Every finding on record at Blossom Nursing and Rehab Center

Based on review of the medical record, review of the facility investigation, interview with staff and review of facility policy, the facility failed to ensure Resident #1 was free from significant medication errors. This affected one resident (Resident #1) of three residents reviewed for medication administration. The facility census was 86. Findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included hydronephrosis, urinary tract infection, acute kidney disease, atrial fibrillation, congestive heart failure, acute metabolic acidosis, diabetes, cerebral ischemia, obstructive sleep apnea, anxiety disorder, and major depressive disorder. Resident #1 was discharged to the hospital on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #1 had intact cognition. Review of the progress note dated 03/31/26 at 10:05 P.M. which was recorded as a Late Entry on 04/01/26 at 6:26 A.M., revealed Resident #1 was given medication that was meant for another resident. A call was placed immediately to the nurse practitioner (NP) and it was explained to the NP what medication was given to the resident. Vital signs were taken and were as followed, Blood pressure 119/70, pulse 72, respirations 18, oxygen level 96 percent, and temperature 97.3, pupils were equal and reactive with pupil size three millimeter bilaterally. The resident was alert and oriented and speech clear. NP was to call back. Review of the progress note dated 03/31/26 at 10:45 P.M. which was recorded as a Late Entry on 04/01/26 at 6:41 A.M., revealed the NP called back and order placed to send Resident #1 to the emergency department (ED) for observation in case of cardiac and blood pressure issues. A call was placed to emergency services, to the Director of Nursing and the ED for nurse-to-nurse report. Resident remained alert and oriented and denied any discomfort or distress.Review of the facility's investigation of a medication error dated 04/01/26 revealed on 03/31/26 Resident #1 was given another resident's medication on the evening of 03/31/26. He was sent to the ED for evaluation. Resident #1 was evaluated and monitored in the ED and found free from injury and was sent back to the facility. The resident's overall condition was being monitored. The resident's physician was at the facility on 04/01/26 and checked the resident and the resident was without injury or harm from the medication error. An in-service was completed with Registered Nurse #173 on 03/31/26. The resident would be monitored for any significant change, and it would be reported to the physician. The son was aware. Medication inadvertently administrated to Resident #1 were carbidopa-levodopa ( anti-Parkinson's) 25/100 milligrams (mg), gabapentin 600 mg (analgesic), pravastatin 40 mg (cholesterol reducing), trihexyphenidyl ( anti-Parkinson's)5.0 mg and ropinirole 0.5 mg ( anti-Parkinson's). Review of the progress note dated 04/01/26 at 2:20 A.M. revealed Resident #1 returned to the facility via ambulance and was assisted back to bed. Resident #1 stated he felt fine. No adverse effects were found during observation. He was resting in bed with his call light within reach.Review of the progress note dated 04/01/26 at 1:47 P.M. revealed Resident #1 remained drowsy and did not arouse to name. His call light was within reach, Skin was warm and dry and his respirations were even and regular. Diet intake was poor due to drowsiness and he was incontinent. Review of the progress note at 04/01/26 at 3:48 P.M. revealed the physician was at the facility to visit Resident #1. New orders received. Review of the new physician's orders for Resident #1 dated 04/01/26 revealed vital signs were to be obtained every two hours for 24 hours the every six hours, check and record fluid intake every day for three days, weights every Monday, Wednesday and Friday and notify the physician of any gain or loss of three or more pounds, and continue to follow the previous laboratory orders for every Monday and Thursday. Notify the physician with any abnormal. On 05/08/26 at 12:50 P.M. an interview with Director of Nursing revealed the nurse had prepared Resident # 52's medications and placed them in the top drawer of the medication cart because she wanted to make sure she got her medication right on time. She stated the nurse was worried if she did not get her medication right on time she would have aggravated symptoms of her Parkinson's disease, so she got them ready ahead of time. However, as she was getting the medication ready for Resident #1 she got an admission and also placed Resident #1 medication in the top drawer of the medication cart to go admit the new resident and when she came back to administer the medication cart she grabbed the wrong medication out of the top drawer for Resident #1 and gave them to him. She indicated it was around 9:00 P.M. She stated the nurse retired after this incident. Review of the facility policy titled, Medication Administration Procedures, dated 04/20 revealed medications would not be pre-poured and to identify the resident before administering medications. This deficiency represents non-compliance investigated under Complaint Number 2984888.

Based on observation, interview, record review, facility policy review, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to ensure staff used appropriate infection control practices using required proper hand hygiene for Resident # 6 with use of gloves during incontinence care for Residents #6. This affected one ( Resident #6) and had the potential to affect all 91 residents residing in the facility.Findings include:Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease, unspecified, Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding, Urinary tract infection, site not specified, Retention of urine, unspecified, Generalized anxiety disorder, Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, Parkinson's disease with dyskinesia, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Personal history of urinary calculi, and Long term (current) use of anticoagulants.Review of the Minimum Data Set (MDS 3.0) assessment dated [DATE] revealed Resident #6 has intact cognition, she has an indwelling catheter and is sometimes incontinent of bowel and dependent for continence care.Observation and chart review on 12/09/25 for Resident # 6 indicated order for catheter care every shift and incontinence care as needed.Observation on 12/10/25 at 9:45 A.M. revealed Resident # 6 for incontinence care with Certified nursing assistant (CNA)# 168 and CNA # 218. CNA #168 and CNA # 218 sanitized hands and donned proper personal protective equipment (PPE) for enhanced barrier precautions (EBP). CNA # 168 emptied catheter bag into graduate cylinder and measured output. Barrier placed under cylinder. CNA# 168 cleaned end of catheter tube with alcohol before securing it. At 9:46 A.M. CNA# 218 emptied urine output measured. (250mL) Urinal rinsed. At 9:49 A.M. CNA # 168 and CNA # 218 changed gloves, did not sanitize or wash hands. Donned new gloves. Resident # 6 dirty brief removed. At 9:51 A.M. CNA # 168 used wet washcloth with soap, cleaned Resident # 6 from front to back. Catheter tube wiped with same washcloth. At 9:53 A.M. Resident # 6 wiped front to back with clean washcloth. At 9:54 A.M. CNA # 168 used dry towel to pat dry front to back. Resident # 6 had bowel movement. Resident # 6 was rolled over and CNA# 218 cleaned Resident # 6 cleaned with wet washcloth front to back, washed with clean washcloth front to back. At 9:55 A.M. CNA # 218 patted Resident # 6 dry. At 9:56 A.M. dirty brief removed from Resident # 6 and clean brief applied to Resident # 6, CNA# 168 and CNA # 218 did not change dirty gloves or wash/sanitize hands prior to handling clean brief. CNA # 218 pulled Resident # 6 blankets over Resident with dirty gloves. At 9:57 A.M. CNA # 168 and CNA # 218 repositioned Resident # 6 with dirty gloves. At 9:58 A.M. all dirty material placed in garbage bag and pulled out of Resident # 6 room. Interviews on 12/10/25 at 9:59 A.M. with CNA# 168 and CNA # 218 confirmed they did not change gloves and did not use proper hand hygiene during entire process after the initial hand washing for Resident # 6.Interviews on 12/11/25 at 9:20 A.M. with Director of Nursing (DON) # 190 confirmed the facility had a policy in place confirming soiled gloves should be changed and hand hygiene should be performed before placing a clean brief on Resident # 6. Staff will be educated on proper hand hygiene and infection control practices. Review of facility policy confirmed Care Standards, dated 04/2018 revealed catheter usage will include avoidance of infection, use infection control aspects of incontinence care. Review of Hand Hygiene in Healthcare Settings, Healthcare Providers, Glove Use, last reviewed 01/08/21, from the Centers for Disease Control and Prevention, located at https://www.cdc.gov/handhygiene/providers/index.html revealed gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene during patient care if gloves become visibly soiled with blood or body fluids following a task and moving from work on a soiled body site to a clean body site on the same patient.

Based on observation, medical record review and staff interview the facility failed to ensure indwelling urinary catheter care was documented and assessed appropriately. This affected one (Resident #78) of two residents reviewed for indwelling urinary catheter use. The facility identified eight residents (#2, #3, #6, #7, #56, #67, #78 and #100) currently utilizing an indwelling urinary catheter. The facility census was 91.Observation of Resident #78 on 12/08/25 at 10:08 A.M. identified the current use of an indwelling urinary catheter. Review of Resident #78's medical record revealed an admission date of 11/30/25 with admission diagnoses that included urinary retention, osteonecrosis of the right knee and convulsions. Further review of the medical record revealed upon admission a physician's order for the use of an indwelling urinary catheter and catheter care to be provided every shift. Further review of the medical record found no evidence of any assessment which identified the current use and indication for the indwelling urinary catheter. Review of the treatment administration record (TAR) revealed no evidence of indwelling catheter care documented as provided as ordered by the physician until 12/07/25.Interview with the Director of Nursing on 12/09/25 at 3:30 P.M. verified no evidence of indwelling catheter care documented as provided from admission to 12/07/25 and no assessment identifying the use and indication for the use of an indwelling urinary catheter was completed.

Based on medical record review and staff interview the facility failed to ensure resident pre-admission screening and resident review (PASARR) was resubmitted after a new psychiatric diagnosis. This affected one (Resident #9) of one residents reviewed for PASARR. The facility census was 91. Review of Resident #9's medical record revealed an admission date of 02/08/23 with admission diagnosis that included mood disorder. Further review of the medical record revealed that on 04/05/23 a new diagnosis of bipolar disorder was added and on 12/13/23 a new diagnosis of schizoaffective disorder was also added. Review of Resident #9's PASARR revealed it was completed on 02/13/23 and identified the diagnosis of mood disorder. No further evidence of any resubmission of PASARR was found after the new psychiatric diagnoses on 04/05/23 and 12/13/23. Interview with Social Services (SS) #117 on 12/09/25 at 11:55 A.M. verified the PASARR was not resubmitted for Resident #9 after new psychiatric diagnoses added on 04/05/23 and 12/13/23.

Based on record review, interview, and policy review, the facility failed to ensure care planned fall prevention interventions were in place to prevent falls. This affected one resident (Resident #8) of three residents reviewed for accidents. The facility census was 92. Findings include: Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including spondylosis without myelopathy or radiculopathy, dementia, difficulty walking, history of falls, and cerebral infarction. The resident was discharged on [DATE]. Review of the plan of care, dated 09/19/23, revealed Resident #8 was at risk for falls with interventions including toileting offer every two hours, staff to check footwear when delivering tray prior to meal, apply proper non-skid footwear if found to have none on prior meal, educate on the use of the call light for assistance, and call light to be kept within reach. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/24, revealed the resident had moderately impaired cognition with poor decision making. The resident required physical assistance for activities of daily living (ADLs). The resident's mobility device was a wheelchair. The assessment indicated there was one fall without injury and one fall with injury since admission or the prior assessment. Review of the fall risk assessment, dated 02/03/24, revealed Resident #8 was at a high risk for falls. Review of the Fall Investigation, dated 02/03/24, revealed the fall occurred on 02/03/24 at 4:01 A.M. The resident was last observed sleeping. The alarm sounded and the nurse entered the bathroom and observed the resident with half of his buttocks on the toilet seat and upper body was propped against a bin that was in the room. The resident was assessed and found to have an abrasion on his back with no additional injuries. The resident was not wearing non-skid footwear, which staff applied following the fall. Further review revealed a subsequent fall on 02/15/24. Review of the Fall Investigation, dated 02/15/24, revealed the fall occurred at 3:20 P.M. Staff responded to the sounding alarm and found the resident in the bathroom kneeling in front of the sink and was not wearing shoes or proper footwear. The resident did not sustain an injury. During interview on 03/25/24 at 12:24 P.M., the Director of Nursing (DON) confirmed Resident #8 was not wearing proper footwear during his falls on 02/03/24 and 02/15/24. The DON confirmed the resident's care plan indicated anti-skid footwear was to be worn by the resident. Review of the facility's policy titled, Fall Prevention and Management Policy, revision date of 02/20/20, revealed to assess resident risk for falls and implement interventions to reduce the incidence of falls and/or mitigate the risk of injury related to falls. This deficiency represents non-compliance investigated under Complaint Number OH00152119.

Based on review of resident accounts and interview, the facility failed to ensure accurate accounting of resident funds were maintained. This affected one (Resident #93) of three residents reviewed for resident funds. The facility identified a total of 58 residents, both current and discharged , who had funds maintained by the facility. Findings include: Review of Resident #93's quarterly fund statement for the first quarter of 2023 revealed social security funds were credited to the account on 01/01/23 and twice on 03/01/23. No pension funds were documented as deposited in January 2023. Pension funds were deposited in February and March of 2023. A liability payment of $1102.00 was withdrawn from Resident #93's account on 01/01/23. No liability was withdrawn in February or March 2023. During review of resident personal funds accounts with Business Office Manager (BOM) #100 on 09/06/23 between 1:45 P.M. and 2:02 P.M., BOM #100 revealed Resident #93 had a patient liability amount of $1169.00 starting 01/01/23. BOM #100 verified no pension deposit was posted in January 2023 and was unable to explain why the patient liability was not withdrawn from the account (full amount) in January or any liability withdrawn in February or March 2023. The BOM verified this was not maintaining accurate records of resident accounts. This deficiency represents non-compliance investigated under Master Complaint Number OH00145438.

Based on resident funds account review, record review, and interview, the facility failed to ensure conveyance of resident funds within 30 days of discharge or death. This affected three (Residents #93, #94, and #95) of three residents reviewed for personal funds. The census was 92. Findings include: 1. Review of Resident #94's closed medical record revealed an admitted [DATE] with diagnoses including cerebral infarction, depression, epilepsy and type two diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was usually able to understand others. Resident #94 was assessed as moderately cognitively impaired. Resident #94 discharged to another facility on [DATE]. Review of Resident #94's personal funds consent dated [DATE] revealed Resident #94 authorized the facility to manage his personal money while he was a resident. Upon discharge, the account would be closed and the funds would be returned to Resident #94. The facility was to furnish a final statement no later than 30 days after discharge. If upon discharge, the resident had unpaid charges, the resident authorized the facility to use his personal needs account funds to pay those charges prior to refusing any excess funds to the resident. Review of Resident #94's quarterly trust fund statements for the first and second quarters of 2023 revealed deposits from Social Security on a monthly basis with interest deposited. No withdrawals from the account were documented. Review of the resident funds balance reports as of [DATE] revealed Resident #94 continued to have funds in the amount of $9659.82 at the facility. During an interview with Business Office Manager (BOM) #100 on [DATE] between 1:45 P.M. and 2:02 P.M., she reported the facility started receiving Resident #94's Social Security funds in [DATE]. Resident #94 discharged to another facility [DATE]. The facility sent a check to Resident #94 in the amount of $750 on [DATE] which accounted for a $50 allowance per month since the facility started receiving Resident #94's funds. BOM #100 stated the facility had never been informed of a patient liability amount for Resident #94. BOM #100 indicated a representative from the Department of Jobs and Family Services was notified Resident #94 was in the facility at the end of 2022 (no actual date available). Because the facility had never been informed if Resident #94 would have patient liability the facility had chosen to hold the remainder of the funds until they received a determination. BOM #100 stated she had phoned a representative from the Department of Jobs and Family Services again on [DATE]. On [DATE] at 2:34 P.M., BOM #100 stated she received a return call from Department of Job and Family Services and was informed there would be no patient liability retro charged so she could release the balance of Resident #94's funds. 2. Review of Resident #93's census information revealed notations that Resident #93 had a hospital leave on [DATE]. Another notation revealed Resident #93 expired at the hospital under hospice care on [DATE]. Review of Resident #93's revealed a check dated [DATE] to the Treasurer of the State of Ohio in the amount of $4541.08, the remainder of the balance in Resident #93's account based on the second quarter resident trust fund statement. During an interview with BOM #100 on [DATE] between 1:45 P.M. and 2:02 P.M., BOM #100 verified she had not conveyed the balance of Resident #93's funds within 30 days of her death. 3. Review of Resident #95's census information revealed Resident #95 had a hospital leave on [DATE]. A notation revealed the hospital notified the facility Resident #95 was transferred from the hospital to a hospice house on [DATE] and would not be returning to the facility. Review of Resident #95's indicated a withdraw of $63.22 to close out the account leaving a balance of $0.00. During an interview with BOM #100 on [DATE] between 1:45 P.M. and 2:02 P.M., a request was made for the check conveying Resident #95's funds. BOM #100 reported the money had not been dispersed yet and she had to send the funds to state recovery. The funds were not listed on the balance report since [DATE]. This deficiency represents non-compliance investigated under Master Complaint Number OH00145438.

Based on observation, record review and interview the facility failed to implement an individualized and effective pressure ulcer prevention program to prevent the in house development and/or worsening of pressure ulcers to Resident #11's bilateral heels. Actual harm occurred on 09/22/22 when Resident #11, who was severely cognitively impaired, required extensive assistance from two staff for bed mobility and was at risk for developing pressure ulcers was identified to have a blister to the left heel without evidence of adequate care/interventions to promote healing. On 09/30/22 Resident #11 was assessed to have a blister measuring 5.0 centimeters (cm) in length by 6.0 cm width with no depth to her right heel with no evidence adequate care/interventions to promote heating. On 10/13/22 the wound physician noted the left heel pressure ulcer had deteriorated and was a deep tissue injury (DTI), a persistent non-blanchable deep red, purple, or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues measuring 6.7 centimeters (cm) in length by 8.0 cm width with an undetermined depth and a DTI pressure ulcer to the right heel which measured 3.7 cm by 5.0 cm and had an undetermined depth. The pressure ulcers continued to deteriorate to unstageable ulcers. The facility failed to timely implement pressure ulcer prevention measures (including pressure relief/reduction measures and a dietitian consult) to prevent and treat the ulcers. This affected one resident (#11) of five residents reviewed for pressure ulcers. Finding included: Review of the medical record revealed Resident#11 was admitted to the facility on [DATE] with diagnoses including gout, hypertension, osteoarthritis, and polyneuropathy. Review of the Admission Skin assessment dated [DATE] revealed Resident #11 had no skin injuries or open areas to either of her heels. Review of the Braden scale for risk for development of pressure ulcers, dated 09/14/22 revealed Resident #11 was at risk for developing pressure ulcers. Review of the physician's orders, dated 09/14/22 revealed Resident #11 had orders for a skin assessment to be completed weekly. Review of the plan of care, dated 09/14/22 revealed Resident #11 had pressure ulcer prevention interventions to float her heels off the bed surface while in bed and to have a pressure relieving mattress. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had severely impaired cognition and required extensive assistance of two staff for bed mobility and transfers. She was admitted to the facility with one Stage II pressure ulcer on her coccyx. Review of the physician orders dated 09/20/22 revealed Resident #11 had orders for ProHeal (a nutritional supplement) everyday for healing and Arginaid (a protein supplement) twice daily for pressure ulcer healing. Review of a skin/body assessment, dated 09/22/22 revealed Resident #11 had a new fluid-filled blister to her left inner heel measuring 6.0 centimeters (cm) in length by 5.0 cm width with no depth noted. Review of the progress note, dated 09/22/22 at 5:26 P.M. revealed during a shower it was noticed Resident #11 had a fluid filled blister to her left inner heel. A new physician order was received to pad and protect the blister area with a thick abdominal (ABD) dressing and wrap with Kerlix gauze wrap daily and as needed. Review of a Braden scale assessment, dated 09/22/22 revealed Resident#11 was at risk for developing pressure ulcers. There was no documentation found to indicate staff were floating Resident #11's heels from the time of admission until 09/22/22 when this pressure ulcer was identified. Review of the plan of care, dated 09/27/22 revealed Resident #11 had a new intervention for a low air loss mattress. There was no physician order written for the low air loss mattress at that time. Review of a skin/body assessment, dated 09/30/22 revealed Resident #11 had new pressure area, a blister measuring 5.0 cm in length by 6.0 cm width with no depth to her right heel. A physician order was obtained this date for nursing staff to pad and protect the right heel blister with an ABD dressing and wrap with Kerlix gauze daily and as needed. Review of a wound physician note, dated 10/06/22 revealed the physician ordered a low air loss mattress, an air boot and a prealbumin test for the resident. Review of the written physician's order dated 10/06/22 revealed Resident #11 was ordered application of skin prep to her heel and cover with a ABD dressings and wrap with Kerlix gauze daily and as needed. Review of a progress note, dated 10/06/22 at 2:15 P.M. (written as a late entry dated 11/29/22 at 12:20 P.M.) revealed Resident #11 was seen by the wound physician who gave an order for an air boot. The note indicated the nurse showed the wound physician the facility's heel protectors and the physician stated those were acceptable to use in place of the air boots. Review of the physician' orders revealed there were no orders written on 10/06/22 for heel protectors or for any substitute for the air boot. Review of laboratory testing results, dated 10/07/22 revealed Resident #11 had a prealbumin level of 17 milligrams/deciliter (mg/dl) (normal range 17-34 mg/dl). Review of a wound physician's note, dated 10/13/22 revealed Resident #11's left heel was a deep tissue injury (DTI), a persistent non-blanchable deep red, purple, or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues was measuring 6.7 cm in length by 8.0 cm width with an undetermined depth. The note indicated the pressure ulcer was deteriorating. Resident #11's right heel DTI measured 3.7 cm in length by 5.0 cm width with an undetermined depth and was noted to be improving. Review of the physician's orders, dated 10/13/22 revealed Resident #11 had a new order to cleanse the left and right heel DTI's with normal saline (NS), pat dry, apply oil emulsion, cover with an ABD and wrap with Kerlix gauze daily and as needed. Review of a wound physician's progress note, dated 10/20/22 revealed Resident #11's left heel DTI measured 3.2 cm in length by 3.5 cm width with an undetermined depth and was improving. The right heel DTI was measured at 4.9 cm length by 5.0 cm depth with an undetermined depth and was assessed to have deterioration. There was a new physician order to change boots from the sponge boots to prevalon pressure-relieving boots and to consult the dietitian concerning her prealbumin level. Review of the physician orders revealed no orders were written by the wound physician on 10/20/22 for prevalon boots or a dietitian consult as he indicated in his progress note. Review of the wound physician progress note, dated 10/27/22 revealed the left heel DTI was assessed to have deteriorated to an unstageable (obscured full-thickness skin and tissue loss) due to necrosis/eschar (black/dark brown dead, devitalized tissue). The wound measured 3.0 cm in length by 3.5 cm width with an undetermined depth and was covered with 70 percent eschar and 30 percent granulation (healthy tissue). Resident #11's right heel was documented as measuring 4.7 cm length by 4.7 cm width with an undetermined depth and still discolored. Review of a wound physician's note, dated 11/10/22 revealed Resident #11's left heel unstageable DTI measured 2.1 cm in length 2.8 cm width with an undetermined depth and was healing. The eschar had unroofed and the area was violet, boggy, with intact skin. The right heel DTI was assessed to have declined and was now unstageable with 100 percent necrosis and measured 2.1 cm in length by 1.5 cm width with an undetermined depth. The wound physician indicated Betadine would be ordered for treatment. Review of the plan of care, dated 11/18/22 revealed a new intervention for pressure relieving ankle foot orthotic (Prafo) boots to both of Resident #11's heels were ordered. However, there was no physician order found for Prafo boots. Review of a physician's order, dated 11/20/22 revealed Resident #11 had a new order for nursing staff to apply Betadine to both of her heels, cover with an ABD and wrap with Kerlix gauze daily and as needed. Review of the wound physician's note dated 11/25/22 revealed Resident #11's left heel unstageable DTI measured 1.6 cm in length by 2.2 cm width with an undetermined depth and had eschar. The note documented the pressure ulcer was stable. Resident #11's right heel unstageable DTI measured 2.0 cm length by 1.5 cm width with an undetermined depth and was covered 100 percent by eschar and was declining. Review of the wound physician's note, dated 12/01/22 revealed Resident #11's left unstageable heel DTI measured 1.6 cm length by 2.2 cm width with an undetermined depth and had eschar. The note indicated the pressure ulcer was stable. Resident #11's right heel was an unstageable DTI and measured 2.1 cm length by 1.3 cm width with an undetermined depth with eschar covering 100 percent of the pressure ulcer wound. On 12/04/22 at 10:00 A.M. Resident #11 was observed in bed with her feet/heels wrapped in Kerlix gauze wrap as ordered, however there was no Prafo boot to either heel (the most current intervention implemented). In addition, the resident's heels were not floated off the bed surface as a pressure reduction intervention. On 12/04/22 at 11:33 A.M., Resident #11's heels were observed propped up on a pillow and not floated off the bed to relieve pressure. Review of the physician's orders, dated 12/05/22 revealed Resident #11 had new orders for heel protectors while in bed and a low air loss mattress. On 12/06/22 at 11:20 A.M. observation of Resident #11's pressure ulcers with Licensed Practical Nurse (LPN) #859 and LPN #886 revealed the resident's left heel had two unstageable black areas, were mushy and the resident stated it hurt. The resident's right heel was observed with black eschar covering the whole heel area. The heel was mushy and the edges were red and inflamed. LPN #859 verified the observation and condition of the resident's heels. On 12/06/22 at 12:55 P.M. interview with LPN #859 revealed Resident #11 was admitted to the facility with a skin alteration to her coccyx but no skin alterations/pressure ulcers to her heels. LPN #859 verified Resident #11 was assessed to be at risk for developing pressure ulcers. LPN #859 indicated Resident #11 had a pressure reliving mattress to the bed on admission which was changed to a low air loss mattress according to the plan of care dated 09/27/22. However, the LPN then indicated the air mattress was not implemented until 10/07/22 and no physician order was written for it until 12/05/22. LPN #859 verified there was never a physician order written for the prevalon boots and no evidence Resident #11 ever received them. LPN #859 verified the plan of care dated 11/18/22 revealed a new intervention for Prafo boots for Resident #11's heels, but no physician order was written. LPN #859 verified she wrote the physician's orders for the heel protectors and loss air loss air mattress on 12/05/22. On 12/07/22 at 9:35 A.M. interview with Dietitian #889 revealed she was never consulted the resident's low pre-albumin (ordered 10/20/22). She indicated if she had been consulted, she may have adjusted supplements to add more protein to aid in healing of Resident #11's pressure ulcers. On 12/07/22 at 10:10 A.M. interview with the Director of Nursing revealed she did not know why the dietitian consult was not completed.

Based on observation, record review and interview the facility failed ensure oxygen tubing/nasal cannulas and aerosol equipment (tubing/mouthpieces) for respiratory treatments were changed and dated weekly and properly stored to prevent infection/contamination when not in use for Residents #8, #36, #37 and #49. This affected four of 13 residents reviewed for oxygen therapy/breathing treatments. Findings included: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included chronic pulmonary (lung) disease, chronic respiratory failure, hypertension, atrial fibrillation, diabetes, anxiety, obstructive sleep apnea, atherosclerotic heart disease, affective mood disorder, and insomnia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was alert,oriented with intact cognition, required extensive assistance of two staff members for bed mobility, transfers, toilet use and one staff member for dressing and personal hygiene. Review of the December 2022 physician's orders revealed Resident #36 had an order for oxygen per nasal cannula at three liters continuous for comfort and for oxygen saturations below 90% and directed that oxygen tubing was to be changed and dated weekly. Resident #36 was also ordered albuterol sulfate solution for nebulization (breathing or aerosol treatments) as needed for shortness of breath. Review of the November and December 2022 Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed no documentation of Resident #36 oxygen tubing or breathing treatment tubing and mouthpiece being changed weekly. Observation on 12/04/22 at 9:37 A.M. revealed the oxygen nasal cannula (nose piece) of her portable oxygen tank for Resident #36 was laying directly on her wheelchair seat and the mouth piece for her her respiratory treatments was laying directly on her bedside table and neither were in protective bag or cover. Resident #36 was observed wearing the nasal cannula connected to the oxygen tubing from her regular oxygen concentrator. The nasal cannula attached to the oxygen tubing she was wearing, the nasal cannula lying in her wheelchair and the mouthpiece for her breathing treatment were not dated to indicate when they were last changed. On 12/04/22 at 9:37 A.M. an interview with Resident #36 revealed she has not had her oxygen tubing, nasal cannulas or aerosol mouthpiece equipment changed in weeks. On 12/04/22 at 10:17 A.M. an interview with Licensed Practical Nurse (LPN) #853 verified Resident #36's her oxygen tubing, nasal cannulas, and aerosol mouthpiece should be dated as to when they were last changed and the nasal cannula for her portable oxygen tank and the aerosol mouthpiece should be stored in a protective bag when not in use to prevent contamination. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included pneumonia, congestive heart failure, atrial fibrillation, chest pain, hypertension, diabetes, anxiety disorder, hypoxemia, dyspnea, and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #8 was alert, oriented and had intact cognition and required oxygen therapy. Review of the December 2022 physician orders revealed Resident #8 had a current order for oxygen per nasal cannula at three liters continuously for her comfort and for oxygen saturation less than 90 percent. Staff were to change her oxygen tubing weekly. Review of the November and December 2022 MARs and TARs revealed no documentation of Resident #8's oxygen tubing being changed. Observation on 12/04/22 at 10:00 A.M. revealed the oxygen tubing and nasal cannula Resident #8 was wearing and her portable oxygen nasal cannula tubing were not dated to indicate when they had last been changed. Resident #8's portable oxygen nasal cannula was not in use and was observed hanging on the back on her wheelchair. It was not in any type of protective bag. On 12/04/22 at 10:16 A.M., LPN #853 verified Resident #8's oxygen tubing and cannulas were not properly dated to determine when they were last changed and her portable oxygen cannula was not in a protective bag when not in use to prevent contamination. 3. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, mental status changed, chronic kidney disease, COVID-19, heart failure, dementia, dependence on supplemental oxygen, sand sleep apnea, chronic obstructive pulmonary disease, and anxiety disorder. Review of the annual MDS assessment dated [DATE] revealed Resident #37 had moderately impaired cognition and received oxygen therapy. Review of the December 2022 physician orders revealed Resident #37 had current orders for oxygen per nasal cannula at two to four liters for resident comfort or for oxygen saturations below 90 present and for ipratropium/albuterol breathing treatments every six hours while awake. Resident #37 also had orders for the oxygen tubing and breathing treatment tubing/mouthpiece to be changed weekly. Review of the November and December 2022 MARs and TARs revealed no documentation of Resident #37's oxygen tubing or aerosol tubing/mouthpiece being changed. Observation on 12/04/22 at 9:45 A.M. revealed the aerosol mouthpiece, the portable oxygen nasal cannula/tubing and the nasal cannula/tubing on the oxygen concentrator which Resident #37 was wearing were not dated to indicated when they were last changed. The portable nasal cannula was hanging uncovered on the back of Resident #37's wheelchair and her breathing treatment mouthpiece was lying directly on her bedside stand and was not in any type of protective bag. On 12/04/22 at 10:15 A.M., LPN #853 verified Resident #37's oxygen tubing, nasal cannulas and aerosol mouthpiece/tubing should be dated as to when it was lasted changed and her portable oxygen nasal cannula and aerosol mouthpiece should be in a protective bag when not in use. 4. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, cerebral infarction, heart failure, lymphedema, major depressive disorder, hemiplegia, and diabetes. Review of the annual MDS assessment dated [DATE] revealed Resident #49 had moderately impaired cognition, and received oxygen therapy. Review of the December 2022 physician orders revealed Resident #49 had current orders for oxygen via nasal cannula continuously, albuterol sulfate breathing treatments four times daily, and staff directed to change the oxygen tubing and breathing treatment tubing/mouthpiece every week. Review of the November and December 2022 MARs and TARs record revealed no documentation of Resident #49's oxygen tubing or breathing treatment tubing/mouthpiece being changed weekly. Observation on 12/04/22 at 10:05 A.M. revealed the oxygen tubing, nasal cannula and breathing treatment mouthpiece for Resident #49 were not dated to indicate when they were last changed. The breathing treatment mouthpiece was lying directly on Resident #49's bedside table and was not covered with any type of protective bag. On 12/04/22 at 10:17 A.M., LPN #853 verified Resident #49's is oxygen tubing, nasal cannula and breathing treatment mouthpiece were not properly dated with the date they were lasted changed. LPN #853 verified Resident #49's breathing treatment mouthpiece should be in a protective bag when not in use.

Based on record review and interview the facility filed to ensure Resident #36 received showers per her preference. This affected one resident (#36) of three reviewed for choices. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included chronic pulmonary disease, chronic respiratory failure, hypertension, atrial fibrillation, diabetes, anxiety, obstructive sleep apnea, atherosclerotic heart disease, muscle weakness, hypothyroidism, affective mood disorder, and insomnia. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #36 had intact cognition, required extensive assistance of two staff members for bed mobility, transfers, toilet use and one staff member for dressing and personals hygiene. Review of the current facility shower schedule revealed Resident #36 was to have a shower on afternoon shift on Tuesdays, Thursdays and Saturdays. Review of progress notes from 09/23/22 to 12/04/22 revealed no evidence Resident #36 had refused to have a shower. Review of the facility showers sheets from 10/01/22 to 12/04/22 revealed Resident #36 had a shower on 10/04/22, 10/09/22, 10/13/22, 10/25/22, 11/01/22, and 12/03/22. On 12/04/22 at 9:37 A.M. an interview with Resident #36 revealed she was to receive three showers a week on Tuesdays, Thursdays and Saturdays. Resident #36 stated she has not been getting her showers. She stated the staff don't tell her why her showers aren't given, they just don't give them to her. Resident #36 said she finally got a shower the night before (12/03/22) because she raised [expletive]. On 12/06/22 at 10:19 A.M., interview with the Director of Nursing (DON) revealed staff should be completing a shower sheet when they give a resident a bath or shower. She stated she educated the staff on filling out shower sheets and to document if the resident had refused. On 12/06/22 at 3:31 P.M., interview with the DON revealed she could find any additional completed shower sheets for Resident #36 then noted above and showers were not provided as planned.

Based on observation, record review and interview the facility failed to ensure resident's confidential information was not left visible on unattended computer screens. This affected three residents (Resident #51, #67 #74) of six observed for medication administration. Findings included: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included diabetes, major depressive disorder, COVID-19, dysphagia, port-traumatic stress disorder, anxiety disorder, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, gout, and osteoarthritis. Observation on 12/05/22 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #815 assembled her equipment and went into the room of Resident #51 to perform blood glucose testing. LPN #815 left Resident #51's medical information on the computer screen. LPN #815 verified at 11:19 A.M. she had not closed out the resident information on her computer screen when she went into the resident's room. Review of the facility policy titled, Privacy, Dignity, and Confidentiality, dated 01/22, revealed residents had the right to privacy including the right to personal privacy and confidentiality of his or her personal and clinical records. The policy indicated residents had the right to personal privacy which included accommodations, medial treatment, written and telephone communications, personal care visits, and meetings of family and resident groups. The policy indicated resident's clinical records would be kept confidential and private. 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included obsessive compulsive disorder, COVID-19, anxiety disorder, hoarding disorder, adult failure to thrive, and hypothyroidism. Observation on 12/06/22 at 8:15 A.M. revealed Registered Nurse (RN) #871 went into Resident #67's room to give her medication. RN #871 left Resident #67's private medical information up on the computer screen while she was inside the resident room. At 8:25 A.M., RN #871 verified she left Resident #67's private information up on the computer screen while she was in the room. Review of the facility policy titled, Privacy, Dignity, and Confidentiality, dated 01/22, revealed residents had the right to privacy including the right to personal privacy and confidentiality of his or her personal and clinical records. The policy indicated residents had the right to personal privacy which included accommodations, medial treatment, written and telephone communications, personal care visits, and meetings of family and resident groups. The policy indicated resident's clinical records would be kept confidential and private. 3. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, COVID-19, dementia, delirium, diabetes, major depressive disorder, delusional disorder, anxiety disorder, social phobia, congestive heart failure, metabolic encephalopathy, and auditory hallucinations. Observation on 12/06/22 at 8:19 A.M. revealed RN #871 went into the room of Resident #74 to give her medication. RN #871 left Resident 74's information up on the computer screen while she was inside the room. At 8:25 A.M., RN #871 verified this concern. Review of the facility policy titled, Privacy, Dignity, and Confidentiality, dated 01/22, revealed residents had the right to privacy including the right to personal privacy and confidentiality of his or her personal and clinical records. The policy indicated residents had the right to personal privacy which included accommodations, medial treatment, written and telephone communications, personal care visits, and meetings of family and resident groups. The policy indicated resident's clinical records would be kept confidential and private.

Based on observation, record review and interview the facility failed to ensure Resident #23 received an appropriate substitution for his physician ordered nutritional supplement and the facility failed to timely assess Resdient #75 for the use of a Broda chair. This affected one of five residents reviewed for nutrition and one of one resident reviewed for a possible restraint. The facility census was 85. Finding included: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included squamous cell carcinoma of skin, acute respiratory failure, severe protein calorie malnutrition, diabetes, atrial fibrillation, chronic lymphatic leukemia, major depressive disorder, chronic obstructive pulmonary disease, hypertension, atherosclerotic heart disease, nutritional deficiency, and anxiety disorder. Review of the significant change Minimum Data Set assessment dated [DATE] revealed Resident #23 had moderately impaired cognition and had a prognosis of less than six months to live. Review of the progress note dated 11/20/22 at 2:41 P.M. revealed Resident #23's appetite was very poor and he hardly ate any food but he did drink his Med Pass nutritional supplement and asked for these cold drinks frequently. Review of the current December 2022 physician orders revealed Resident #23 still had a physician order for 120 milliliters (mls) of Med Pass (nutritional supplement) three times a day. Review of the December 2022 medication administration record revealed Resident #23 did not receive the 120 mls of Med Pass on 12/03/22 and 12/04/22 because it was not available. Observation on 12/06/22 at 7:51 A.M. revealed Licensed Practical Nurse (LPN) #849 poured a five-ounce plastic cup three fourths full with Jevity 1.5 and administered it to Resident #23 to drink. LPN #849 indicated she was using it in replace of the Med Pass supplement which the resident was ordered. LPN #849 said they were not able to order Med Pass supplement due to a manufacture supply issue. The facility dietitian provided a list of supplements acceptable to use due to supply chain issues. This list revealed acceptable substitutions for the Med Pass supplement would be facility health shakes, sugar-free healthshakes, Mighty shakes or sugar-free Mighty shakes. Jevity 1.5 was not on the list of acceptable substitutions for Med Pass. Review of the manufacture information for Jevity 1.5 Cal revealed it was a calorically dense, fiber-fortified therapeutic nutrition that provided complete, balanced nutrition for long-term or short-term tube feeding and was only to be used with residents with altered taste perception. Comparison of nutritional values revealed 120 mls of Med Pass three times a day provided 720 calories and 30 grams of protein and Jevity 1.5, 120 mls, three times daily only provided 535 calories and 23 grams of protein. On 12/06/22 at 12:24 P.M. interview with Dietitian #889 revealed she was not aware nursing staff was substituting Jevity 1.5 for Med Pass for Resident #23. Dietitian #889 stated it was not a one to one equivalent replacement for Med Pass. She stated they should have been using one of the other equivalent health shakes/in-house supplements from the list she had provided to the facility for a one to one substitution when there were supply chain issues. On 12/06/22 at 3:30 P.M., interview with Resident #23 revealed the supplement the nursing staff had been giving him to drink tasted horrible. He stated he did not know what it was called but it was not the same one he had been receiving before. On 12/07/22 at 8:54 A.M., interview with the Director of Nursing verified there were no additional physician's orders obtained to change nutritional supplements for Resident #23, when the ordered Med Pass supplement was not available. 28701 2. Observation of Resident #75 on 12/04/22 at 9:30 A.M. and at 10:25 A.M. revealed Resident #75 sitting in a reclined broda chair (an adaptive, reclining seating device) in the unit lounge area. Review of Resident #75's medical record revealed an admitted [DATE] with diagnoses that included Parkinson's disease and Alzheimer's disease. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] indicated Resident #75 had severely impaired cognition and no restraints were used and he required staff assistance for all acitivities of daily living. Review of Resident #75's nursing progress notes and occupational therapy notes revealed the use of a the broda chair had been used admission. Review of the physician's orders revealed no evidence of a physician's order in place for the use of a broda chair until 12/05/22. Review of Resident #75's assessments found no evidence of an assessment for the use of the broda chair to determine if it was a restraint or a safety intervention until 12/06/22. Interview with the Director of Nursing on 12/07/22 at 10:22 A.M. verified there was no physician's order for the use of the broda chair since admission until 12/05/22 and there was assessment of this potential physical restraint/assistive device for comfort completed until 12/06/22.

Based on interview and record review, the facility failed to ensure glasses were provided for Resident #17 in a timely manner following a optometry appointment. This affected one of one resident reviewed for vision. The facility census was 85. Findings include: Review of Resident #17's medical record revealed an admitted [DATE] with diagnoses that included congestive heart failure, pressure ulcer to the sacrum and diabetes mellitus. Review of the 360 Optometry consult revealed Resident #17 was evaluated in the facility on 07/24/22. At that time the optometrist ordered new glasses pending insurance/payer approval. The Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 11/03/22 revealed Resident #17 was alert and oriented with intact cognition. This assessment indicated Resident #17 had impaired vision and but did not use any corrective lenses. Further review of the medical record found no evidence of any approval or additional notes related to approval or lack thereof for Resident #17's glasses. Interview with Resident #17 on 12/04/22 at 10:54 A.M. revealed she had saw the optometrist several months ago and had not received her glasses which were ordered at that time. On 12/07/22 at 10:18 A.M. interview with the Director of Nursing verified Resident #17 has not received her glasses and the facility has not followed up to determine the status of glasses.

Based on observation, record review and interview, the facility failed to ensure Resident #186's meal consistency was provided per the physician order. This affected one (Resident #186) of seven residents reviewed for food and nutrition. Findings include: Review of Resident #186's medical record revealed she was admitted on [DATE] with diagnoses including cardiomegaly, diabetes and hemiplegia. Review of Resident #186's physician orders revealed an order dated 11/29/22 for a pureed diet with sugar substitute and thin liquids. Observation on 12/05/22 at 12:10 P.M. revealed Resident #186 was sitting in the dining room on the 100/200 units and she was served a pureed plate of stuffed cabbage with mashed potatoes. On the left side of the plate was a square piece of white cake with icing which was not pureed as indicated in the physician orders. Interview on 12/05/22 at 12:10 P.M. with Dietary Supervisor #885 confirmed Resident #186 was served white cake with icing which had a regular consistency, which was an error and it should have been a pureed consistency based on the physician orders.

Based on observation, record review and interview the facility failed to perform hand washing prior to administering insulin to Resident #51 to prevent the potential spread of infection. This affected one resident (Resident #51) of two observed for injections. Findings include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included diabetes, post-traumatic stress disorder, anxiety disorder, and chronic obstructive pulmonary disease. Review of the December 2022 physician orders revealed Resident #51 had a order for Humalog, an injectable insulin medication for diabetes, 10 units three times daily. Observation of glucometer testing on 12/05/22 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #815 assembled her equipment and went into Resident #51's room. LPN #815 completed the blood sugar test with the glucometer and placed it on Resident #51's bedside table. LPN #815 went back to the medication cart in the hallway cleaned the glucometer with a Sani-wipe, a disinfectant wipe, and placed it in a disposable plastic cup and removed her gloves. LPN #815 did not wash or sanitize her hands and proceeded to retrieve Resident #51's Humalog insulin Flex-pen from the top drawer of the medication cart. She went into Resident #51's room without washing her hands, put on gloves and administered the insulin to Resident #51. LPN #815 went back out the the medication cart and placed the insulin Flex-pen back into the top drawer of the medication cart and then sanitized her hands. Interview with LPN #815 on 12/05/22 at 11:19 A.M. verified she had not washed or sanitized her hands after obtaining the glucometer reading, touching the medication cart and prior to administering Resident #51's insulin. Review of the facility policy titled, Handwashing/Hand Hygiene, dated 04/20, revealed practicing hand hygiene was a simple effective way to prevent infections by preventing the spread of germs. Staff were directed to wash their hands after removing gloves and before and after nursing treatment or procedures.

Based on observation, record review and interviews the facility failed to ensure appropriate nail care was provided to Resident #32, who was dependent on staff for her personal care. This affected one of three residents reviewed for activities of daily living (ADLs). Findings included: Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included dementia, chronic kidney disease, weakness, macular degeneration, diabetes, major depressive disorder, anemia, congestive heart failure, hypothyroidism, osteoarthritis, and COVID-19. Review of the plan of care dated 11/20/18 revealed Resident #32 was limited in her ability to perform all ADLs due to chronic kidney disease, acute kidney failure, and diabetes with neuropathy. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #32 had moderately impaired cognition and required extensive assistance of one staff for personal hygiene. Review of the progress notes dated 05/22/22 through 11/30/22 revealed no evidence Resident #32 refused to have her finger nails cleaned and trimmed. Review of the facility shower sheets dated 09/28/22, 09/29/22, 10/05/22, 10/06/22, 10/19/22, 10/27/22, 10/29/22, 11/16/22, 11/29/22, 11/30/22, and 12/01/22 revealed no documentation that Resident #32 had her nails trimmed or cleaned. The shower sheets had a box to check if this care was provided and it was not checked on any of the shower forms for any of these dates. Observations on 12/04/22 at 9:28 A.M., 11:30 A.M. and 1:53 P.M. revealed Resident #32 had very long dirty finger nails. At 1:53 P.M., an interview with Resident #32 revealed her nails had not been trimmed in a while and she did not like them long. Observation on 12/05/22 at 9:15 A.M. revealed Resident #32's finger nails were still very long and dirty. On 12/05/22 at 11:22 A.M. interview with the Director of Nursing (DON) revealed nails should be trimmed and cleaned on shower days and as needed. The DON verified Resident #32's finger nails were long and dirty. At the time of this observation, Resident #32 stated she was glad they were going to trim them for her. Review of the undated facility policy titled, Nail Care, revealed the purpose of this procedure was to provide guidelines for the provision of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. Nail care including trimming and filing would be provided as needed. Nails should be kept smooth to avoid skin injury.

Based on interview and record review the facility failed to provide medical records as requested by a representative. This affected one resident, Resident #87, of three residents reviewed for medical records. The facility census was 86. Findings include: Review of the medical record for the Resident #87 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/17/20, revealed the resident had intact cognition. Resident #87 required extensive two-person physical assistance for bed mobility; extensive one-person physical assistance for transfers, dressing, toilet use, and personal hygiene; and supervision set up help only for eating. Resident #87 was frequently incontinent of urine and occasionally incontinent of bowel. Review of the nurse's note dated 08/24/20 at 2:21 P.M. for Resident #87 revealed the resident's plan was to remain in the intermediate level of care due to her spouse no longer being able to manage her at home. Review of nurse's note dated 09/08/20 at 12:04 P.M. revealed Resident #87's spouse had called the facility and requested her to be discharged home on 09/10/20. A call was placed to the physician and discharge orders with home health care were obtained. Interview on 02/18/22 at 9:20 A.M. with the Administrator and the Director of Nursing (DON) revealed they have received multiple requests for medical records from the family of Resident #87. They reported the one request they did receive in writing from the family, as protocol states, it was sent to the corporate risk manager. The DON revealed she has been handling all medical record requests until the position at the facility can be filled. Interview on 02/18/22 at 11:01 A.M. with Director of Risk Management #301 revealed he did receive a written medical record request dated July of 2021 for Resident #87 in January 2022. Risk Management #301 reported he would normally create a compact disk of the records and send them off but due to working from home he was unable to accommodate that, so he requested the facility send off medical records as requests were approved. Interview on 02/18/22 at 11:47 A.M. with Paralegal #302 involved with the case, confirmed her office had not received the medical records as requested in July 2021. Interview on 02/18/22 at 11:52 A.M. with the Administrator and the DON confirmed the facility did not send off the medical records for Resident #87 as requested and approved. Review of written request from law office representing Resident #87 dated 07/30/21 revealed a proper request for medical records was submitted to the facility in writing with written authorization form filled out and signed by Resident #87's husband on 07/07/21. Review of facility policy requesting clinical records, revised June 2016 revealed requests from outside persons/agencies: When a written request is received to view or receive a copy of all or part of a resident's clinical record, request the resident/legal representative to authorize such release by signing an authorization for release of clinical information. All required items on this form must be completed. In the case of a minor resident that is physically or mentally incapable of authoring release of clinical information, the resident's parent/legal representative will authorize the release of confidential information on the resident's behalf and include his or her relationship to the resident on the authorization form. Examples of such request include insurance companies, government agencies, and attorneys (except the facilities attorneys). This deficiency substantiates Complaint Number OH 981.

Based on medical record review and staff interview, the facility failed to ensure Activities of Daily Living (ADLs) were documented as provided for residents requiring staff assistance. This affected three (Residents #25, #33 and #90) of three residents reviewed for ADLs. The facility census was 94. Findings include: 1. Review of Resident #25's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 3.0 Minimum Data Set (MDS) quarterly assessment with a reference date of 07/06/21 indicated Resident #25 required extensive assistance from staff members for eating meals, toileting and personal hygiene. Review of the State tested Nurse Aide (STNA) Point of Care History documentation revealed documentation of assistance provided for meal assistance, toileting assistance and personal hygiene provided only on 07/15/21 day shift, 07/05/21 night shift, 07/04/21 afternoon shift, 07/02/21 night shift, 07/01/21 day shift. 2. Review of Resident #33's medical record revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 3.0 MDS quarterly assessment with a reference date of 05/25/21 indicated Resident #33 required total staff assistance for eating meals and personal hygiene. Review of the STNA Point of Care History documentation revealed documentation of assistance provided for meal assistance and personal hygiene provided only on 07/19/21 night shift, 07/18/21 afternoon shift and night shift, 07/07/21 day shift and 07/04/21 afternoon shift. 3. Review of Resident #90's medical record revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the 3.0 MDS quarterly assessment with a reference date of 07/04/21 indicated Resident #90 required limited staff assistance for eating meals and extensive assistance from staff for toileting and personal hygiene. Review of the STNA Point of Care History documentation revealed documentation of assistance provided for meal assistance, toileting assistance and personal hygiene provided only on 07/15/21 day shift, 07/04/21 afternoon shift and 07/02/21 night shift. Observations on 07/19/21 at 10:10 A.M. revealed residents clean and dressed, with no evidence of incontinence or being disheveled. Staff members were observed providing timely resident care including toileting, morning care, showers and meal assistance. Interview with Residents #13, #33 and #87 on 07/19/21 from 10:20 A.M. to 10:35 A.M. revealed resident care needs provided timely as needed. Interview with Licensed Practical Nurse #113, STNA #129 and STNA #151 on 07/19/21 from 10:50 A.M. to 11:40 A.M. revealed resident care needs provided timely as needed but several staff members were not documenting resident care provided when it was. Interview with the Director of Nursing on 07/19/21 at 1:10 P.M. verified lack of documentation for ADL assistance provided for Residents #25, #33 and #90.

Based on interview, record review, review of the facility abuse policy and a Self Reported Incident, the facility failed to thoroughly investigate an allegation of emotional/ verbal abuse of Resident #98. This affected one resident (Resident #98) of three residents reviewed for abuse. The facility census was 97. Findings include: 1. Review of closed medical records [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #98 was admitted under hospice/ respite care. On 05/10/21, Resident #98 was discharged from the facility to home. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #98 had intact cognition and no memory issues. 2. Review of open medical records for Resident #91 revealed, on 11/08/19, Resident #91 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed Resident #91 had mild cognitive impairment with fluctuating disorganized thinking and delusions. Review of Self Reported Incident (SRI) Report dated 05/10/21 revealed, on 05/10/21 while being discharged from the facility Resident #98 reported an incident with Resident #91 (her roommate) to the Social Services Director (SSD) #131 where Resident #91 attempted to climb into bed with Resident #98, but Resident #98 stopped her. Resident #98 also reported a discussion with Resident #91 about a family member of Resident #91. The SRI included statements from Resident #98 by SSD #131, interviews with Resident #91 and other staff members who witnessed the incident. The Director of Nursing (DON) completed the investigation which was found to be unsubstantiated. Interview on 06/14/21 at 2:03 P.M. with the DON verified she had not completed a thorough investigation as she had not interviewed any other residents concerning the incident regarding Resident #98 and Resident #91. The DON stated she attempted to contact Former Resident #98 by telephone, but the resident never returned her call. The DON stated a family member of Former Resident #98 stated she believed Resident #98 was upset about a situation at home and exaggerated an incident at the facility. The DON stated she unsubstantiated the allegations with only the statements of Resident #98, statements of Resident #91 denying the allegations and statements of staff. Review of the facility Abuse Prevention Program Policy and Procedure revised on 01/2021 revealed all allegations of Resident to Resident Abuse will be investigated by DON and or Administrator. Investigations for potential abuse will not be dismissed in cases where either both residents have a cognitive impairment or mental disorder. It also stated investigation will identify that the actions were deliberate regardless of whether the individual intended to inflict injury or harm. No protocol on steps to take to complete investigation are noted. Review of the Abuse Prevention Program Seven Components revised 01/2021 revealed the Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Procedure for investigation was listed.

Based on interview, record review, review of the facility abuse policy and review of a Self-Reported Incident (SRI) the facility failed to ensure they implemented their abuse policy related to investigation of an allegation of emotional/ verbal abuse for Former Resident #98. This affected one (Former Resident #98) of three residents reviewed for abuse. The facility census was 97. Findings include: 1. Review of closed medical records [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #98 was admitted under hospice/ respite care. On 05/10/21, Resident #98 was discharged from the facility to home. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #98 had intact cognition and no memory issues. 2. Review of open medical records for Resident #91 revealed, on 11/08/19, Resident #91 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed Resident #91 had mild cognitive impairment with fluctuating disorganized thinking and delusions. Review of the Self Reported Incident (SRI) Report dated 05/10/21 revealed, on 05/10/21 while being discharged from the facility Resident #98 reported an incident with Resident #91 (her roommate) to the Social Services Director (SSD) #131 where Resident #91 attempted to climb into bed with Resident #98, but Resident #98 stopped her. Resident #98 also reported a discussion with Resident #91 about a family member of Resident #91. The SRI included statements from Resident #98 by SSD #131, interviews with Resident #91 and other staff members who witnessed the incident. The Director of Nursing (DON) completed the investigation which was found to be unsubstantiated. Interview on 06/14/21 at 2:03 P.M. with the DON verified she had not interviewed any other residents concerning the incident regarding Resident #98 and Resident #91. The DON stated she attempted to contact Former Resident #98 by telephone, but the resident never returned her call. The DON stated a family member of Former Resident #98 stated she believed Resident #98 was upset about a situation at home and exaggerated an incident at the facility. The DON stated she unsubstantiated the allegations with only the statements of Resident #98, statements of Resident #91 denying the allegations and statements of staff. The DON confirmed she had not followed their abuse policy. Review of the facility Abuse Prevention Program Policy and Procedure revised on 01/2021 revealed all allegations of Resident to Resident Abuse will be investigated by DON and or Administrator. Investigations for potential abuse will not be dismissed in cases where either both residents have a cognitive impairment or mental disorder. It also stated investigation will identify that the actions were deliberate regardless of whether the individual intended to inflict injury or harm. No protocol on steps to take to complete investigation were noted. Review of the Abuse Prevention Program Seven Components revised 01/2021 revealed the Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Procedure for investigation was listed.

Based on record review and interview, the facility failed to ensure Resident #10 received proper assistance with bed mobility. Actual harm occurred when Resident #10 was moved in bed with one staff person instead of two. Resident #10 fell out of bed, hitting her head, and requiring a hospital visit and three sutures to close her [MEDICAL CONDITION]. This affected one of three residents reviewed for falls. Findings include: Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]., and difficulty walking. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed she required extensive assistance with two staff for bed mobility. Resident #10's current comprehensive care plan revealed she was limited in her ability to perform any Activities of Daily Living (ADLs) including bed mobility and transfers. Staff were to provide assistance for all ADL's as needed. Review of Resident #10's ADL tracking form completed by the state tested nursing assistants (STNAs) each shift for (MONTH) and April, (YEAR) revealed Resident #10 required extensive to total dependence with two staff every shift and every day, except once on 04/07/18 and 04/22/18. Review of Resident #10's fall investigation from a fall on 04/22/18 revealed Resident #10 fell out of bed while aides were changing her. Resident #10 received a laceration to the right side of forehead and was sent to the hospital at the request of the family. Review of Resident #10's hospital report, dated 04/22/18, revealed she sustained a laceration to the the right side of her face measuring 2.5 centimeters and required three sutures to close the wound. Review of the facility fall investigation revealed a witness statement from STNA #222, dated 04/22/18. STNA #222 said she was changing Resident #10 when she rolled the resident towards her. STNA #222 said she was also putting new sheets on the mattress. STNA #222 had Resident #10 rolled on her side towards her and when she pulled the bed sheet, Resident #10's top half rolled off the bed and she fell on to the floor. STNA #222 no longer worked at the facility and was not able to be interviewed. The statement from the Director of Nursing (DON) dated 04/23/18 said she interviewed Registered Nurse (RN) #100. RN #100 said STNA #222 was turning Resident #10, who had a low air loss mattress on her bed. When the aide reached to the top corner to attach the new sheet, the pressure from that action caused the resident to fall off the bed. Interview on 06/06/18 at 10:43 A.M. with Assistant Director of Nursing (ADON) #221 revealed since the MDS identified Resident #10 as requiring two staff for bed mobility, the nurse should make the assessment to determine if one person could move the resident in bed. ADON #221 confirmed there was no evidence the nurse assessed Resident #10 on 04/22/18 to determine she only needed one staff assistance with bed mobility. Interview on 06/06/18 at 10:50 A.M. with RN #223 confirmed Resident #10 was coded on the MDS assessment prior to the fall as needing two staff with extensive assistance for bed mobility. RN #223 stated the MDS assessment is used to generate the plan of care. This deficiency substantiates Complaint Number OH 131.

Based on observation, record review and interview the facility failed to ensure the timely implementation of nutritional interventions and dietary notification to prevent a severe weight loss for Resident #5 and failed to ensure the resident received timely assistance with the lunch meal on 10/03/17. Actual harm occurred when Resident #5, who was assessed to sustain a severe 10.3% weight loss within thirty days, did not receive timely or adequate assistance with his meal tray to promote oral intake. This affected one resident (Resident #5) of five residents reviewed for nutrition. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed to exhibit cognitive impairment. Review of Resident #5's meal ticket revealed the resident was on a regular diet. Review of Resident #5's nutritional care plan initiated 06/17/14 revealed the resident was a risk for nutritional and hydration deficits related to dementia. The goals included to receive adequate nutrition and hydration as evidenced by stable weights, oral intake, lab values and no skin impairments. Interventions included assistance with meals, diet providing 1800 milliliters of fluids per day, encourage fluids at bedside and with activities, monitor for signs and symptoms of fluid imbalances, monitor meal intakes, offer substitutes if resident consumes less than 50% of meals, and weigh resident every month and as needed and notify the physician of significant weight loss. Review of the activities of daily living (ADL) care plan, dated 01/30/13 revealed the resident had multiple medical problems that impacted his abilities to perform his own activities of daily living (ADL's). Further review revealed to monitor and assist at meal times, including setting up tray, providing appropriate level of assistance with meals, and notify the nurse, dietician and/or speech therapy if deficit noted. Review of daily preference and activities care plan revealed to offer snacks between meals. Review of state tested nursing assistant (STNA) care guide revealed the resident was to eat in the 400 main dining room and was set up with meal trays. There was no evidence the resident required assistance with meals. Review of Resident #5's meal intake records dated 09/01/17 to 09/30/17 revealed the resident had refused at least one meal 20 out of 30 days. There was no evidence of the amount of daily fluid intakes, snack intakes or refusal, or if the resident was offered alterative meal if he refused meal or ate less then 50%. Review of Resident #5's medication administration records (MAR) dated 09/01/17 to 09/30/17 revealed on 09/23/17 the resident was started on a nutritional supplement, Med pass 90 cubic centimeters (cc's) three times a day, however there was no evidence of the amount of intake of the supplement. The resident was receiving a multivitamin daily since 09/22/16 and Potassium 20 milliequivalent (meq) twice daily since 04/19/17. Review of Resident #5's weights revealed on 09/04/17 the resident weighed 181.6 pounds and on 10/04/17 the resident weighed 158.7 pounds with a reweight documented to be 161.4 pounds which reflected a 20.2 pound weight loss in one month. Review of the resident's weights during the previous 90 days prior to the identified weight loss revealed the resident's weights averaged between 177-182 pounds. Review of Resident #5's meal intake records dated 10/01/17 to 10/03/17 revealed Resident #5 had refused four out of eight meals and only ate 50% of the four meals he ate. There was no evidence of the amount of daily fluid intakes, snack intakes or refusal, or if the resident was offered an alterative meal if he refused meal or ate less than 50%. Review of Resident #5's MAR indicated [REDACTED]. Review of dietary note dated 10/04/17 revealed the resident's monthly weight was 158.7 pounds with reweigh requested for verification. The September 2017 monthly weight was 181.6. Noted initiation of 90 cc of med pass supplement three times a day on 09/23/17 related to recent decrease in appetite and oral intake. Noted refusal of breakfast on 10/03/17. The note indicated to increase dietary supplement to 240 cubic centimeters (cc's) four times daily for additional 480 kilocalories/8 ounces and 20 grams protein and continue multi vitamin. The resident was to be placed on weekly weights for close monitoring. On 10/03/17 at 7:25 A.M., observation of Resident #5 revealed the resident's lips were dried, cracked, and he had a line of dried blood on the bottom lip. On 10/03/17 observation of Resident #5 during the lunch meal revealed the resident was lying in bed asleep. The bed was in low position, the left side of the bed was against the wall, on the right side of the bed was a grey floor mat. The lunch trays arrived on the floor at 11:30 A.M. At 11:45 A.M., the resident remained in bed. His lunch tray was on the bedside table that was located next to the door and on the other side of the grey mat. The lunch meal was not in the resident's reach and was unopened. There was a small unopened health shake (supplement) carton, a small plastic glass of red juice with a lid on it, and his lunch tray was covered. There was no evidence of staff assisting the resident or setting his tray up. STNA #130 was observed assisting another resident in the dining room and STNA #71 was observed answering call lights on the unit at this time. At 11:48 A.M. STNA #71 returned to the floor and reported to STNA #130 that management wanted them to get Resident #5 out of bed and bring him to the dining room. STNA # 71 verbalized she was unable to get Resident #5 out of bed this morning and she could not feed him his lunch in his room and answer call lights at the same time. At 11:56 A.M., STNA #71 placed a walker in Resident #5's room and walked out. At 12:11 P.M., both STNAs entered the resident's room and shut the door. Staff documented Resident #5 had refused lunch meal on 10/03/17. On 10/03/17 at 4:53 P.M., Resident #5 was observed in bed asleep. Observation with Licensed Practical Nurse (LPN) #3 revealed the resident had been up in a wheelchair, however, had put himself to bed. The resident's lips were observed to be dry and there was a Styrofoam cup filled approximately three quarters full on the end table (not in the resident's reach). On 10/04/17 at 9:16 A.M., observation of Resident #5's room with Dietician Technician (DT) #6 revealed no evidence the resident had a water pitcher or any type of fluids in his room. The resident was observed in the 400-dining room without evidence of any fluids on the table or in his reach. On 10/04/17 at 10:10 A.M., observation of Resident #5's room with the Administrator revealed no evidence of any fluids in the resident's room. The Administrator obtained a water pitcher and cups for the resident's room. On 10/04/17 at 8:57 A.M., interview with DT #6 revealed she was not notified until yesterday of the resident's meal refusals, increase in need for meal assistance, and weight loss. DT #6 reported her expectation is to be notified if a resident had two meal refusals in 48 hours. DT #6 reported she would have implemented new interventions if she was aware of the resident's meal refusals and decline. DT #6 reported she would recommend assistive dining, weekly weights, and would speak with the director of nursing regarding her expectations for notification. The DT indicated she was at the facility twice a week. On 10/04/17 at 10:35 A.M., DT #6 confirmed Resident #5 was assessed to sustain a significant weight loss of 10.3 % in one month. DT #6 revealed the last assessment indicating the resident's nutritional needs and ideal body weight was completed approximately three years ago on 12/11/14. DT #6 verified there was discrepancy with the resident's height which could also affect his nutritional needs. The last assessment completed in 2014 indicated the resident was 5'8 however hospital notes indicated the resident was 6'2. DT #6 confirmed she did not review the actual amount of supplement intake the resident was receiving, she had just asked the nurse if he was accepting the supplement. On 10/04/17 at 12:20 P.M., interview with DT #6 confirmed there was no evidence the resident was offered or received a snack, no evidence the resident was offered an alternate meal when he ate less than 50%, or amount of daily fluid intake being documented. RT #10 reported the facility should be documenting snack and fluid intake as well as offering an alternate meal. On 10/04/17 at 12:39 P.M., interview with Registered Nurse (RN) #47 verified the facility only documented the level of assistance a resident required for residents receiving skilled care, which Resident #5 was not. RN #47 reported for residents not receiving therapy or skilled services she would interview the staff to determine the amount of assistance they needed to complete the comprehensive Minimum Data Set (MDS)3.0 assessments quarterly and annually. On 10/05/17 at 11:30 A.M., interview with RN #101 revealed she had noted the resident had a decline in oral intake and assistance with meal intakes after recent falls. On 09/23/17 she had notified the doctor the resident was not eating or drinking and requested an oral supplement. RN #101 confirmed she did not notify the dietician of the resident's decline because she did not have her telephone number. The RN indicated she updated the staff working on the floor that day, however it was not documented or communicated on the care guide sheets to reflect the resident's changes in assistance required for meals. On 10/05/17 at 11:35 A.M., interview Registered Dietician (RT) #10 revealed the resident's weight loss could have been related to decrease in activities of daily living, meal refusals, medications and/or sinus infection, however it was nursing judgement/assessment to determine the cause of the weight loss. She confirmed the resident's height was inaccurate on the original assessment completed in 2014 however they were not able to obtain an accurate height until today when they measured the resident wing span and determined he was 5'10. The RT reported she visited the facility once a month and sees the high-risk residents only. The DT will leave a list of residents that need to be seen that she feels are high risk. The RT indicated she would re-evaluate the resident next week to adjust the nutritional intervention. She can make recommendations for lab however did not because she was not aware the resident had signs or symptoms of dehydration. The RT confirmed she understood there was great concerns regarding the resident's current weight loss, lack of documentation, and prompt notification to the dietician.

Based on observation, interview and record review the facility failed to ensure the proper use of a mechanical/Hoyer lift resulting in a fall and fracture of the right ankle for Resident #32. This affected one of three residents reviewed relative to falls. The facility census was 94. Findings include: Review of the medical record for Resident #32 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was morbidly obese and on 08/01/2012 weighed 237 pounds. A comprehensive assessment dated [DATE] revealed the resident was alert and oriented and required total assistance of two plus persons for transfers to and from the bed and chair. Review of a fall risk assessment dated [DATE] revealed a score of 15, which based on a scale of 10 or greater, identified the resident as high risk for a fall. Review of a care plan relative to falls revealed the resident was at risk for a fall due to morbid obesity, unable to bear her own weight and required transfer by mechanical lift. Review of updated information added to the care plan revealed on 08/17/2012 revealed staff were to be more cautious of Hoyer strap placement. Review of a fall investigation for Resident #32 revealed on 08/17/2012 at 3:40 P.M., during a transfer from a wheel chair to the bed by Hoyer lift, one strap of the Hoyer pad got caught on the wheel chair. When staff unhooked the strap from the wheel chair, the strap also came unhooked from the Hoyer lift. Review of the investigation revealed only three remaining straps were secured to the Hoyer, the staff held the unhooked strap and lowered the resident to the floor. The investigation revealed the resident immediately began complaining of lower back and right foot pain and the State tested Nurse Aides (STNA) were re-educated to be more cautious with regard to strap placement with the use of a Hoyer lift. The fall investigation documentation revealed the resident complained of lower back and right ankle pain immediately following the fall. Review of an X-ray report dated 08/17/2012 at 10:27 P.M., seven hours later, revealed a fracture of the right ankle in early stages of healing. Review of the nurse's notes revealed Resident #32 took Tylenol 650 milligrams, for complaints of pain but refused to be seen by an orthopedic specialist. On 09/27/2012 at 10:15 A.M., staff were observed using a Hoyer lift to transfer Resident #32 from the bed to the wheel chair. No issues were identified relative to the STNAs use of the lift, however, during the transfer Resident #32 pointed to a spot on the floor near the foot of the bed and said "That's where they dropped me on the floor." On 09/27/2012 at 12:37 P.M., a follow-up interview with Resident #32 verified that on 08/17/2012 at 3:40 P.M., staff dropped her onto the floor during a transfer from her wheel chair to the bed. The resident explained the wheel chair started to come up off the floor and when staff tried to pull it lose the strap came unhooked from the lift and she started to fall backwards. The STNA grabbed the strap but she landed "hard on the floor" and hurt her right foot and her back. The resident revealed she still hurts a little but she doesn't like to take pills. On 09/27/2012 at 1:40 P.M., interview with LPN #15 revealed on 08/17/2012 she entered Resident #32's room when staff called for help. She found one STNA lowering the lift and the other hanging onto the unhooked Hoyer strap. The resident's body was touching the floor. LPN #15 did not think the resident fell but the resident's right ankle had landed on top of the metal base of the lift. The strap was hooked again to the lift and the three staff members used the Hoyer to get Resident #32 back to bed. On 09/27/2012 at 4:20 P.M., an interview with the Director of Nursing verified during transfer with a Hoyer lift, staff failed to maintain secure strap placement and Resident #32 fell and fractured her ankle. This deficiency substantiates Complaint Number OH 269.

Based on observation, interview and record review, the facility failed to provide range of motion services to Resident #109 (who entered the facility with no limitations in range of motion), in order to maintain and/or prevent a decline in range of motion to her bilateral lower extremities. This resulted in actual harm to Resident #109 as both of her legs were contracted up near her chest. This affected one of four residents reviewed with contractures, of 49 residents identified with contractures. The facility census was 95 residents. Findings include; Resident #109 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set assessment ((MDS) dated [DATE] indicated the resident was cognitively impaired, the resident required extensive assistance of two staff for bed mobility and transfers, and the extensive assistance of one for dressing, eating and toileting. The MDS also indicated the resident had no impairments in functional range of motion in the upper or lower extremities. The MDS dated [DATE] indicated the resident was dependant for bed mobility, did not transfer, and was dependant for activities of daily living. The most recent MDS dated [DATE] indicated the resident was severely cognitively impaired, and was dependant for transfers and ADLs. The MDS also showed the resident suffered an impairment in functional range of motion on bilateral lower extremities. The resident's activities of daily living (ADL) care plan, dated 02/11/11 and updated through 11/30/11, indicated the resident had multiple medical problems that impact her abilities to perform own ADLs. The additions/updates to the problems area of the care plan were not dated. The care plan stated the resident had limitations in ROM with potential for contractures (unknown date according to care plan). The interventions included referral to physical and /or occupational therapy and/or restorative nursing. The resident was seen by physical and occupational therapy from 02/01/11 to 02/22/11. The resident was discharged from occupational therapy due to a decline in all functional goals; the resident was also lethargic and not following commands. The physical therapy discharge note stated the resident made very little progression and was being discharged from therapy due to lack of progression. Neither note indicated the resident was resistive or agitated with therapy, nor was there documentation that the resident had any limitation in range of motion. The restorative nursing referral form completed by therapy dated 02/21/11 was reviewed. The therapy anticipated discharge date was 02/22/11. Therapy recommended restorative nursing programs for the resident. The programs included active assisted range (AAROM) of motion exercises to both upper and lower extremities for twenty repetitions each, ambulation program, and transfers. The restorative progress note dated 02/24/11 was reviewed. The note stated the resident was not a candidate for a restorative program. The note stated the resident had no safety awareness, kept eyes closed, pulled away from staff when touched, did not comprehend ambulation, and would not stand to do anything. The note stated when passive range of motion (PROM) was attempted, the resident became more agitated with touch. The note also stated the functional range, but did not do any self care. Nurses notes from February through August 2011 were reviewed. There was no indication the resident was resistive or agitated with care. Nurses notes indicated the resident was compliant with care. The resident was observed on 08/17/11 at 2:00 P.M., 3:30 P.M., and 5:45 P.M. lying in bed with specialty air mattress in place. The resident had a pillow between her knees and both legs were contracted up near her chest. The resident had no splints on her legs. State tested Nursing Assistant STNA #14 was interviewed on 08/17/11 at 2:30 P.M., and said the resident was not on a restorative nursing program. STNA #14 said she recognized the resident had contractures on both legs, and tried to straighten them at times. The restorative nurse, Registered Nurse (RN)#1 was interviewed on 08/17/11 at 3:50 P.M. RN #1 was asked about the restorative progress note dated 02/24/11, and said she did not re-approach the resident to attempt to provide the recommended program. RN #1 said when residents were discharged from therapy, they were referred to restorative nursing for programs. The restorative staff then sees the residents for an amount of time that was needed and then discharged from formal restorative. RN #1 said she does not refer range of motion (ROM) programs to the floor staff for residents with contractures. When asked who provided the ROM programs when the residents were discharged from restorative nursing, RN #1 said she assumed the residents were receiving ROM with daily care. RN #1 verified there were no forms or documentation to ensure the state tested nursing assistants knew which residents required ROM. The MDS nurse, RN #13, was interviewed on 08/17/11 at 4:16 P.M. RN #13 verified the MDS assessments dated 02/04/11 and 05/02/11 indicated Resident #109 had no limitations in ROM in either upper or lower extremities, however the MDS dated [DATE] showed the resident had suffered a decline to the ROM in her bilateral lower extremities. RN #13 was asked if she had notified either therapy or restorative of the resident's decline and she stated she had not. The therapy manager, Speech Therapist (ST) #15, was interviewed on 08/18/11 at 9:50 A.M. ST #15 said all residents were referred to restorative nursing upon discharge from therapy. ST #15 said Resident #109 was mostly compliant with therapy and there were no issues in therapy with non-compliance by the resident. RN #12 was interviewed on 08/18/11 at 10:15 A.M., and said she had reviewed the resident's record but could not find documentation that the resident was resistive or agitated with care. RN #1 was interviewed again on 08/18/11 at 10:44 A.M. RN #1 said when she did not pick the resident up for restorative she did nothing further and did not educate the staff on care of the resident. RN #1 said currently there were 2 full time restorative STNAs, and they both get pulled to the floor 25 percent (%) to 50% of the time, and were not able to do all their programs. RN #1 said she set the restorative programs for 2 to 6 times per week because the STNAs get pulled from the restorative programs to work on the floor and she wanted to be able to meet the goals. RN #1 was asked why there were no floor ROM programs. RN #1 said she did not think the staff had the time to do the ROM programs, and since reheab keeps discharging residents and refers every resident to restorative, she had to choose who she kept on restorative and who to discharge.

Based on observation, record review and interview, the facility failed to ensure an area of deep tissue injury to Resident #54's right heel was promptly identified. The facility also failed to ensure pressure relieving interventions and physician ordered treatments were provided to promote healing. This affected one of two residents reviewed for pressure ulcers, out of five residents identified with pressure ulcers. The facility census was 95 residents. Findings include: Resident #54 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #54's mental status was moderately impaired, and she demonstrated no behaviors and was not resistant to care. The same MDS assessment indicated Resident #54 required extensive assistance of two persons for bed mobility. The skin risk assessment dated [DATE] identified Resident #54 at "automatically high risk" for the development of pressure sores. The "Actual and/or Potential for Skin Breakdown" plan of care was initiated on 05/10/09 and remained current. The care plan identified that Resident #54 was at risk for skin breakdown related to limitations in mobility, incontinence, thin, fragile skin and [MEDICAL CONDITION]. The care plan identified a history of healed pressure ulcers. Interventions included to turn and reposition Resident #54 every two hours, to elevate her heels off the surface of the bed, and to provide treatments to the area as per doctor's order. A "Condition Change Form" dated 08/09/11 at 1:30 P.M., revealed a state tested nurses aide (STNA) reported a black/purple/mushy spot on Resident #54's right heel. The form indicated a new order was given to pad and protect the area and to continue to elevate her heels. A corresponding physician's orders [REDACTED].#54's right heel. The dressing was to be changed every three days and as needed. The order indicated to continue to elevate the heel. A "Weekly Pressure Ulcer Progress Report" (skin grid) was initiated on 08/09/11 that identified a suspected deep tissue injury to Resident #54's right heel. The area measured 2.5 centimeters (cm) by 2.5 cm. The color of the wound was described as red with purple hues. Purple or very dark areas that are surrounded by profound redness, [MEDICAL CONDITION], or induration suggest that deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of a Stage III or IV pressure ulcer. On 08/18/11 at 6:36 AM, Resident #54 was observed lying in her bed with both of her heels resting directly on the mattress. No dressing was observed in place on the resident's right heel. The old gauze dressing was observed loosely gathered around the lower one/third of her right calf. There was no pillow on the bottom of the bed. Resident #54's eyes were open, but she did not respond to the surveyor. During an interview on 08/18/11 at 6:42 A.M., Licensed Practical Nurse (LPN) #11 verified Resident #54's heels were in direct contact with the mattress and no dressing was in place to the wound on the right heel. LPN #11 acknowledged the dressing should have been in place and Resident #54's heels were to have been elevated off the mattress. LPN #11 confirmed there was no pillow or blanket available in the room to elevate the resident's heels off the bed. LPN #11 indicated that it was the expectation that the STNAs would report to the nurses when the dressing was not in place and were responsible for elevating the resident's heels off the mattress. On 08/18/11 at 6:51 A.M., LPN #11 re-entered Resident #54's room, carrying dressing supplies and a rolled up bath blanket. She explained there was no pillow available to elevate Resident #54's heels. Resident #54 did not respond to LPN #11. LPN #11 lifted Resident #54's right heel from the bed to reveal an oval shaped area that measured approximately 3.0 cm by 2.5 cm. with a crescent shaped area of black eschar. Eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. The area surrounding the eschar was red, soft and mushy. After applying the dressing, LPN #11 placed the rolled up bath blanket under Resident #54's right heel. During an interview on 08/18/11 at 8:20 A.M., Quality Assurance Nurse/Registered Nurse #12 verified that the pressure ulcer on Resident #54's right heel was not discovered until it had progressed to the point of suspected deep tissue injury. RN #12 acknowledged that at the time of discovery Resident #54's right heel was soft, and red and purple in color.