchair at the desk, directly next to her while she was talking on the telephone.Interview on 01/13/26 at 2:42 P.M. with Resident #50 confirmed she does not get offered any private area or private telephone when she would like to make a personal call and was given the desk phone at the nursing station. Resident #50 confirmed she would prefer a private area for her personal telephone calls. Interview on 01/14/26 at 1:35 P.M. with Registered Nurse (RN) #165 stated the cordless telephone at the main nursing station was used for residents to make private calls. RN #165 verified the telephone does not work on the 300-hall.Interview on 01/14/25 at 1:35 P.M. with Maintenance Director (MD) #128 stated the cordless telephone does not work on the 300-hall. Review of the admission packet dated 2020 revealed the resident has the right to have reasonable access to the use of a telephone, and a place in the facility where calls can be made without being overheard.

Based on staff interview, policy review and record review, the facility failed to notify the provider and resident representative of a resident's change in condition. This affected one (Resident #9) of one resident reviewed for notification of change. The facility census was 34.Findings include:Review of the medical record for Resident #9 revealed an admission date of 10/19/22. Diagnoses included epilepsy. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had moderately impaired cognition.The care plan, last revised on 10/17/25, revealed Resident #9 had impaired neurological status related to seizure disorder. Interventions included to monitor and report any seizure activity, monitor environment if involuntary muscle movements place the resident at risk for injury, monitor for need of padding to side rails or wheelchairs, monitor vital signs as needed, and report abnormal to physician.Review of Resident #9's progress notes dated 01/07/25 to 01/14/25 revealed no documentation of Resident #9 having a seizure or notification to the resident representative or provider of Resident #9 having a seizure.Interview on 01/13/26 at 7:05 A.M. with Licensed Practical Nurse (LPN) #149 stated Resident #9 had a seizure last night (01/12/26) around the start of his shift. LPN #149 confirmed the oxygen was being administered to Resident #9 at two and a half liters. LPN #149 stated Resident #9 doesn't need the oxygen, he only put it on due to Resident #9 seizing last night. Interview on 01/14/26 at 7:29 A.M. with the Director of Nursing (DON) confirmed no documentation in Resident #9's record of seizure that happened on 01/12/26 and no documentation of notification to provider or resident representative. The DON also confirmed no order for oxygen in Resident #9's record.Interview on 01/14/26 at 8:11 A.M. with LPN #149 stated Resident #9's seizure from 01/12/26 lasted about five minutes. When Resident #9 was lying on his back, he was having difficulty breathing, then gave Resident #9's order for scheduled Keppra (anti-seizure medication). LPN #149 applied oxygen when Resident #9 started to have the seizure, LPN #149 said the other LPN (#141) got an order from the provider for oxygen while he was in the room. Interview on 01/14/26 at 1:15 P.M. with Nurse Practitioner (NP) #178 confirmed she was not notified of Resident #9 having a seizure on 01/12/26 until this morning (01/14/26). NP #178 stated if she was made aware of Resident #9's seizure on 01/12/26, they would have ordered for labs to be drawn.Interview on 01/14/26 at 10:05 AM with LPN #141 revealed Resident #9 had a seizure on 01/12/26 that lasted about five to ten minutes. LPN #141 confirmed he did not notify the provider, and did not speak to the provider about the oxygen.Review of the policy titled Acute Condition Changes Clinical Protocol, dated 03/2018, revealed the nursing staff will contact the physician based on the urgency of the situation. The staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and diagnostic test results. If necessary, the physician will order diagnostic tests and evaluate the patient directly.

Based on record review, resident and staff interviews, and policy review, the facility failed to ensure resident care conferences occurred quarterly with the Interdisciplinary Team and the resident and/or resident representative. This affected three (#8, #9, and #34) of three residents reviewed for care conferences. The facility census was 34. Findings include:1. Review of the medical record for Resident #34 revealed an admission date of 04/01/14. Diagnoses included diffuse traumatic brain injury, disease of digestive system, diabetes mellitus, dysphagia, and major depressive disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had severe cognitive impairment. The care plan revealed Resident #24 was a long term resident with no plans to discharge at this time. Interventions included to review with resident at least quarterly for any changes in discharge planning needs. Review of Resident #34's medical record revealed Resident #34 had one care conference held in the year of 2025, which was on 07/17/25. There were no care conferences held the first (01/2025 to 03/2025), second (04/2025 to 06/2025), and fourth quarter (10/2025 to 12/2025) of 2025. Interview on 01/13/26 at 7:16 A.M. with MDS Coordinator #155 confirmed Resident #34 had only one coare conference on 07/17/25 for the year of 2025. There were no care conferences held for Resident #34 for the first, second, and fourth quarter of 2025. 2. Review of the medical record for Resident #9 revealed an admission date of 10/19/22. Diagnoses included epilepsy, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and major depressive disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact.Review of Resident #9's medical record revealed there was no third quarter 2025 (07/2025 to 09/2025) care conference for Resident #9.Interview on 01/12/26 at 9:44 A.M. with Resident #9 revealed he could not remember any care conferences he attended or was asked to attend. Interview on 01/13/26 at 7:16 A.M. with MDS Coordinator #155 confirmed no care conference was completed for Resident #9 in the third quarter of 2025.3. Review of the medical record for Resident #8 revealed an admission date of 11/03/24. Diagnoses included chronic obstructive pulmonary disease, nonrheumatic aortic stenosis and chronic atrial fibrillation. The MDS 3.0 assessment dated [DATE] revealed Resident #8 had moderately impaired cognition.The care plan revealed Resident #8 was a long term resident with no plans to discharge. Interventions included to review with resident at least quarterly for any changes in discharge planning needs. Review of Resident #8's medical record revealed there was no first quarter (01/2025 to 03/2025) care conference for 2025.Interview on 01/13/2026 at 7:16 A.M. with MDS Coordinator #155 confirmed no care conference was completed for Resident #8 for the first quarter of 2025. Review of the facility's admission packet dated 2020 revealed the resident right to participate in the development and implementation of his or her person centered plan of care.Review of the policy titled Resident Participation Assessment Care Plans dated 2001 revealed the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan.

Based on record review, observations, policy review, and staff and resident interviews, the facility failed to ensure a resident who was dependent on staff for personal hygiene and bathing received adequate assistance with nail care. This affected one (#11) of 12 residents reviewed for activities of daily living (ADL). The facility census was 34.Findings include:Review of the medical record for Resident #11 revealed admission date of 08/23/22. The resident was admitted with diagnoses including stroke, dementia without behaviors, type two diabetes mellitus, depression, anxiety and polyneuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively impaired. Resident #11 was dependent upon staff for personal hygiene and toileting.Review of the care plan revealed Resident #11 had a physical functioning deficit with interventions which included nail care as needed.Observation and interview on 01/12/26 at 11:01 A.M. revealed Resident #11's fingernails had extended approximately one eighth of an inch beyond his fingertips. His nails were observed to be encrusted with a dark brown substance. Resident #11 stated staff had not offered to clean and trim his nails and acknowledged he would like assistance with nailcare.Observation and interview on 01/13/26 at 11:36 A.M. with Certified Nurse Assistant (CNA) #118 verified Resident #11's fingernails were long and dirty. She stated another CNA had told her she would take care of his nails. She added she would clean them and inform the nurse Resident #11's nails needed cut, explaining Resident #11 was diabetic and CNAs were unable to cut the nails of residents who were diabetic.Interview on 01/13/26 at 12:25 P.M. with Licensed Practical Nurse (LPN) #152 stated it was the expectation the CNAs to clean and trim a resident's nails during showers and/or bed baths. LPN #152 explained the residents who were diabetic, it would be the responsibility of the nurse or podiatrist to ensure they were trimmed.Observation on 01/14/26 at 8:34 A.M. revealed Resident #11's fingernails were clean, however; they remained uncut.Interview on 01/14/26 at 8:34 A.M. with the Director of Nursing (DON) revealed the DON was informed Resident #11's request for nail care.Review of the progress note dated 01/14/26 at 9:58 A.M. revealed Resident #11's fingernails were cut per his request, hands were washed with soap and water, rinsed and dried.Review of the facility policy titled Activities of Daily Living (ADLs) dated 2001 documented residents who were unable to carry out ADLs independently would receive appropriate support and assistance with hygiene (bathing dressing, grooming and oral care).This deficiency represents non-compliance investigated under Complaint Numbers 2573072 and 2703714.

Based on record review and staff interviews, the facility failed to ensure a resident received adequate care and treatment for intravenous line placements, skin assessments, and a wound vac. This affected one (Resident #46) of five residents reviewed for hospitalization. The facility census was 34.Findings include:Review of Resident #46's medical record revealed an admission date of 08/05/25 with diagnoses including acute respiratory failure with hypoxia, anxiety disorder, tracheostomy status, and depression. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had moderately impaired cognition, and dependent on staff with toileting and bathing. Resident #46 discharged from the facility on 08/12/25.Review of Resident #46's assessments from 08/05/25 to 08/12/25 revealed there were no wound or skin assessments completed upon admission or after. Review of Resident #46's physician orders dated 08/05/25 revealed wound vac to abdomen at 100 millimeters of mercury (mmHg) suction to be changed every Monday, Wednesday and Friday dayshift. The care plan dated 08/06/25 revealed wound vac to abdomen as per orders with settings as per orders. Resident #46 had an intravenous dressing and interventions included observe dressing, change dressing and record observations of site per physician orders. The progress note dated 08/07/25 at 2:24 P.M. revealed the wound vac applied to Resident #46's abdomen. Review of the Treatment Administration Record (TAR) revealed wound vac was applied on 08/07/25, and there were no further wound vac changes done. Physician orders revealed the wound vac should have been changed on Friday 08/08/25 and Monday 08/11/25.Review of Resident #46's progress notes dated 08/06/25 revealed Resident #46's intravenous (IV) pump continued to alarm when attempting to infuse via the peripheral line to the resident's right shoulder. The writer attempted to use the peripheral to the residents' left hand, and when attempting to flush, the resident stated that it was painful. Also noted some erythema to the area beneath the transparent dressing, so this access was removed. The Nurse Practitioner (NP) was notified. Peripheral IV to resident's left shoulder was flushed with no issues and the IV medications were continued via this access with no further issues noted. The NP note dated 08/08/25 revealed Resident #46 had three peripheral intravenous lines: a 20-gauge in the left wrist, a 20-gauge in the left shoulder, and a 18-gauge int he right forearm.The progress notes and TAR from 08/06/25 to 08/12/25 revealed no intravenous site care and monitoring of the access sites.Interviews on 01/14/26 at 10:25 A.M. with the Director of Nursing (DON) confirmed Resident #46 did not get skin/wound assessment done on admission through discharge. On 01/15/26 at 10:12 A.M., the DON confirmed Resident #46 had no wound vac changes done from 08/07/25 until discharge on [DATE]. The DON confirmed Resident #46 had no intravenous site care done from admission on [DATE] until discharge on [DATE].This deficiency represents non-compliance investigated under Complaint Numbers 2589893 and OH00164513 (1367213).

Based on observations, resident and staff interviews, record review, and policy review, the facility failed to ensure fall interventions were in place for a resident who had a history of falling. This affected one (Resident #9) of two residents reviewed for accidents. The facility census was 34. Findings include:Review of the medical record for Resident #9 revealed an admission date of 10/19/22. Diagnoses included epilepsy, cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had moderately impaired cognition and was dependent on staff for toileting, bathing, and personal hygiene.The care plan dated 11/07/23 revealed Resident #9 was at risk for falls related to impaired mobility. Interventions included bilateral fall mats to floor on each side of bed, call light in reach at all times when in bed, educate/remind to use call light prior to transfer, encourage resident to use call light for assistance for toileting needs, ensure personal items are within reach at all times, and sign hung at eye level to remind to use call light for assistance with toileting.The progress note dated 10/03/25 revealed Resident #9 had a fall. Review of Resident #9's fall investigation revealed an intervention of bilateral fall mats to each side of bed.Observation of Resident #9's room on 01/12/26 at 9:43 A.M. revealed Resident #9 was lying in bed and there were no fall mats on the floor. The fall mat was leaning against the wall near his bed. Observation on 01/12/26 at 12:01 P.M. revealed Resident #9 was lying in his bed with his eyes closed. There were no fall mats on the floor.Observation on 01/12/26 at 1:02 P.M. revealed Resident #9 was lying in bed and there was one fall mat on the floor on the right side only.Observation and interview on 01/12/26 at 1:17 P.M. with Resident #9 revealed he needed help with his adult briefs and the call light was not within his reach. The call light was lying on the floor of Resident #9's room next to the bed. On 01/12/26 at 1:22 P.M., Certified Nursing Assistant (CNA) #104 confirmed Resident #9's call light was not within reach.Observation and interview on 01/12/26 at 2:24 P.M. revealed Resident #9 was lying in bed and the fall mat was leaning on the wall and not on the floor next to his bed. CNA #104 confirmed Resident #9 was lying in bed and his fall mat was next to the wall and not on the floor beside Resident #9's bed.Observations on 01/13/26 at 7:50 A.M. and 10:24 A.M. revealed Resident #9 was lying in bed and there was one fall mat on the floor on the right side only.Review of the policy titled Call System, Residents dated 09/2022 revealed each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting, bathing facilities and from the floor. Review of the policy titled Falls and Fall Risk Managing dated 2001 revealed the staff will implement a resident centered fall prevention plan to reduce the specific risk factor of falls for each resident at risk or with a history of falls. This deficiency represents non-compliance investigated under Complaint Number 2703714.

Based on record review, staff interview, and facility policy review, the facility failed to ensure residents were provided with a proper discharge. This affected one (#100) of the three residents reviewed for discharges. The facility also failed to ensure the discharges were reported to the local ombudsman office. This affected one (#100) of the three residents reviewed. The facility census was 33.Findings include: 1) Review of the medial record or Resident #100 revealed the resident was admitted to the facility on [DATE] and discharged to his home on [DATE]. Diagnoses included orthostatic hypotension, diabetes mellitus (DM), dehydration, dysphagia, and anxiety disorder.Review of the Care Plans dated 04/18/25 for Resident #100, revealed no care plan developed for discharge planning.Review of the April and May 2025 physician orders for Resident #100, revealed no orders for the resident to be discharge from the facility.Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #100 was cognitively intact. Resident #100 was dependent on staff for medication administration and required set-up assistance for other activities of daily living (ADLs). Review of a progress note for Resident #100 dated 05/05/25, revealed a referral was faxed to Queen City Home Health per the resident's request. Review of a progress note for Resident #100 dated 05/15/25 at 6:15 P.M., revealed the resident and sister were aware that the appeal was denied and the resident declined to complete another appeal. The resident wanted to discharge home tomorrow. Resident #100 would be discharged home on [DATE] with the home health care agency referral in place.Review of Nurse Practitioner (NP) progress note for Resident #100 dated 05/15/25, revealed the resident was seen related to a discharge visit. Notes indicated the resident resided in an Assisted Living Facility (ALF) and was receiving primary care services. The resident was planned on being discharged tomorrow but expressed discomfort with the discharge plan. The resident was stable but stated he felt as if he was not being adequately monitored and was unsure if he was ready to go home and did not feel comfortable administering his insulin. Review of a progress note dated 05/16/25 at 12:06 P.M., revealed the social worker contacted the resident's sister to schedule a discharge time. The resident's sister stated she would pick up the resident today at 5:15 P.M. Review of a progress note for Resident #100 dated 05/16/25 at 5:10 P.M., revealed the resident was discharged home with his personal belongings and medications including 19 tablets of Lomotil (anti-diarrhea) and 27 oxycodone (narcotic pain relief) five milligrams (mg). Diabetes teaching was completed, medications were discussed, and the nurse instructed the resident to follow-up with his primary care physician. All questioners were answered, and the resident left in private vehicle with no distress. There were no additional progress notes about a discharge summary being completed or being provided to the resident. Review of the Recapitulation of Stay dated 05/16/25 for Resident #100, revealed the only section completed was section two (Social Services). Social Services noted a referral was made to a home health agency and sent a referral to obtain a primary care physician. The admission information, discharge information, summary of stay, nursing services, dietary services, activities, and rehabilitation services were all blank, and the form was not signed. Interview on 10/29/25 at 9:20 A.M. with the Director of Nursing (DON) #52 from the ALF community where the resident was listed as being discharged to, revealed Resident #100 never resided in the ALF. DON #52 stated Resident #100 had always lived in an independent living apartment and was discharged back to his independent living apartment from the facility. Interview on 10/29/25 at 9:53 A.M. with Nurse Practitioner (NP) #501 revealed Resident #100 expressed concerns about not being ready to go home related to his insulin. NP #501 stated she thought Resident #100 was discharged to an ALF and was surprised to learn Resident #100 was discharged to an independent living apartment. NP #501 stated she was certain Resident #100 went home with home health referral because a home health care nurse called her to ask for a prescription for insulin because the resident was discharged without any insulin and without having a primary care physician in place.Interview on 10/29/25 at 10:25 A.M. with Home Health Care Registered Nurse (RN) #504 stated Resident #100 was discharged from the facility to an independent living apartment with no primary care physician to follow him. RN #504 stated she visited Resident #100 on 05/17/25 and the resident did not have any insulin in his apartment. RN #504 stated she reached out to NP #501 because Resident #100 did not have a primary care physician to contact. RN #504 requested an insulin order from NP #501 and to be sent to Resident #504's independent living apartment. RN #504 stated she had to assist Resident #504 with finding a primary care physician. Interview with the Administrator on 10/29/25 at 1:54 P.M. verified Resident #100 was discharged from the facility without a discharge summary or a discharge plan. The Administrator stated Resident #100 was discharged from the facility without a primary care physician in place or a scheduled follow up appointment with a primary care physician.Review of the facility policy titled Discharge Summary and Plan dated October 2022, revealed when a resident's discharge is anticipated, a discharge summary and post discharge plan is developed to assist the resident with discharge. The discharge summary of the resident's stay at the facility and final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and permitted by the resident. A copy of the resident's post-discharge plan and discharge summary will be filed in the Residents medical record.2) Review of the May 2025 through October 2025 information sent to the Ombudsman's Office for discharges, revealed each monthly cover sheet was sent to an unknown fax number. Each cover sheet contained a list of discharges from the facility; however, there was no documented evidence that the information was sent and /or received by the Ombudsman's Office. Interview with Ombudsman #506 on 10/29/25 at 9:08 A.M,, revealed the Ombudsman's Office did not receive any notification of discharges from the facility in the past six months. Ombudsman #506 verified they were not aware Resident #100 was discharged . Ombudsman #506 stated the fax number listed on the facility's cover sheet was not a fax number for the Ombudsman's Office.Interview with the Administrator on 10/29/25 at 1:54 P.M., stated a list of the discharges were to be faxed to the local Ombudsman's Office monthly. The Administrator reported the facility was not aware of the incorrect number where the faxes were being sent. The Administrator verified the facility had no documented evidence that the Ombudsman's Office was being notified of the facility discharges. This deficiency represents non-compliance investigated under Complaint Number 1367217.

Based on observations, interview, and facility policy review the facility failed to ensure enhanced barrier precautions were followed for one resident (#36) and failed to ensure soiled gloves were removed prior to touching clean items for one (#36) of three residents reviewed. The facility census was 42. Findings Included: Review of medical record for Resident #36 revealed a re-admitted [DATE], and an initial admitted [DATE]. Diagnoses included anoxic brain damage, stage four pressure ulcer of left elbow and sacrum which were documeted to be present on admission to the facility. Observation on 08/14/24 at 11:42 A.M. Registered Nurse (RN) #329 and State tested Nurse Aide (STNA) #405 enter Resident #36 room to perform incontinence care, repositioning, wound care, and to check urinary catheter for position. The staff were observed to bring the wound treatment cart into Resident #36's room and the staff were observed to put on gloves to provide care to the resident. No other personal protective equipment (PPE) was used by the staff during the observation. STNA #405 was observed to uncover the resident, reposition the resident and open the incontinent brief prior to assisting RN #329 with wound care. STNA #405 had touched Resident #36's linens, and incontinent brief. RN # 329 asked STNA # 405 to get an additional four-by-four dressing out of the treatment cart during wound care. STNA #405 did not remove her soiled gloves, perform hand hygiene and don new gloves prior to searching in the treatment cart's first and second drawers to grab another four-by-four sterile dressing. STNA #405 was observed to open the first and second drawer of the treatment cart with her soiled gloves on, locate a four-by-four dressing and give it to the RN #329 to finish cleansing Resident #36 coccyx wound. Interview on 08/14/24 at 1:00 P.M. with Director of Nursing (DON) confirmed the treatment cart should have not been taken into Resident #36's room, due to the resident being in enhanced barrier precaution. Interview on 08/14/24 at 1:42 P.M. with DON confirmed she expected staff to use correct ppe when taking care of a resident. Interview on 08/14/24 at 5:00 P.M. with RN #329 stated yes, that STNA #405 should have never reached into the treatment cart for supplies when having dirty gloves while caring for Resident #36 in his room for personal, and wound care. Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 08/2022 revealed that the facility enhanced barrier precaution are used as a infection prevention and control interventions to reduce the spread of multi-drug resistant organisms (MDRO) to residents. 2. EBP employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. EBP use of gown and gloves is required for high contact care activities including toileting, wound care, and device care including urinary foley care.

Based on observation, record review, facility staff interview, and policy review the facility failed to timely repositioning and turn one resident (#36) of three reviewed for pressure ulcers. The facility census was 42. Findings Included: Review of medical record for Resident #36 revealed a re-admitted [DATE], and an initial admitted [DATE]. Diagnoses included anoxic brain damage, stage four pressure ulcer of left elbow and sacrum which were documeted to be present on admission to the facility. Review of plan of care dated 06/18/24 revealed that Resident #36 had actual stage four pressure ulcer to the left elbow. Interventions included turning and repositioning schedule per assessment, turn side to side in bed every one to two hours, and treatments as ordered. Resident #36 also had a stage four pressure ulcer to right sacrum plan of care that included interventions of pillows for positioning, low air loss mattress, turning and repositioning and weekly wound assessment. Resident #36 was at risk for pressure ulcers due to impaired mobility. Interventions included weekly skin inspection, and repositioning schedule per assessment. Review of Braden Scale for predicting pressure ulcer risk dated 08/11/24 revealed Resident #36 was at high-risk to develop pressure ulcer with a score of 10.0. The Braden scale scoring criteria was severe risk scored 9 or less, high risk scored 10 through 12, moderate risk scored 13 through 14, mild risk scored 15 through 18, and no risk scored 19 through 23. Observation on 08/14/24 from 9:40 A.M. through 11:42 A.M. revealed Resident #36 was laying in bed on their left side. At 11:42 A.M. Registered Nurse #329 and State tested Nursing Assistant (STNA) #405 were observed to provide Resident #36 incontinence care, wound care and repositioning. Interview on 08/14/24 at 10:50 A.M. with STNA #405 confirmed she was caring for Resident #36 and verified she had not turned or repositioned Resident #36 on the day shift on 08/14/24. STNA #406 stated she clocked in later due to being called in to work. Interview on 08/14/24 at 1:43 P.M. with STNA #284 who stated Resident #36 was on her assignment and verified she worked the day shift but left the facility around 8:30 A.M. due to not feeling well. STNA #284 verified she had not provided any care, repositioning or turning to Resident #36 on 08/14/24. Interview on 08/14/24 at 3:37 P.M. with STNA #369 who worked the overnight shift verified stated Resident #36 was changed and repositioned in bed at 5:00 A.M. on 08/14/24 to his left side. STNA #369 stated she remembered that time, because she assisted the nurse with treatments. This was the only repositioning care staff remembered providing the resident on 08/14/24 from 5:00 A.M. through 11:42 A.M. when RN #329 and STNA #405 were observed to provide incontinent care, wound care and repositioning for Resident #36. Review of policy titled Prevention of Pressure Injuries with a revision date of April, 2020 revealed The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Reposition the resident as indicated on the care plan. This deficiency represents non-compliance investigated under Complaint Number OH00156007.

Based on observation, resident interview, and staff interview, the facility failed to ensure exterior windows in resident rooms were maintained. This affected seven (Residents #03, #09, #11, #25, #26, #30, and #31) of 37 residents residing at the facility. Findings include: Observation of the facility on 04/26/24 at 11:21 A.M. revealed there was plastic covering Resident #09 and Resident #11's windows and blinds, and the blinds could not be opened without poking a hole in the plastic. Further observation of the facility revealed there were no screens in the exterior windows in Resident #03, #25, #26, #30, and #31's rooms. Interview with Maintenance Director #80 on 04/26/24 at 11:21 A.M. verified there was plastic covering Resident #09 and Resident #11's windows and blinds, and the blinds could not be opened without poking a hole in the plastic. Maintenance Director #80 stated Resident #09 and Resident #11 had plastic over their exterior windows and blinds because the windows were old and allowed cold air in Resident #09 and Resident #11's rooms. Maintenance Director #80 stated the plastic was placed on the windows to keep the cold air from coming in the room. Maintenance Director #80 also confirmed there were no screens in the exterior windows in Resident #03, #25, #26, #30, and #31's rooms and that all windows were made with screens. Maintenance Director #80 stated some of the windows had been missing screens for a long time. Interview on 04/26/24 at 11:28 A.M. with Resident #25 revealed she was not able to open her window because there was not a screen in her window. Resident #25 stated that a squirrel came in her room one time when she had her window open because there was no screen in the window. Interview with Resident #09 on 04/26/24 at 11:35 A.M. revealed he had plastic over his window in his room because his room got cold. Resident #09 stated his room had been warmer since the plastic was applied over the window. Interview with Resident #11 on 04/26/24 at 11:42 A.M. revealed he had plastic over his window in his room because he had big temperature fluctuations in his room. Resident #11 stated the plastic has helped with the fluctuations. Resident #11 stated he thought the fluctuations were due to the windows being old. Interview with Resident #03 on 04/26/24 at 11:54 A.M. revealed he did not think he had a screen in his exterior window in his room. Resident #03 stated he enjoyed opening the window in his room and did not have any issues with bugs entering his room. Interview with Maintenance Director #80 on 04/26/24 at 11:51 A.M. revealed he did not have any documentation of any window invoices, repairs, or assessments for Resident #03, #25, #26, #30, and #31's missing screens in their windows or Resident #09 or Resident #11's windows that allowed in cold air and were covered with plastic. Interview with Maintenance Director #80 on 04/26/25 at 1:06 P.M. revealed the plastic was placed over Resident #09 and Resident #11's windows and blinds in December 2023 or January 2024. This deficiency represents non-compliance investigated under Complaint Number OH00152112.

Based on of open and closed medical record review, staff interviews, resident representative interview, review of hospital records, review of the death certificate, and review of facility policy, the facility failed to appropriately assess and provide timely intervention for Resident #45 following a change in condition. This resulted in Immediate Jeopardy and placed Resident #45 at risk for serious life-threatening harm, negative health outcomes, and/or death when on [DATE] at approximately 3:06 P.M., Resident #45 complained of lower abdominal pain to Assistant Director of Nursing (ADON) #02 and was unable to tolerate palpation to his abdomen. After Resident #45 complained of abdominal pain, his bowel sounds were not assessed and the physician ordered imaging results, which indicated a possible bowel obstruction, and the results were not relayed to the physician timely. Consequently, Resident #45 was transferred to the hospital on [DATE] at 11:47 A.M. at the request of Resident #45 and his representative and was treated for severe sepsis before passing away on [DATE]. This affected one (Resident #45) of three residents reviewed for a change in condition. The facility census was 42. On [DATE] at 12:08 P.M., the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO) #300, and Regional Nurse #400 were notified Immediate Jeopardy began on [DATE] at approximately 3:06 P.M. when Resident #45 complained of abdominal pain and was not adequately assessed by licensed nursing staff. Resident #45 had test results that indicated a possible bowel obstruction, which was not addressed until Resident #45, and his representative requested Resident #45 be transferred out to the hospital for further evaluation. Resident #45 passed away on [DATE] due to pneumoperitoneum (air or gas in the abdominal cavity). The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 1:00 P.M., Registered Nurse (RN) #500, Licensed Practical Nurse (LPN) #12, LPN #14, LPN #68, Minimum Data Set (MDS) LPN #72, and LPN #600 completed comprehensive assessments on all residents in the facility to identify any change of condition, evidence of constipation, and confirming dates of last bowel movement. Physicians will be notified of any changes as appropriate. On [DATE] at 1:00 P.M., MDS LPN #72 reviewed the records of all residents receiving opioids and/or who are assessed to be at risk for constipation, to ensure care plans addressing the risk have been implemented, if appropriate. On [DATE] at 1:00 P.M., Regional Nurse #400 reviewed all test results completed today to ensure the physician has been notified of the results, if appropriate. On [DATE] at 1:05 P.M., RN [NAME] President of Clinical Services (VPCS) #800 reviewed the Change in Condition and Notification Policy to include steps on physician notification. On [DATE] at 2:00 P.M., the DON initiated in servicing for all nursing staff and respiratory staff in the facility on the revised Change in Condition and Notification policy, and on the need to ensure assessments are completed and documented if a resident experiences a change in condition. Licensed nurses will also be in serviced on the need to ensure that the physician is timely notified of all diagnostic testing results. Staff who are not educated by [DATE] will not be permitted to work until the in-servicing is completed. On [DATE] at 5:00 P.M., an ad hoc Quality Assurance (QA) Meeting was held with Medical Director (MD) #700, the Administrator, and DON, and reviewed the findings, discussed, and approved the plan of action. The DON, ADON #02, and MDS LPN #72 will audit 24-hour reports and bowel movement records for physician and family notification of change in condition and diagnostic test results, and assessment of residents who experienced a change in condition or who had no bowel movement for three days and/or complaints of constipation. Audits will be completed daily for two weeks, and then three times a week for two weeks. The QA Committee will monitor the results of the audits and follow-up as needed. Review of the QA meeting minutes dated [DATE] from 5:00 P.M. to 6:00 P.M. revealed the Administrator, DON, and MD #700 participated in a meeting regarding change in condition and notification. Interviews on [DATE] from 6:00 P.M. to 6:15 P.M. with LPN #16 and LPN #68 verified they had received education related to change in condition and bowel assessments. Review of assessments dated [DATE] for Residents #12, #25, #27, #28, and #29 revealed they had been assessed by the facility for any changes in condition. Review of staff education dated [DATE] confirmed LPN #16 and LPN #68 acknowledged they had received education on this date. The education included policies on pain management and notification of change as well as charts on how to respond to gastrointestinal signs and symptoms and laboratory tests/diagnostic procedures. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #45 revealed he was admitted to the facility on [DATE], transferred to the hospital on [DATE], and passed away on [DATE]. Diagnoses included cerebral infarction due to embolism of unspecified cerebral artery, cerebral edema, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, occlusion and stenosis of unspecified carotid artery, acute embolism and thrombosis of left femoral vein, chronic atrial fibrillation, other low back pain, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, rheumatoid arthritis, other intervertebral disc degeneration lumbar region, old myocardial infarction, hyperlipidemia, and major depressive disorder. Review of the Admission assessment dated [DATE] revealed Resident #45 ' s bowel elimination pattern was constipation. Review of the plan of care initiated on [DATE] and revised on [DATE] revealed Resident #45 was at nutritional/dehydration risk related to diagnoses of cerebral infarction due to embolism of unspecified cerebral artery, hypertension, hypotension constipation, depression, atrial fibrillation, hyperlipidemia, and chronic obstructive pulmonary disease. Interventions included administering medications per order and monitoring for ineffectiveness and/or side effects and notifying physician of abnormal findings. Review of the plan of care initiated on [DATE] and revised on [DATE] revealed Resident #45 required pain management and monitoring related to chronic back pain. Interventions included administer pain medication as ordered, evaluate, and establish level of pain on numeric scale/evaluation tool, evaluate characteristics and frequency/pattern of pain, evaluate need for routinely scheduled medications rather than as needed pain medication administration, evaluate what makes the pain worse, and observe for potential medication side effects. Review of the physician orders revealed Resident #45 had orders with start dates of [DATE] for MiraLax Oral Powder 17 grams (GM)/scoop to be given as one scoop by mouth one time a day for constipation, Sennosides-Docusate Sodium 8XXX,d+[DATE] milligrams (mg) with a dosage of one tablet by mouth at bedtime for constipation, Docusate Sodium 100 mg with a dosage of one tablet by mouth two times a day for constipation, and Bisacodyl Rectal Suppository with instructions to insert one suppository rectally as needed for constipation once daily. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #45 had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene as well as supervision and setup assistance for eating. Review of the pain levels documented under the vitals tab of the electronic health record, revealed Resident #45 reported a pain score of eight on a zero to ten pain scale on [DATE] and [DATE]. Review of the medication administration notes dated [DATE] and [DATE] revealed Resident #45 received as needed oxycodone hydrochloride oral tablet 5 mg with a dosage of one tablet by mouth every six hours as needed for pain. Review of the progress note dated [DATE] at 11:50 P.M. revealed Resident #45 complained of nausea and a new order for Zofran 4 mg as needed every six hours was ordered. Review of the medication administration notes dated [DATE] at 12:52 A.M. and 3:23 A.M. revealed Resident #45 complained of constipation and requested as needed rectal suppository, and the administration was noted as effective due to the resident having a medium bowel movement. There is no documentation related to an assessment of Resident #45 ' s bowels or that Resident #45 ' s representative had been notified. Review of the nursing progress note dated [DATE] at 3:06 P.M. revealed Resident #45 reported having pain in his lower abdomen. Resident #45 stated he last had a bowel movement the previous day that was loose. The on-call provider was notified and gave an order for a kidney, ureter, and bladder (KUB) X-ray. Review of the KUB X-ray results electronically signed by the interpreting physician on [DATE] at 5:02 A.M. documented Resident #45 had dilated loops of bowel, colonic fecal residual noted, an ileus type pattern favored, and an obstruction not excluded. The results recommended a computed tomography (CT) scan or follow-up as clinically warranted. Review of the nursing progress notes on [DATE] between 5:02 A.M. and 11:47 A.M. revealed no documentation that the physician or Resident #45 ' s representative had been notified of the KUB X-ray results. Review of the nursing progress note dated [DATE] at 11:47 A.M. revealed Resident #45 complained of severe abdominal pain and being unable to urinate. Resident #45 and his representative requested for him to be sent to the emergency room (ER) for further evaluation. Certified Nurse Practitioner (CNP) #200 was contacted, and Resident #45 was transferred to the hospital. Review of the hospital triage complaint dated [DATE] revealed Resident #45 presented to the ER with a complaint of abdominal pain that was a ten out of ten across his lower abdomen, which started yesterday morning. Resident #45 reported the pain was sharp, constant, and gradually worsening. Resident #45 expressed he had been constipated for the last two or three days. The complaint indicated Resident #45 ' s abdomen was distended with involuntary guarding particularly all across the lower abdomen and there was tenderness to percussion. Per the triage complaint, Resident #45 had a CT scan that noted free air and fluid in the abdominal cavity, which was compatible with perforation. The suspected perforation was located within the sigmoid colon (portion of large intestine before reaching the rectum), and secondary to acute sigmoid colonic diverticulitis (occurs when colon wall protrusions become infected; usually caused by a blockage of the inside space of a structure such as intestine or obstruction from stool; can burst open and spill fecal matter into the bloodstream causing sepsis). The CT scan also noted an associated small bowel obstruction. The triage complaint listed diagnoses of pneumoperitoneum, acute renal failure, severe sepsis, small bowel obstruction, abdominal aortic aneurysm without rupture, complete intestinal obstruction, and diverticulitis of sigmoid colon for Resident #45. Resident #45 was transferred to another ER for further evaluation and treatment. Review of the hospital history and physical dated [DATE] revealed Resident #45 ' s abdomen was distended, and no bowel sounds were heard. Review of the hospital attending note dated [DATE] revealed Resident #45 appeared visibly uncomfortable and had a nasogastric tube with bilious output (bile). The physician relayed to Resident #45 regarding concerns for perforated colon and how sick he is and could continue to become if he does not get prompt surgical intervention. The note indicated that treatment was discussed with Resident #45 and his wife, including the possible complications and concerns related to Resident #45 ' s medical history and current medical conditions. It was noted Resident #45 declined to pursue aggressive treatment with his wife in agreement. The recommended treatment plan was antibiotics administered intravenously as Resident #45 and his wife were likely pursuing comfort care. Review of the death certificate dated [DATE] revealed Resident #45 died on [DATE] from pneumoperitoneum due to sigmoid diverticulitis at the hospital. During a telephone interview on [DATE] at 10:01 A.M. with Resident #45 ' s representative stated Resident #45 was septic and in organ failure when he arrived at the hospital. The representative stated Resident #45 had started feeling sick on [DATE], complained of pain, and had vomited what he described to her as grass green throw-up. Surgery was an option, but there were concerns related to Resident #45 ' s prognosis because of his condition. Resident #45 ' s representative stated no staff from the facility alerted her to his condition when he first started feeling sick, and she only received information from Resident #45 via telephone. During an interview on [DATE] at 12:55 P.M., ADON #02 stated Resident #45 reported to her that he was having pain in his lower abdomen. ADON #02 stated when she went to palpate his stomach that Resident #45 would not allow her to palpate much or with pressure due to pain. ADON #02 expressed that she contacted the on-call provider and received an order for the KUB to determine if Resident #45 had a blockage. ADON #02 indicated Resident #45 had some bowel movements that were loose. ADON #02 advised the results from the KUB were received the next day, but that she was unaware what night shift had done with the results. ADON #02 stated she contacted Resident #45 ' s representative when she saw the results, and advised his wife that it was up to her if she wanted him sent out. ADON #02 stated she contacted the provider for Resident #45 to be sent out for evaluation. ADON #02 stated it would be normal to listen to bowel sounds when a resident had complaints like Resident #45 ' s, but ADON #02 confirmed she had not listened to Resident #45 ' s bowel sounds on [DATE]. ADON #02 also verified no documentation in Resident #45 ' s medical record of notification to his representative of his change in condition, or to the physician and Resident #45 ' s wife regarding the KUB results. During an interview via telephone on [DATE] at 2:14 P.M., LPN #54 stated she had received report at the start of her shift on [DATE] between 7:00 A.M. to 7:30 A.M. that Resident #45 had a KUB, and the results indicated he was impacted. LPN #54 stated the aide informed her that Resident #45 was in pain, and LPN #54 expressed she noted Resident #45 ' s abdomen was distended upon her examination of him prior to Resident #45 being transferred to the hospital but advised Resident #45 refused to allow much palpation due to pain. During an interview on [DATE] at 2:32 P.M., the DON and Regional Nurse #400 stated the facility had no procedure related to residents with constipation. Regional Nurse #400 stated a bowel assessment would be performed based on resident symptoms and if they had continued issues with constipation. Regional Nurse #400 advised Resident #45 had bowel movements on [DATE] and [DATE], and therefore would not pose a concern to staff, despite Resident #45 complaining of constipation and abdominal pain on [DATE]. During an interview on [DATE] at 8:53 A.M., the DON and MDS LPN #72 revealed Resident #45 was at risk for constipation and prescribed routine and as needed medications for treatment of constipation. The DON verified the intervention on Resident #45 ' s care plan related to constipation was to administer medications as ordered. The DON and MDS LPN #72 advised bowel assessments would be conducted based on clinical judgement and on a case-by-case basis but were unable to elaborate how facility staff should know when such assessment should be performed. The DON advised Resident #45 had two bowel movements on [DATE] that were documented as constipated/hard. During an interview via telephone on [DATE] at 9:08 A.M., CNP #200 stated she had been made aware that Resident #45 had complained of abdominal pain on [DATE] and had a KUB. CNP #200 indicated a possible obstruction would be an urgent situation like appendicitis, and that a resident should be sent out within a matter of hours following review of X-ray results, and even earlier than that based on individual symptoms. CNP #200 inquired as to the timeframe between when the X-ray results were received by the facility and when Resident #45 was transferred out to the hospital because based on her understanding Resident #45 was transferred out shortly following review of the X-ray results. Review of the facility policy titled Notification of Changes, dated [DATE], revealed the facility must inform the resident, consult with the resident ' s physician and/or notify the resident ' s family member or legal representative when there is a change requiring such notification. The policy indicated circumstances requiring notification included significant change in the resident ' s physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, and circumstances that require a need to alter treatment. This deficiency represents non-compliance investigated under Complaint Number OH00148932.

Based on medical record review, observations, resident interview, staff interview, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to provide services and implement interventions to prevent pressure ulcers including a failure to perform routine skin assessments and pressure relief interventions. This resulted in actual harm when Resident #1 developed an avoidable stage three pressure ulcer on the heel. This affected one (#1) out of three residents reviewed for pressure ulcers. The facility identified 13 residents with pressure ulcers. The facility census was 33. Findings include: Review of Resident #1's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission minimum data set 3.0 ((MDS) dated [DATE] revealed a brief interview of mental status (BIMS) of 15, the resident was at risk for developing pressure ulcers, no behaviors noted, and no rejection of care identified. Resident #1's functional status was extensive assist with bed mobility and turning, the resident required total dependence on dressing, toileting, and personal hygiene. Further review of Resident #1's medical record revealed a physician's progress note from the facility's medical director and acting medical director from a previous facility the resident resided dated 02/20/17 included [DIAGNOSES REDACTED]. The admission acute care-plan dated 03/14/17 identified potential for altered skin integrity with interventions to assess skin on admission and weekly, complete Braden scale on admission and monthly, treat skin conditions, wounds etc. as ordered, labs as ordered, and dietician to evaluate. A request was made for staff to provide full updated care-plan. A printed care-plan was presented as the completed care plan with review dates prior to survey included: nutritional status 03/16/17, indwelling urinary catheter related to [DIAGNOSES REDACTED]. One preventative measure was identified in the resident's record upon admission revealed only by a check mark by mattress. There were no identified problems in the completed, revised care plan addressing skin impairment, pressure ulcer prevention, behaviors, fluid volume excess related to [MEDICAL CONDITION], chronic pain, risk for [MEDICAL CONDITION] related to hypertension, diabetes mellitus, and risk for respiratory distress related to [MEDICAL CONDITION]. These were added on the last day of the survey on 05/09/17. Resident #1's record review further revealed on admission date of [DATE], the Braden scale and admission observation was performed. The assessment notes revealed a right shin venous ulcer was identified on 03/14/17 during the admission skin assessment. There were no other skin assessments documented until 05/05/17. On 05/05/17 the left heel was observed to have a stage three pressure ulcer measuring 6 centimeters (cm) by 6.5 cm (no depth documented). The facility's electronic documentation software described a stage three pressure ulcer as a full thickness of skin is lost, exposing the subcutaneous tissues; presents a deep crater without undermining adjacent tissue. The description of the wound described moderate purulent exudate with foul odor. It further described no [MEDICAL CONDITION] present and that the resident had a pain level of seven. Matrix's example of a level seven pain, checked by the nurse for Resident #1, was described as severe pain, horrible/ intense. The interventions marked in the skin assessment area dated 05/05/17 were turning and repositioning, pressure ulcer care, applications of dressings to feet. The treatment described being performed included cleansing with dakins, calcium alginate ag (silver), cover with ABD pad and wrap with kerlix. Observation made on 05/08/17 at 2:52 P.M., Resident #1 was lying in bed awake. When asked if she had any sore areas on her bottom she stated, Oh yeah, just pick a place. The resident had a sheet over her and could visualize a dressing on the left ankle/ foot beneath it. Licensed Practical Nurse (LPN) #800 was asked to remove the sheet. LPN #800 stated she has a wound on her heel that she thought was a pressure wound (the dressing was dated 05/07/17 and was clean and dry). Another foam dressing was noted on the front shin of the left leg just above the kerlix dressing of the heel. The resident could not describe what the dressing on the foot was for. The residents' lower legs were on a pillow and a folded blanket but the heels were observed to be lying directly on the bed. LPN #800 stated, That doesn't look like that's working well and lifted Resident #1's legs to reposition them off the bed. The resident told her she didn't like them like that. After LPN #800 asked how she wanted them, the resident stated to keep them where they were. LPN #800 left the feet floating off the mattress. When Resident #1 was asked if she could turn herself, the resident stated she could not and proceeded to state she didn't like being on her side. LPN #800 stated Resident #1 is immobile. LPN #800 stated the resident used to kick her pillows out from underneath her feet but doesn't do that as much as she has declined. On 05/08/17 at 4:42 P.M. Resident #1 was observed asleep in her room positioned on her back. Resident #1's feet were covered with a sheet. Observations made on 05/09/17 at 8:55 A.M., Resident #1 was mumbling repetitively, I just need something, Hi, Hi, I'm alive. Oh God yes, How are you guys? I need pink warm air. Hi everybody. Resident #1 was lying slightly on her right side. State tested Nursing Assistant (STNA) #100 was asked to come in and lift the sheet off the resident's feet. STNA #100 lifted the sheet to observe and confirmed the right heel was resting on the mattress, left heel was also touching the mattress but with less pressure than the right. Resident stated they just changed the dressing this morning. Resident #1 stated that the left foot is throbbing, hurts, of course it hurts. The aide walked out of room and did not reposition the heels off the bed after confirming they were resting on the mattress. Interview with STNA #100 on 05/09/17 at 9:02 A.M. revealed she has worked at the facility for five years. She stated they watch for reddened skin areas, check bottoms, bruising, and let the nurse know if they see this. She also stated Resident #1 was complaining she wanted a towel under her feet since she has been hurting. The prior Director of Nursing (DON) was watching it and putting skin prep on it. The other aid, STNA #350 usually has her for an assignment. STNA #100 stated Resident #1 just repeats herself when you ask her questions. During an interview with LPN #200 on 05/09/17 at 9:52 A.M., she revealed does work on the 300 hall. She stated skin check audits are done if they are on TAR, it is a weekly check head to toe. LPN #200 stated she typically does the skin assessment when it is their shower or bed bath. LPN #200 stated the nurses perform the skin assessments and if the aides see anything, the aides report it and then the nurses reassess. LPN #200 stated, I worked that hall one shift a couple of weeks ago. I walked in and saw her (Resident #1) heel bleeding actively on the sheets and pillows, it was open and had an odor, puss, and draining. This was the first I had been on the hall in a while. It wasn't this past week. I wasn't here on Friday (05/05/17) so it had to have been before that. I worked last Wednesday and last Thursday. When asked if LPN #200 charted what she observed; she stated, There should be an entry about new orders. She was asked again, if she charted about the condition of the heel and what she observed. LPN #200 stated I am not sure, I would have to check. It would have been charted in progress notes. She refused about eight times to let us touch her, it took a while until we could clean it. She also refused medication. She finally let me give her pain medicine and then she would let me touch it. LPN #300 was asked if she has witnessed other aides allowing heels on the bed? She stated the aide came in asked for more education. She stated she explained they needed two finger widths between the heels and the mattress. An observation was made 05/09/17 of a late entry added to Resident #1's medical record on 05/09/17 at 2:53 A.M. The entry read 05/03/17 at 2:50 P.M. called into residents room by STNA due to drainage noted on sheets, when further assessed resident noted to have drainage to left lower leg and a stage 3 noted to bottom of heel. Treatment initiated and resident to be added to weekly wound rounds. Interview with STNA #350 on 05/09/17 at 9:34 A.M. revealed she has worked at the facility for nine years, was off then back a year in June. She stated she works all the halls. STNA #350 stated, I let the nurse know if there was a sore on their bottom, or bruise and I let the nurse know. Redness, if it's just from a diaper I don't tell the nurse, if it's a pressure sore on their bottom or heels, elbows - if that's red I tell them. We prop their feet, keep heels from hitting the bed, if heels feel soft, pillows under arms, turn and reposition. Some don't keep their heels on pillows we let the nurses know that. State law is every two hours, it just depends on the person, some we turn more than every two hours. During an interview on 05/09/17 at 10:30 A.M. with Assistant Director of Nursing (ADON) #300, she confirmed Resident #1 had skin integrity addressed once on the acute admission care plan. She confirmed this had not been revised and did not include interventions either on the care plan or the physician orders for pressure ulcer prevention. She also confirmed the weekly skin assessments would be documented in the computer charting system and if they were not there they were not completed. There were no additional skin assessments completed between admission on 03/14/17 and 05/05/17. Interview with the clinical compliance specialist (CCS) #250 on 05/09/17 at 11:20 A.M. confirmed the staff are to document weekly skin assessments on the treatment administration form that they have completed the assessment. If the assessment reveals no skin issues they do not create a skin assessment in the computer charting system. A review of the March, April, and May TAR's were silent for any documentation that a skin assessment was completed on Resident #1. A review of Resident #1's orders, care plan, and TAR revealed there were no preventative measures in place that included recognizing the resident as high risk for skin breakdown, turn and repositioning, air mattress/ gel mattress, floating heels, heel protectors, or routine observations of skin condition. Review of the facility policy dated 04/16 titled, Preventative Skin Care revealed: 4. Residents identified as being high risk for potential breakdown shall be turned and repositioned frequently to prevent redness that does not fade or blanche. 5. Air mattresses/ gel mattresses and wheelchair cushions may be used on those residents identified as being high risk for potential breakdown. 6. Pillows and other devices may be used between two skin surfaces or to slightly elevate bony prominences /pressure areas off the mattress. 7. Heel protectors may be used to protect heels on those residents identified to be high risk. 8. Pillows may be sued to float heels to prevent potential pressure sores on those residents identified to be high risk. 17. Nursing staff will observe resident's skin while providing skin care throughout the day. Information from the NPUAP was reviewed. According to the review a Stage 3 Pressure Ulcer is a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/ or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Further review of pressure ulcer prevention points revealed for at risk individuals to ensure that heels are free from the bed. This deficiency substantiates Complaint Number OH 907.

Based on record review, review of a fall investigation, review of nursing assistant worksheets, and staff interview, the facility failed to identify and communicate to staff the level of supervision a resident required for toileting transfers and failed to provide the appropriate level of staff assistance to ensure a safe transfer. This resulted in actual harm for one resident (#1) when a State tested Nurse Aide transferred the resident alone without a mechanical (Hoyer) lift, which resulted in the resident being lowered to the floor and sustaining a fracture to the left lower extremity. This affected one (#1) out of three residents reviewed for falls. The facility identified ten residents who required the assistance of two staff for transfers. The facility census was 39. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set assessment, dated 02/03/17, revealed the resident had severe cognitive impairment. The resident was coded as having both delusions and hallucinations during the review period. The resident required extensive assistance from two staff for transfers and bed mobility, and extensive assistance of one staff for toileting. Review of care plan dated 07/19/16 revealed the resident had a history of [REDACTED]. The care plan was silent to the type of assistance the resident required to transfer or how the staff was to transfer the resident. On 03/30/17 a new fall intervention was added to the care plan for strips to the bathroom floor. Review of progress note dated 03/27/17 at 1:21 P.M. revealed the resident was having knee and ankle pain and had bruising to the left lower extremity. The resident was having trouble bearing weight on the left lower extremity. The physician assistant was in the facility at this time. Review of physician telephone orders revealed on 03/27/17 an order was received for an X-ray of the left knee, two views due to [DIAGNOSES REDACTED].#1 had an acute proximal fibula fracture. Review of the progress note dated 03/29/17 at 11:00 A.M. documented the resident sent to the hospital for evaluation of left fibula. Review of the Fall Event Information form dated 03/30/17 at 5:44 P.M. revealed on 03/25/17 at 5:44 P.M. an unidentified State tested Nurse Aide (STNA) had lowered Resident #1 to the floor. The resident had normal range of motion (ROM) and no injuries noted at the time. The form documents on 03/27/17 at 1:21 P.M., the resident complained to physical therapy of left knee and ankle pain. Bruising was noted to the left lower extremity and the resident was having difficulty bearing weight. Further review of the medical record revealed the record was silent to the fall incident other than the Fall Event Information form. Telephone interview on 04/12/17 at 1:50 P.M., Licensed Practical Nurse (LPN) #75 revealed she was the nurse working on the hallway the evening Resident #1 sustained her fall. LPN #75 stated STNA #100 had attempted to transfer the resident on her own and had to lower the resident to the floor. LPN #75 stated the STNA had said the resident had told her she was able to transfer with one staff. LPN #75 stated when STNA #100 made this statement, Resident #1 replied that was not true. LPN #75 stated there was a Hoyer pad observed in place in the resident's wheelchair and she had observed the STNA's going in the room in pairs to care for Resident #1. LPN #75 stated the resident was assessed at the time of the fall. The resident did not have complaints of pain at the time of the fall and her ROM was normal. Interview on 04/12/17 at 2:25 P.M., STNA #105 revealed the facility does not have any form of documentation to let the STNA's know the level of assistance residents require for transfers or if a resident requires a mechanical lift to transfer. STNA #105 stated the other staff or the previous shift would tell you how much assistance a resident required for care. Interview on 04/12/17 at 2:25 P.M., LPN #80 stated there was a nursing assistant worksheet in the nurses station which had information on if for the residents in the facility. Review of the information provided by LPN #80 revealed Resident #1's information had not been updated since before a room change on 01/25/17. LPN #80 verified the information on this form was not current. Interview on 04/12/17 at 2:27 P.M., STNA #105 verified Resident #1 required a mechanical Hoyer lift for transfers. STNA #105 indicated the resident had used the mechanical lift for the last few months. Interview on 04/12/17 at 2:30 P.M., STNA #115 verified Resident #1 utilized a Hoyer lift for transfers and was a Hoyer lift at the time of her fall. STNA #115 stated the staff who transferred Resident #1 on the day of her fall did not use the Hoyer lift and tried to transfer her on alone. Interview on 04/12/17 at 2:45 P.M., LPN #85 stated she had been working the day Resident #1 had been lowered to the floor. LPN #85 indicated STNA #100 had come into the hall to have her help transfer the resident from the floor. LPN #85 indicated LPN #75 was also present in the room to assist. LPN #85 verified the STNA had not used the Hoyer lift to transfer the resident. Interview on 04/12/17 at 4:00 P.M., the Administrator and Clinical Compliance Specialist #70 verified Resident #1 suffered a fall due to staff not using the Hoyer lift and transferring the resident with only one staff member. Clinical Compliance Specialist #70 reported the facility felt Resident #1's fracture occurred as a result of being lowered to the floor on 03/25/17. Interview on 04/12/17 at 4:24 P.M., STNA #120 stated Resident #1 required a Hoyer lift for transfers. STNA #120 stated she knew this information from the off going shift. Interview on 04/12/17 at 4:40 P.M., Clinical Compliance Specialist #70 verified there was no information available for the staff to use to know what interventions the residents required for their care, to identify who required a mechanical lift, and to identify the number of staff required to provide care. This deficiency substantiates Complaint Number OH 527.