Every finding on record at Brethren Care Village Health Care Center

Based on observation, medical record review, staff interviews, review of a facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure proper infection control practices were maintained for residents in isolation. This affected one (#86) of one residents reviewed for transmission-based precautions with the potential to affect all seven (#19, #27, #48, #49, #83, #87, and #88) additional residents that resided on the skilled unit. The facility census was 64.Findings include:Review of the medical record revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, pneumonia, and dementia.Review of Resident #86's physician orders for June 2026 revealed on 06/16/26 the resident was placed on contact isolation for Clostridioides difficile (C. diff, a highly contagious bacterium that infects the large intestine causing diarrhea and colitis).Review of the care plan dated 06/16/26 for Resident #86 revealed she had C. diff with interventions including placing the resident on contact precautions.Observation and interview on 06/23/26 at 9:35 A.M. revealed Certified Occupational Therapist Assistant (COTA) #900 used hand sanitizer instead of washing her hands when she left Resident #86's room. COTA #900 touched Resident #900's door handle and was carrying a bag of linens in her hand. COTA #900 stated she did not know that she had to wash her hands instead of using hand sanitizer. COTA #900 stated that she would wash her hands after she dropped off the bag. Interview on 06/25/26 at 1:50 P.M. with the Director of Nursing (DON) revealed that hands must be washed with soap and water for C. diff and hand sanitizer did not work. Review of the facility policy titled, Standard Precautions Policy and Procedure- Point of Care Risk Assessment, revealed regardless of a resident's transmission-based (isolation) precautions, hand hygiene must be performed after personal protective equipment removal and before leaving the room.Review of the Centers for Disease Control and Prevention (CDC) guidelines for preventing C. diff revealed washing hands with soap and water was the best way to prevent the spread of C. diff from person to person.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure a care plan was initiated to provide interventions for a resident with post-traumatic stress disorder. This affected one (#8) of one residents reviewed for post-traumatic stress disorder. The census was 64.Findings include:Review of the medical record for Resident #8 revealed an admission date of 03/13/22. Diagnoses included post-traumatic stress disorder (PTSD), Parkinson's disease, Alzheimer's disease, hypertension, and heart failure.Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with PSTD as a diagnosis and was cognitively impaired.Review of Resident #8's comprehensive care plan initiated on 07/19/22 revealed no evidence of PTSD being addressed.Review of the psychiatric evaluation dated 12/18/25 revealed Resident #8 was being seen because staff stated he was having flashbacks and had been more tearful about the war. Resident #8 was experiencing increased symptoms of depression and had been anxious. PTSD was added as a diagnoses.Interview on 06/25/26 at 10:30 A.M. with MDS Nurse #402 and MDS Nurse #504 revealed PTSD would be addressed in the admission Assessment. Interview on 06/25/26 at 12:47 P.M. with Master of Social Work (MSW) #505 revealed Resident #8 initially denied any history of PTSD upon initial admission. MSW #505 stated in December 2025, the resident mentioned concern about being in the war. MSW #505 stated the other social worker addressed concern with him immediately with a referral to psychiatric services. MSW #505 verified there was no PTSD assessment or admission Assessment to select from under the Assessment tab; however, she believed there used to be an option for that. MSW #505 verified Resident #8's PTSD was not addressed in his care plan.Review of the undated facility policy titled, Trauma Informed Care, revealed it was the policy of the facility to closely monitor all residents who exhibit signs/symptoms of trauma. The facility would produce, document, and implement trauma informed care plans for residents identified as having experienced and been adversely affected by trauma in their lives.

Based on medical record review, review of resident trust statements, review of a written check, and staff interview, the facility failed to ensure resident funds were conveyed for final accounting of resident funds within 30 days of death. This affected one (#89) of one residents reviewed for personal funds final conveyance. The facility census was 64.Findings include:Review of the medical record for Resident #89 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic pulmonary disease, diabetes mellitus, and kidney disease. Further review of the medical record revealed Resident #89 expired at the facility on [DATE].Review of Resident #89's personal funds account balance as of [DATE] revealed the resident had $300.06 in the account. Review of Resident #89's personal funds account balance as of [DATE] revealed the resident had #300.17 in the account.Review of a checked dated [DATE] revealed [DATE] revealed $300.17 was written to the Attorney General office to close Resident #89's account.Interview on [DATE] at 1:15 P.M. with Business Office Manager (BOM) #415 verified the lack of timely conveyance of funds for Resident #89.

Based on medical record review, observations, staff interview, review of the facility's infection control logs, review of facility in-services, review of the Centers for Disease Control and Prevention (CDC) guidance, review of the manufacturer's instructions, and review of the facility's policy, the facility failed to prevent and respond to an increased pattern of urinary tract infections (UTIs). This affected two (Resident #1 and #28) of two residents reviewed for urinary tract infections. The facility also failed to complete blood sugar checks in a sanitary manner. This affected three (Resident #1, #18, and #37) of nine residents who required blood sugar checks. The facility census was 75. Findings include: 1. Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/01/22, revealed Resident #28 was severely cognitively impaired and required extensive assistance from staff for toileting. The resident had an indwelling catheter and was always incontinent of bowel. Review of the infection control logs dated 03/01/22 through 07/31/22 revealed Resident #28 was identified to have a [CONDITION(S)] on 04/13/22, 05/10/22, 05/30/22, and 06/17/22. The urine culture for the [CONDITION(S)] on 05/10/22 identified Escherichia coli (E. coli) in the resident's urine. All UTIs were monitored and treated. 2. Review of Resident #1's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 02/22/22, revealed Resident #1 had an indwelling catheter. Review of the quarterly MDS assessment, dated 08/19/22, revealed the resident was cognitively intact and required total assistance of two staff for toileting. The resident had an indwelling catheter and was frequently incontinent of bowel. Review of the infection control logs dated 03/01/22 through 07/31/22 revealed the resident was identified to have a [CONDITION(S)] on 04/02/22 which was resolved on 04/15/22. The urine culture for the [CONDITION(S)] identified E. coli in the resident's urine. 3. Review of the infection control logs for 03/01/22 through 07/31/22 revealed there were 44 UTIs which were not present upon admission identified within this timeframe, 20 of which were identified to have E. coli. Three UTIs were identified to have began in March 2022. 12 UTIs, six of which had E. coli were identified to have began in April 2022. 13 UTIs, six of which had E. coli were identified to have began in May 2022. Six UTIs, two of which had E. coli were identified to have began in June 2022. 10 UTIs, six of which had E. coli were identified to have began in July 2022. Attempted review of the infection control logs for 08/01/22 through 09/22/22 revealed logs were incomplete for this time period. Review of the staff in-services dated 01/01/2020 through 09/21/22 revealed no in-services pertaining to prevention of UTIs. Interviews on 09/21/22 at 3:55 P.M. and on 09/22/22 at 10:15 A.M. with the Director of Nursing (DON) revealed the facility identified an increase in UTIs and discussed this during a Quality Assurance and Performance Improvement (QAPI) meeting in July 2022. The DON verified no education or in-services had been completed or provided to staff and should have been. Review of the facility's undated policy titled Infection Control Program revealed the facility has developed and maintains an Infection Control Program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease or infection. 4. Review of the medical record revealed Resident #1 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #18 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #37 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 09/21/22 at 7:27 A.M. revealed Licensed Practical Nurse (LPN) #601 was observed checking a blood sugar for Resident #37 who was seated at the dining room table. LPN #601 placed the glucometer and test strip with blood directly on the dining room table. LPN #601 was observed cleaning the glucometer with an alcohol wipe between residents. Observations on 09/21/22 at 7:32 A.M. revealed LPN #601 was observed testing blood sugars for Resident #1 and #18 who were lying in bed. LPN #601 placed the glucometer and test strip with blood directly on bedside table. LPN #601 was observed cleaning the glucometer with an alcohol wipe between residents. Interview on 09/21/22 at 7:52 A.M. with LPN #347 stated the glucometer could be cleaned with a sani-cloth or alcohol wipe. LPN #347 stated the policy directed staff to clean the glucometer with an alcohol wipe. LPN #347 verified the same glucometer was utilized for Resident #1, #18, and #37. Interview on 09/21/22 at 3:30 P.M. with the Director of Nursing (DON) verified the manufacturer's instructions for the lucimeter did not include the use of a alcohol wipe. Review of the Centers for Disease Control and Prevention titled Infection Prevention during Blood Glucose monitoring and Insulin Administration summary dated 03/02/11 revealed if glucometers must be shared, the device must be cleaned and disinfected after every use, per manufactures instructions. Review of the manufacturer's instructions revealed glucometers should be cleaned using Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Disinfectant Towels with bleach caviwipes and PDI Super Sani-Cloth Germicidal Disposal Wipes for disinfecting the assure prism multi meter. Review of the facility's policy titled Guidelines and Policy for Glucometer Use, dated 2022, revealed staff are to clean with Super Sani-Cloth (per manufacture guideline).

Based on medical record review, staff interview, and review of the facility's policy, the facility failed to timely and routinely assess a resident who had significant weight loss two months in a row. This affected one (Resident #60) of three residents reviewed for nutrition. The facility identified eight residents with unplanned significant weight loss/gain. The facility census was 75. Findings include: Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/09/22, revealed the resident was cognitively impaired and required supervision and setup assistance for eating. Review of Resident #60's nutritional assessment and plan of care, dated 05/09/22, revealed the resident's weight had been stable since admission. Resident #60 was prone to fluid or electrolyte concerns, inadequate intake, and received medications which could cause appetite changes, gastrointestinal distress, and/or other nutrition-related side effects. Interventions included offering substitutes for uneaten foods, snacks per resident preference and choice to meet nutritional and quality of life needs, and offering supplements as ordered. Review of Resident #60's weight record revealed Resident #60 weighed the following: 189.8 lbs. on 05/04/22, 168.5 lbs. on 08/18/22, and 157.6 lbs. on 09/15/22. On 08/18/22, Resident had a 21.3 lbs. weight loss and a 11.2 significant weight loss in three months. On 09/15/22, Resident #60 had a 10.9 lbs. weight loss and a 6.5% significant weight loss in one month and a 32.2 lbs. weight loss in four months and was a 17% significant weight loss. Further review of Resident #60's medical record revealed Resident #60's significant weight loss was not addressed by the Registered Dietitian (RD) or Physician from 08/18/22 through 09/19/22. Resident #60 was last assessed by the RD on 05/09/22. Review of Resident #60's physician orders, dated 09/20/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 09/21/22 at 2:22 P.M. with RD #326 revealed RD #326 was not aware of Resident #60 sustaining any significant weight loss while residing in the facility. RD #326 reported she was typically notified of significant weight loss when quarterly MDS assessments were completed and reported there was no formal process for monitoring weights in between quarterly assessments. RD #326 verified Resident #60 appeared to have sustained significant weight loss during the aforementioned dates. RD #326 verified she was unaware of any significant weight loss sustained by Resident #60 until brought to her attention during the survey on 09/20/22. RD #326 also verified there were no nutritional supplements ordered for Resident #60 until 09/20/22, after nutritional documents for Resident #60 were requested during the survey. Review of the facility's policy titled Weight, revised September 2018, revealed a significant weight change included a weight change greater than five-percent in the past 30 days or ten-percent in the past 180 days. The policy further revealed when a significant weight change was identified and verified, the interdisciplinary team, including physician and dietitian, and resident or person responsible were notified.

Based on medical record review, observation and staff interview, the facility failed to apply a resident's preventative barrier cream as physician ordered. This affected one (#30) of seven residents reviewed for preventative skin care. Facility census was 77. Findings Include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) 3.0 dated 05/23/22 revealed Resident #30 is cognitively intact, had no hallucinations, delusions or behaviors. Resident #30 requires extensive assist for bed mobility, dressing, toileting, personal hygiene, is dependent on staff for transfers, and is supervision for eating. Resident #30 has an indwelling catheter for bladder elimination and is coded as frequently incontinent of stool. Resident #30 is coded as at risk for pressure ulcer, is coded as not having any pressure ulcers, is coded as having a pressure reducing device to the chair, and a turning/repositioning program. Resident #30 is coded as having applications of ointments other than to the feet and as having application of non-surgical dressing with or without topical medications other than to the feet. Review of Resident #30's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's treatment administration record (TAR) revealed the barrier cream to the peri rectal area after each incontinence episode for preventative skin care was not on the TAR and there was no documentation the application of preventative barrier cream being applied after each episode of incontinence. Observation of Resident #30's buttock at 2:15 P.M. revealed the resident had been incontinent of stool, the staff provided peri care and cleansed the resident with cleansing wipes as per standard. The observation revealed Resident #30 had barrier cream on the bedside table and staff was asked if the resident receives protective barrier cream and Licensed Practical Nurse (LPN) #305 stated the resident gets barrier cream when she needs it but she normally uses the bed pan. LPN #305 indicated Resident #30 did not need barrier cream at this time and the resident had incontinent brief re-applied and her pants put back on with no barrier cream application. During an interview on 07/11/22 at 5:00 P.M. LPN #300 confirmed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #300 confirmed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 965.

Based on record review, staff interviews, review of facility self-reported incidents (SRI) review and policy review, the facility failed to ensure residents were free from emotional and verbal abuse. This affected one (Resident #61) of three residents reviewed for abuse. The facility census was 64. Findings include: Record review revealed Resident #61 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment, dated 05/03/21, revealed the resident had moderate cognitive impairment. The resident required extensive assistance of two staff members for bed mobility, transfers, and toileting. Review of the plan of care, dated 06/17/21, revealed Resident #61 had unsettled relationships with staff due to an incident where staff broke Resident #61's trust. Interventions included assessing the resident for unfulfilled needs, assisting the resident in developing effective coping strategies, allowing the resident to have choice in who provided care to them, continuance of care provided by two staff members to ensure continuity and safety, listening objectively to the resident's complaints and clarifying misconceptions, and maintaining a calm environment and approach to the resident. Review of the facility's Self Reported Incident (SRI) revealed the incident occurred on 06/16/21 at 8:00 P.M. The report was filed the next day, on 06/17/21 at 1:14 P.M Charge Nurse #872 reported to the Director of Nursing (DON) that Resident #61 stated State tested Nursing Assistant (STNA) #282 yelled at Resident #61 when Resident #61 asked to go to bed, threw Resident #61's pads and foot pedals in the corner of the room and stated call your mommy and tell on me. STNA #282 was placed under suspension pending the facility's investigation. During the investigation, several staff members shared concerns regarding their experience with STNA #282 on 06/16/21. Statements were taken from STNA #285, STNA #286, and Licensed Practical Nurse (LPN) #366. The facility noted that verbal and emotional abuse were substantiated based on inappropriate language and attitude displayed by STNA #282 during the investigation. STNA #282 was terminated on 06/22/21 and the Nurse Aide Registry was notified. All staff were in-serviced on verbal and emotional abuse. Review of a witness statement, dated 06/17/21, written by STNA #286, revealed Resident #61 had asked STNA #282 to take Resident #61 to her room because it was close to the Cleveland Indians game. STNA #282 responded with who the **** adds a Indian game to a care plan? Resident #61 became upset and stated Resident #61's daughter would tell STNA #282 and Resident #61 proceeded to call her daughter. Shortly after this occurrence, STNA #282 was observed removing the foot pedals from Resident #61's wheelchair and tossing them on the floor. Resident #61 commented don't break them and STNA #282 responded with then move your feet. STNA #282 proceeded to hand Resident #61 Resident #61's phone and said here, call your daughter again. Resident #61 began crying and STNA #286 told STNA #282 if Resident #61's call light came on STNA #286 would get it. During interview on 07/08/21 at 3:43 P.M., STNA #286 verified the details provided in her witness statement. During interview on 07/08/21 at 4:05 P.M., the Administrator verified the events of the SRI and that the facility determined verbal and emotional abuse had occurred. Review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 01/31/17, revealed Brethren Care Village Health Care Center will not tolerate Abuse, Neglect, Exploitation, or Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 557.

Based on record review, staff interview, facility self reported incident review and policy review, the facility failed to ensure staff immediately reported allegations of abuse. This affected one (Resident #61) of three residents reviewed for abuse. The facility census was 64. Findings include: Record review revealed Resident #61 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's self reported incident (SRI) revealed an incident involving abuse occurred on 06/16/21 at 8:00 P.M. The report was not filed until 06/17/21 at 1:14 P.M Charge Nurse #872 reported to the Director of Nursing (DON) that Resident #61 reported State tested Nursing Assistant (STNA) #282 yelled at Resident #61 when Resident #61 asked to go to bed, threw Resident #61's pads and foot pedals in the corner of the room and stated call your mommy and tell on me. STNA #282 was placed under suspension pending the investigation. During the investigation, several staff members shared concerns regarding their experience with STNA #282 on 06/16/21. Statements were taken from STNA #285, STNA #286, and Licensed Practical Nurse (LPN) #366. The facility substantiated verbal and emotional abuse based on inappropriate language and attitude displayed by STNA #282 during the investigation. Review of the facility's investigation, dated 06/17/21, revealed STNA #286 witnessed the incident on 06/16/21 at approximately 8:00 P.M. but did not report the incident to the Administrator per facility policy. Resident #61 reported the incident to Charge Nurse #872 on 06/17/21 at 7:30 A.M., and Charge Nurse #872 immediately notified the Director of Nursing (DON). During interview on 07/08/21 at 3:43 P.M., STNA #286 stated she did not report the incident to the DON or Administrator because LPN #366 was standing in the hallway when the incident occurred. The following morning, STNA #286 received a phone call from the DON inquiring about what had occurred and then provided a witness statement. During interview on 07/08/21 at 4:00 P.M., LPN #366 stated she did not witness any incidents between STNA #282 and Resident #61 or any other residents. LPN #366 reported no staff member informed her of what had occurred, therefore she had not reported the incident to administration. During interview on 07/08/21 at 4:05 P.M., the Administrator stated the incident occurred on 06/16/21 at approximately 8:00 P.M. and STNA #282 continued working until the end of her shift. Administration was not notified of the incident until 06/17/21 at 7:30 A.M. Review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 01/31/17, revealed All Incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 557.

Based on observations, staff interviews, review of facility policy and review of Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement proper infection control practices ensuring staff wore eye protection in all resident care areas. This had the potential to affect all 58 residents (Residents #101 through #158.) The facility identified 20 residents to be COVID-19 positive. The facility census was 58. Findings include: 1. Observation on 12/20/20 from 9:19 A.M. to 9:24 A.M. revealed Registered Nurse (RN) #200 and State tested Nursing Assistant (STNA) #500 were caring for residents on the 100 unit. Both health care personnel were wearing prescription glasses but no goggles or facemask. One resident, #124, resided on the 100 unit who was positive for COVID-19. Interview with RN #200 and STNA #500 on 12/20/20 at 9:27 A.M. revealed that they were wearing only prescription glasses and they were unaware that further eye protection was needed. 2. Observation on 12/20/20 at 11:05 A.M. revealed Housekeeper #300 and STNA #300 were working in the 300 and 400 halls. Both staff members were wearing prescription glasses but no goggles or face shields. One COVID-19 positive resident, #105, resided on the unit. Interview with STNA #300 on 12/20/20 at 11:08 A.M. revealed the staff was to wear goggles or face shields when caring for COVID-19 residents. Interview with the Director of Nursing on 12/20/20 at 10:30 A.M. revealed the facility followed the guidelines set forth by the Centers for Disease Control and the Ohio Department of Health. Review of the COVID-19 Nursing Home data website (https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg) of the most recent county positivity rates revealed the facility's county percent positivity in prior fourteen days was coded the color red indicating substantial community transmission. Review of the Center For Disease Control guidelines all healthcare personnel working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. Healthcare personnel should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. They are to wear an N95 or equivalent or higher-level respirator, instead of a facemask, for aerosol generating procedures. Review of facility policy titled Coronavirus (COVID-19), dated 11/12/20, revealed Brethren Care Village will continue to follow all infection control provided by the Ohio Department of Health (ODH) and the Center for Disease Control (CDC) in regards to personal protective equipment. These policy's will stay aligned with the recommended usage unless contingency or crisis capacity is implemented. Contingency and crisis is still under the guidance of the ODH and CDC.

Based on observation of medication administration, medical record review, staff interview and review of a facility policy, the facility filed to ensure staff followed infection control policy when obtaining resident's blood glucose levels and administering insulin. This affected one (#56) of five resident's observed for medication administration. The facility identified three residents who received blood glucose level checks. The facility census was 82. Findings include: Medical record review revealed Resident #56 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. Review of an order dated 04/25/19 revealed the resident was to be administered 10 units of [MEDICATION NAME]before meals. Observation on 09/25/19 at 4:16 P.M., revealed Licensed Practical Nurse (LPN) #181 obtained a glucometer (device used to obtain a sample of blood for glucose testing) out of the medication cart and proceeded to Resident #56's room. LPN #181 obtained the resident's blood glucose level then returned to the medication cart and placed the glucometer back into the top drawer. LPN #181 was not observed to clean the glucometer prior to or after obtaining the resident's blood glucose level. LPN #181 then proceeded to prepare the resident's [MEDICATION NAME]for administration. LPN #181 took the opened vile of [MEDICATION NAME] out of the drawer and inserted a needle into the rubber [MEDICATION NAME] and drew up 10 units of the insulin. LPN #181 then proceeded to the resident's room and administered the insulin to Resident #56. LPN #181 was not observed to clean the rubber [MEDICATION NAME] on the vile of insulin prior to obtaining the resident's dose of insulin. Interview on 09/25/19 at 4:27 P.M., LPN #181 revealed glucometers were used for multiple residents and were cleaned daily on the night shift. LPN #181 confirmed she did not clean the glucometers between use for multiple residents, prior to obtaining Resident #56's blood glucose level. LPN #181 further revealed insulin vile rubber [MEDICATION NAME] were supposed to be cleaned with alcohol prior to obtaining a dose of insulin. LPN #181 further confirmed she did not clean the rubber [MEDICATION NAME] of the [MEDICATION NAME]vile prior to obtaining Resident #56's insulin. Review of a facility policy titled Guidelines and Policy for Glucometer Use, dated 01/2012, revealed the facility would promote the safe and efficient measurement of blood glucose levels for residents. Further review revealed staff were supposed to clean glucometers with a disinfectant wipe and allowed to dry at least three minutes before using it on another resident. Review of a facility policy titled Subcutaneous Medication Administration, dated 07/01/12, revealed staff were supposed to clean the rubber [MEDICATION NAME] of a vile with alcohol prior to obtaining the dose of medication required for injection.

Based on medical record review, staff interview, and review of facility policy, the facility failed to timely notify the physician of abnormal laboratory test results for three (#7, #24 and #133) of four residents reviewed for urinary tract infections. The facility census was 82. Findings include: 1. Review of Resident #24's medical record identified admission to the facility occurred on 11/02/18. [DIAGNOSES REDACTED]. Review of progress notes and physician's orders [REDACTED].#24 had foul smelling urine and was having increased agitation and restlessness. The physician was noted to order a urinalysis test to determine if an infection was present. The record identified on 08/23/19 at 1:23 [NAME]M. Resident #24 was straight catheterized to obtain a urine sample. The laboratory testing results, dated 08/23/19 at 11:55 [NAME]M. revealed they received Resident #24's urine sample. The testing report identified the culture was completed on Sunday 08/25/19 at 8:22 [NAME]M. and was sent to the nursing facility on 08/25/19 at 10:01 [NAME]M. The progress notes and the laboratory report dated 08/25/19 identified no evidence the physician was notified of the positive urinalysis results until 08/26/19 (Monday), when they ordered an antibiotic for a urinary tract infection. The report evidenced the nursing staff faxed the results on Sunday 08/25/19. Interview with the Director of Nursing (DON) on 09/24/19 at 1:09 P.M. confirmed the staff faxed and did not call the physician when Resident #24's urinalysis test was positive. 2. Review of Resident #133's medical record identified admission to the facility occurred on 09/06/19. [DIAGNOSES REDACTED]. Review of Resident #133's medical record revealed a urinalysis was collected from Resident #133 on 09/11/19. The laboratory test identified the facility was notified of the positive results of the urinalysis on 09/12/19. The culture and sensitivity results returned on 09/15/19. The record identified the nursing staff faxed the physician the results on 09/15/19 with no evidence of telephone notification. The record identified the physician was not contacted by phone until 09/16/19, when an antibiotic was started. Interview on 09/24/19 at 1:09 P.M. the DON confirmed the staff faxed and did not call the physician when Resident #133's urinalysis test was positive. The DON confirmed the nursing staff should be calling and not faxing positive results. 3. Medical record review revealed Resident #7 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a urinalysis with a culture and sensitivity, collected for the resident on 09/14/19, revealed the laboratory faxed the final results of the test to the facility on [DATE] at 10:35 [NAME]M. The results revealed the resident had a urinary tract infection. Facility staff did not notify the resident's physician of the positive results until 09/17/19 and the resident was started on an antibiotic. Interview on 09/25/19 at 1:25 P.M., Registered Nurse (RN) #136 revealed staff were expected to call the physician with any abnormal lab reports. RN #136 confirmed staff should have called Resident #7's physician on 09/16/19 and notified him of the resident's positive urinalysis with a culture and sensitivity. Review of an undated facility policy titled Obtaining Lab Samples and Reporting of Values revealed any lab value that fell outside of the normal range limit, as indicated on the lab report, were supposed to be faxed to the primary care physician (PCP) as well as called to the PCP to ensure prompt attention to the results. Further review revealed any lab value identified as critical by the lab were phoned by the lab to the nurse who was supposed to notify the PCP immediately.

Based on medical record review, staff interview, and review of facility policy, the facility failed to follow up with the physician regarding the continued use of a [MEDICATION NAME] antibiotic in the presence of infections not treated by the antibiotic. This affected one (#43) of six residents reviewed for antibiotic use. The facility census was 82. Findings include: Review of Resident #43's medical record identified admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the urology notes dated 11/06/18 identified Resident #43 has recurrent urinary tract infections, significant rectocele and was not candidate for surgical interventions. The recommendations identified Resident #43 would require catheterization to obtain all urine specimens. The notes further identified a [MEDICATION NAME] antibiotic, [MEDICATION NAME] 100 milligrams daily was ordered with follow up to occurred in six months. The note identified the appointment was set for 05/13/19. Review of laboratory report dated 01/05/19 identified Resident #43 had a positive stool test for ,[MEDICAL CONDITION]. difficule ([MEDICAL CONDITION]). Review of the medical record revealed the facility did not follow up with the urologist to inform of the presence of the [MEDICAL CONDITION] to determine if the [MEDICATION NAME] antibiotic treatment should continue. Review of a laboratory report dated 06/17/19 identified a urinalysis culture and sensitivity revealed the resident's urine was positive for Escheria Coli. The sensitivity revealed the bacteria was resistant to the treatment of [REDACTED]. Review of laboratory report dated 06/25/19 identified Resident #43 had another stool test positive for [MEDICAL CONDITION]. The notes identified the [MEDICATION NAME] antibiotic continued with no follow up occurring with the urologist to inform of the development of antibiotic-resistant organism. Review of a urinalysis test dated 09/13/19 identified Resident #43 test was negative for a urinary infection. Review of Resident #43's Medication Administration Record [REDACTED]. Interview on 09/25/19 at 4:04 P.M., the Director of Nursing (DON) identified the facility has established criteria for urinary tract infections and when antibiotic use is appropriate. The interview confirmed Resident #43 did not have a current urinary tract infection, however remains on the antibiotic. The interview confirmed there was no evidence Resident #43 was evaluated for continued use of the [MEDICATION NAME] antibiotic following the laboratory tests which were positive for [MEDICAL CONDITION] and the urinalysis culture and sensitivity which identified the antibiotic was not effective against the bacteria present. Review of the undated facility policy titled Criteria of Urinary Tract Infections, Lower Respiratory Tract Infections and Skin Infections, revealed unnecessary antibiotic use can result in side effects and drug resistant bacteria. The policy indicated the minimum criteria for initiation of antibiotic in long term care residents identified at least one of the following: fever greater than 100 degrees Fahrenheit, new costovertebral tenderness (back kidney area), rigors (chills) and new onset of [MEDICAL CONDITION].

Based on medical record review, facility policy review, and staff interview, the facility failed to provide the pneumococcal vaccination to one (#23) of five sampled residents. The facility census was 82. Findings include: Review of Resident #23's medical record identified admission occurred on 01/18/19. [DIAGNOSES REDACTED]. The record identified Resident #23's daughter signed a consent and requested for her to receive the pneumococcal (PCV 13) vaccine on 01/18/19. The record lacked any evidence Resident #23 received the vaccine. Interview with the facility Director of Nursing occurred on 09/25/19 at 4:04 P.M. and confirmed Resident #23 did not receive the PCV13 vaccine and this was missed by the staff. Review of the facility policy titled Pneumococcal Vaccination Policy, dated 04/25/16, identified each resident will be offered the vaccination upon admission, in accordance with the center for Disease control (CDC) guidelines. Interview with the facility Director of Nursing occurred on 09/25/19 at 4:04 P.M. The interview confirmed Resident #23 did not receive the PCV13 vaccine and this was missed by the staff.

Based on medical record review and staff interview, the facility failed to accurately code a discharge tracking Minimum Data Set assessment for one (#85) out of three residents reviewed for discharge. The facility census was 82. Findings include: Review of Resident #85's medical record identified admission to the facility on [DATE]. [DIAGNOSES REDACTED]. The record identified Resident #85 was sent to the emergency roiagnom on [DATE] and expired shortly after arrival. Review of the discharge tracking Minimum Data Set (MDS) assessment, dated [DATE], identified Resident #85 was discharge return not anticipated instead of death in facility. Review of the MDS (YEAR) instruction manual, page ,[DATE] identified death in facility refers to when the resident dies in the facility or dies while on a leave of absence (LOA). The facility must complete a Death in facility tracking record. A discharge assessment is not required. Interview with Licensed Practical Nurse (LPN) #55 on [DATE] at 3:00 P.M. confirmed the discharge tracking assessment should have been identified as a death in the facility because Resident #85 was not at the hospital for greater than 24 hours.

Based on staff interview, review of the medical record, and review of the hospice contract, revealed the facility failed to ensure the hospice plan of care and visit notes were available in the facility for one (#59) of one resident reviewed for hospice services. The facility identified 10 residents were receiving hospice services. The facility census was 82, Findings include: Review of Resident #59's medical record revealed she admitted to the facility, on 08/02/19. [DIAGNOSES REDACTED]. She was receiving hospice services at the time of admission. Review of Resident #59's Minimum Data Set (MDS) assessment, dated 08/08/19, revealed she was seriously cognitively impaired. The assessment identified Resident #59 was receiving hospice. Further review of Resident #59's medical record lacked any evidence of her hospice plan of care and visit notes. During an interview on 09/25/19 02:11 at P.M., Licensed Practical Nurse (LPN) #56 revealed hospice was to keep their documentation in Resident #59's paper chart. LPN #56 stated hospice did not keep a separate binder nor was their documentation scanned to the electronic medical record. Interview on 9/25/19 at 4:04 P.M. with Social Worker #131 revealed the facility had requested and just received the hospice documentation from the hospice provider on 9/25/19 at 2:30 P.M. Social Worker #131 confirmed the facility had no hospice documentation in the record prior to oday. Review of the hospice contract dated 02/27/18 revealed hospice shall provide the nursing facility with the following: a copy of the most recent plan of care, a copy of the hospice election form and advanced directives, names and contact information for hospice personnel, instructions on how to access the hospice's twenty four hour on call system, a copy of hospice medication information specific for each resident.

Based on medical record, resident interview, and staff interview, the facility failed to ensure new glasses were received in a timely manner for one (#8) out of one resident reviewed for vision. The facility census was 82. Findings include: Review of Resident #8's medical record identified admission to the facility occurred on 01/18/19 with medical [DIAGNOSES REDACTED]. Review of the vision visit form, dated 06/06/19, identified Resident #8 had been assessed by the optometrist. The resident's chief complaint was his glasses were old and he would like a new pair. The form identified an eyeglasses order will be processed. Interview on 09/23/19 at 10:21 [NAME]M., Resident #8 identified he saw the eye doctor several months ago and was told new glasses were ordered for him, but he has not gotten them and/or heard anything about them being available. Interview on 09/24/19 at 9:10 [NAME]M., Social Services Designee (SSD) #63 confirmed Resident #8 was seen by the optometrist on 06/06/19 and the note identified glasses were ordered for Resident #8. SSD #63 confirmed no further up had been completed. SSD #63 identified she called the vision group whom visited on 09/24/19 and they confirmed there was a mix up and Resident #8's glasses were never ordered. SSD #63 stated the glasses would be ordered today.

Based on medical record review, staff interview and review of a facility policy, the facility failed to ensure residents did not receive unnecessary [MEDICAL CONDITION] medications and as needed medications were not ordered for longer than 14 days. This affected two (#53, #23) of five residents reviewed for unnecessary medication. The facility census was 82. Findings include: 1. Medical record review revealed resident #53 admitted to the facility on [DATE] with a most recent readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #53's physician orders [REDACTED]. Both orders were discontinued when the resident discharged to an acute care hospital on [DATE]. The resident was readmitted on [DATE] and was ordered to to receive [MEDICATION NAME] 25 mg daily along with 12.5 mg at bedtime. Both orders were discontinued on 07/22/19 and the order was changed for the resident to receive 12.5 mg of [MEDICATION NAME] twice a day. None of the resident's orders listed an indication for the use of an anti-psychotic medication. Review of the resident's nursing progress notes and physician progress notes [REDACTED]. Review of the resident's behavior charting from 06/01/18 through 09/25/19, lacked any evidence for indications for the use of [MEDICATION NAME]. Interview on 09/25/19 at 1:04 P.M., State tested Nursing Assistant (STNA) #64 revealed Resident #53 did not have any behaviors. STNA #64 stated the resident became anxious when she was scheduled to leave the facility for an appointment. Interview on 09/25/19 at 1:08 P.M., Licensed Practical Nurse (LPN) #181 revealed Resident #53 did not have any behaviors. LPN #181 stated the resident experienced anxiety at times when she was having increased back pain. Interview on 09/25/19 at 1:11 P.M., Registered Nurse (RN) #136 revealed she was the Unit Manager for Resident #53's hall. RN #136 revealed Resident #53 did not have any behaviors. RN #136 stated the resident was depressed over her current situation and experienced anxiety related to her chronic back pain and pending surgery. Additionally, Resident #53's physician orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the resident's 08/2019 and 09/2019 Medication Administration Record [REDACTED].M. and 8:13 P.M., 08/25/19 at 5:16 [NAME]M., 08/29/19 at 11:46 [NAME]M., and on 09/01/19 at 10:36 P.M., 09/03/19 at 7:57 [NAME]M., 09/10/19 at 6:32 [NAME]M. and 09/14/19 at 8:05 [NAME]M. No documentation of non-pharmacological interventions attempted prior to the administration of the [MEDICATION NAME] was observed in the medical record. Interview on 09/26/19 at 3:13 P.M., the Director of Nursing (DON) confirmed the resident received the above listed doses of as needed [MEDICATION NAME] without documented evidence staff attempted non-pharmacological interventions prior to administering the medication. The DON further confirmed the resident's as needed [MEDICATION NAME] order was not limited to 14 days and there was no rational documented by the resident's physician to continue the medication beyond 14 days. 2. Review of Resident #23's medical record revealed she admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #23's physician's orders [REDACTED]. On 04/05/19 Resident #23 was ordered [MEDICATION NAME] 25 mg PRN before bathing. The prescription did not document the required rationale and determined duration to extend both PRN anti-anxiety orders past the allotted 14 days. Interview on 9/26/19 at 3:13 P.M., the DON verified the prescriber did not provide a rationale or determine a duration for the PRN anti-anxiety medication that was required after 14 days. Review of a facility policy titled [MEDICAL CONDITION] Medication Policy and Procedure, undated, revealed [MEDICAL CONDITION] medications would not bed used unless the medication was necessary to treat a specific condition that was diagnosed and documented in the clinical record. The policy further stated residents would not receive [MEDICAL CONDITION] medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions had failed to address the resident's target behavioral goals. Further review of the policy revealed PRN orders for [MEDICAL CONDITION] medications would be limited to 14 days unless the physician identified the rationale to extend the medication beyond 14 days. PRN anti-psychotic medication would be limited to 14 days and would not be renewed unless the physician evaluated the resident for appropriateness of the medication.

Based on medical record review, observation, staff and resident interview and policy review the facility failed to ensure a resident with limited range of motion received range of motion services. The facility did not indicate the reason the resident was not receiving services. This affected one (Resident #8) of one resident reviewed for positioning and mobility. The facility census was 84 . Findings include: Medical record review revealed Resident #8 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the minimum data set assessment admission assessment for functional limitation in range of motion dated 05/04/18 revealed Resident #8 had an upper extremity impairment on one side and lower extremity impairments on both sides. Further review of the admission assessment revealed Resident #8 was cognitively intact. Review of referral therapy screens dated 05/09/18 revealed Resident #8 had limited range of motions in the bilateral lower extremities and limited range of motion of the right upper extremity. Resident #8 was recommended for occupational therapy (OT) for wheel chair positioning only. There was no recommendation for physical therapy or restorative services. Review of an OT note dated 05/23/18 revealed Resident #8 had completed 50% of normal range of motion in right upper and lower extremities and 25% of normal range of motion in left upper and lower extremity. Review of an occupational therapy discharge summary note dated 06/20/18 revealed Resident #8 received services for wheel chair positioning. There were no recommendations for restorative services. Review of an interdisciplinary patient review form dated 08/08/18 revealed Resident #8 had no changes in range of motion or contractures. There were no recommendations for restorative services including active or passive range of motion. Review of an interdisciplinary patient review form dated 08/15/18 revealed Resident #8 had no worsening contracture or change in status. Staff would continue to monitor for contracture management and declines related to comorbidities on a regular basis. There were no recommendations for physical therapy or restorative services including active or passive range of motion. Review of Resident #8's physician orders [REDACTED]. Observations on 08/14/18 at 1:05 P.M. and 08/15/18 at 8:31 A.M. revealed Resident #8 was unable to use her right arm and hand. Resident #8 had contractures of the bilateral lower extremities. Interview on 08/14/18 at 1:25 P.M. with the restorative Registered Nurse (RN) #300 revealed Resident #8 had not been referred for restorative services. Interview on 08/14/18 at 1:32 P.M. with restorative State tested Nursing Assistant (STNA) #100 revealed Resident #8 was not on her list of residents who received restorative services for range of motion. Interview on 08/15/18 at 12:55 P.M. with Resident #8 revealed staff had not offered her any restorative services. Resident #8 revealed staff had not performed active or passive range of motion. Resident #8 further revealed she would be willing to participate in restorative exercises and range of motion services if offered. Interview on 08/16/18 at 8:22 A.M. with the Physical Therapy Director (PTD) #80 revealed Resident #8 had not experienced any decline in range of motion. Further interview with PTD #80 revealed there had been no recommendations for restorative services or range of motion for Resident #8. Review of the Restorative policy dated 11/25/13 revealed residents who showed impairment or decline would be referred to the therapy department for screening by a member of the nursing team. The therapist treating the resident would assess the progress being made and determine the need for restorative programs once therapy has ended. Further review of the policy revealed restorative programs included toileting, splinting, dining, ambulation, transfers, bed mobility, communication, grooming, passive range of motion, active range of motion and prosthesis device wearing for amputations.

Based on medical record review, staff interviews, review of facility policy and procedures and review of Center for Disease Control (CDC) guidelines the facility failed to ensure one (Resident #52) of five sampled residents was offered the flu and pneumococcal vaccine in the past year. The census was 84. Findings include: Review of Resident #52's medical record identified admission to the facility occurred on 08/31/11. [DIAGNOSES REDACTED]. Resident #52 was over [AGE] years of age. Further review of the medical record revealed in 2011, Resident #52 received pneumococcal [MEDICATION NAME] vaccine (PPSV23). There was no evidence Resident #52 was offered any additional pneumococcal vaccines. Interview with the facility Director of Nursing (DON) on 08/15/18 at 1:54 P.M. confirmed there was no evidence in the medical record of any additional pneumococcal vaccines for Resident #52 since 2011. Review of the facilities pneumococcal vaccination policy dated 04/25/16 identified each resident will be offered the pneumococcal vaccinations in reference to the CDC Guidelines. Review of the CDC guidelines dated 11/30/15, which was attached to the facilities policy identified timing for pneumococcal vaccines for adults [AGE] years or older, that have received one dose of PPSV23 and no doses of PCV13 (new pneumococcal vaccine) should receive one dose of PCV13 at least one year after the dose of PPSV23.

Based on medical record review, staff interview, review of facility policy and procedures, the facility failed to notify the physician and family of a significant change in condition for one (#88) of three residents reviewed discharged to the hospital. The facility census was 87. Findings included: Medical record review revealed Resident #88 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITIONS], muscle weakness, hypertension and diabetes. Review of the comprehensive assessment dated [DATE] revealed Resident #88 was cognitively intact. Review of Resident #88's progress note dated 02/28/18 at 5:23 A.M., revealed Resident #88 was very confused and was talking about her mother, and the resident attempted to urinate on the floor and trash can. The resident was assisted into bathroom to and then assisted back to bed. Additional progress note dated 03/01/18 at 4:57 A.M., revealed Resident #88 was very confused, standing in the hall with her brief pulled down. The resident said she was going to go to the bathroom, on the floor, and was redirected to the bathroom. At 3:48 P.M., it was noted Resident #88 continued to have confusion. She was not aware of where she was. An attempt to orient the resident was made, and had no results. The medical record was silent to any notification to the family or physician, regarding Resident #88's confusion from 02/28/18 at 5:23 A.M., through 03/01/18 at 3:48 P.M., at which time a Consulting Physician (CP) #400 was contacted by Resident #88's family with concerns. CP #400 then reviewed Resident #88's elevated laboratory values, and gave an order to send the resident to the hospital for an evaluation. Interview with the Director of Nursing (DON) on 5/30/18 at 12:47 P.M., confirmed there was no notification to the family, or physician regarding Resident #88's confusion from 02/28/18 through 03/01/18. Review of the facilities Change in Condition policy dated (MONTH) 2003, revealed in the event of a change in the resident's physical or mental condition, the following will be notified; Resident's primary physician and designated contact. The policy further revealed significant changes in condition included, onset of confusion. This deficiency substantiates Complaint Number OH 006.

Based on review of a closed medical record, staff interviews, review of a facility policy, review of the Ohio Revised Code (ORC), and review of the Ohio Administrative Code (OAC), the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) or contact Emergency Medical Services (EMS) timely for one (#9) resident found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. Life threatening harm and death occurred when Resident #9 did not receive CPR or Emergency Medical Services and expired at the facility. This resulted in Immediate Jeopardy for one of nine residents reviewed for an emergent change in condition and death. The facility identified a total of 16 current residents who were designated as having a Full Code status. The facility census was 71. On [DATE] at 2:03 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 5:18 A.M., when Resident #9 was found unresponsive, without a pulse, respirations, or blood pressure, and Licensed Practical Nurse (LPN) #101 failed to initiate CPR or contact EMS. Resident #9 expired at the facility. The Immediate Jeopardy was removed on [DATE] at 6:00 P.M. when the facility implemented the following corrective actions: · On [DATE] at 9:30 A.M., the facility Utilization Review (UR) committee discussed whether or not there were any other residents in the facility who wanted to change their code status. At this time no other residents were identified. · On [DATE], Administrative Assistant #120 performed an entire building audit and noted changes that needed to be made to the code status of residents based on discrepancies of the Electronic Medication Administration Review (EMAR) not reflecting what the actual signed code status indicated. There changes were all corrected on this day, [DATE]. · On [DATE], Advance Directives and code status were discussed at the monthly Quality Assurance meeting and Administrative Assistant #120 would be performing code status audits to ensure they were accurate. These audits will be conducted upon admission and at the time of the resident's care conference. · On [DATE], the DON performed a random audit which included code status. The results of the audit were discussed in the weekly resident focus meeting on [DATE]. There were seven residents who had discrepancies in their code status regarding the medical record and the electronic chart. These were corrected on this day, [DATE]. · On [DATE] at 2:14 P.M., an Advanced Directive In-Service was developed in reference to Advanced Directives and the protocol to follow for a Code Blue and the need for CPR. · On [DATE] at 2:17 P.M., in-service education began for all facility staff on Advanced Directives and Code Blue Protocol. The education was provided by Human Resource (HR) staff #117 and Assistant HR staff #118, Social Worker (SW) #105 and Assistant SW #107, the DON, Assistant Director of Nursing (ADON) #116, and the Administrator. · On [DATE] at 3:47 P.M., LPN #101, the nurse on duty at the time of Resident #9's death, was given a written counseling form on Advanced Directives, the EMAR, physician orders, and code status. LPN #101 was counseled by the DON and HR staff #117. · On [DATE] at 4:35 P.M., SW #105 completed an audit regarding code status for all residents currently in the facility. The audit included an Advanced Directive care plan, EMAR, physician orders, and signed code status documents. No concerns were identified. · On [DATE] at 5:30 P.M., all residents responsible for making their own decisions were interviewed about Advanced Directives, ensuring they were in agreement with the signed code status order. This was completed by Assistant SW #107 and Minimum Data Set (MDS) Coordinator #119. · On [DATE] at 5:33 P.M., all residents who were unable to make their own decisions had their primary contact or Power of Attorney (POA) contacted to ensure they were in agreement with the signed code status order. · On [DATE] by 6:00 P.M., all facility employees had been educated on Advance Directives and Code Blue protocol. Staff were in-serviced in person or via telephone. For individuals unable to be reached, a message was left, and the employee would not be permitted to return to work until the in-service had been completed. · On [DATE] between 9:17 A.M. and 9:26 A.M., LPN's #111, #112, #113 and #114, verified they received training on [DATE] regarding code status, Advanced Directives, Code Blue Protocol and the CPR policy. · Nine additional residents who expired in the facility and 14 additional current residents were reviewed for code status and no additional concerns were identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #9's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the document titled, Full Code Resuscitate Order dated [DATE], revealed Resident #9 and Physician #121, who was the resident's attending physician, signed the document indicating the resident was to be a Full Code. The Full Code order indicated in the event of a cardiac or respiratory arrest, CPR would be performed. Review of the [DATE] physician orders [REDACTED].#9's advanced directives were a Full Code. Review of Resident #9's care conference note dated [DATE] revealed Resident #9 was recently admitted to the facility, required extensive to total assistance with Activities of Daily Living (ADL's), sometimes made himself understood, and was receiving therapy. The note further revealed the family of Resident #9 was concerned about pain and anxiety and they were waiting on laboratory results from a urinalysis. The code status documented on the care conference assessment indicated a Full Code. There was no evidence the family of Resident #9 had wanted to change the code status to anything different than a Full Code. Review of Resident #9's comprehensive care plan revealed the Full Code status was not addressed in the care plan. A care plan regarding the option to choose a code status was located in the care plan, however, the code status care plan was not completed. Review of Resident #9's [DATE] Medication Administration Record [REDACTED]. No laboratory results had been obtained at the time of Resident #9's death. Review of Resident #9's nursing progress notes revealed an entry by LPN #101, dated [DATE] at 3:17 A.M., documenting LPN #101 was in to check on the resident, respirations were even and non-labored, and no evidence of distress was noted. There was no further documentation and/or change noted in Resident #9's condition until a progress note dated [DATE] at 5:18 A.M. written by LPN #101 which stated Resident #9 appeared to be lifeless at this time, pale color, no respirations noted, no pulse, and no blood pressure were noted. The note indicated State tested Nursing Assistant (STNA #300) had been in the resident's room a little after 4:00 A.M., completing bed checks. The note did not indicate the On-Call Physician (#115) was notified regarding the unresponsiveness of Resident #9. An additional note on [DATE] at 6:09 A.M. by LPN #101 documented the DON was notified of Resident #9's death at 6:00 A.M. The family was notified and stated they would call back. An additional note on [DATE] at 6:30 A.M. by LPN #101 revealed the county coroner was notified of Resident #9's death. Review of Resident #9's nursing progress notes revealed no evidence of a code being called or CPR being initiated. Review of Resident #9's Certificate of Death revealed the resident expired on [DATE] at 6:00 A.M., with the immediate cause of death documented as debility. During a telephone interview on [DATE] at 9:06 A.M., LPN #101 stated she had been an employee at the facility for about six months. She stated she usually worked night shift on the hall where Resident #9's room was, and had cared for Resident #9 multiple times during his stay at the facility. LPN #101 stated a resident's code status could be found on a paper in the record and also on the electronic charting system. LPN #101 stated if a Full Code resident was found unresponsive with no pulse, blood pressure, or signs of life, she would initiate CPR immediately. LPN #101 stated she was working with Resident #9 the night he expired, and verified the resident was a Full Code. She stated the resident had been declining in the days before he died and the social worker had discussed with the family about a potential change in code status. LPN #101 stated there was no specific order for a Do Not Resuscitate (DNR) in place at the time Resident #9 expired. She stated she found Resident #9 unresponsive with no pulse or blood pressure in the early morning and did not initiate CPR, did not call a Code Blue, and did not contact EMS. LPN #101 stated she called On-Call Physician #115 after she found Resident #9 unresponsive and explained the situation to the physician instead of initiating CPR immediately. LPN #101 further indicated she called the DON after the resident expired, and the DON told LPN #101 to notify the coroner and then the funeral home came later to take Resident #9 to the funeral home. LPN #101 stated she would normally automatically initiate CPR on a Full Code resident but knew the family was waiting on laboratory results to determine if there would be a change in code status, so she called On-Call Physician #115 and explained the situation instead of initiating CPR. An attempt was made on [DATE] at 9:36 A.M. to contact the physician who was on-call the morning of [DATE]. On-Call Physician #115 was not available as he was on vacation. Interview on [DATE] at 9:48 A.M. with Assistant SW #107 revealed she stated she had been the person who worked with Resident #9 and his family regarding the code status. ASW #107 stated she had talked to the family of Resident #9 in a care conference the day before he expired and the family had expressed they may want to change his code status to a DNR due to an overall decline in his health status, but wanted to wait to hear back the laboratory results prior to making a decision. ASW #107 stated she did not document any of the conversations she had with the family regarding the decline and interest in a potential change of code status. ASW #107 stated she never received a phone call or indication from the family of Resident #9 that they were ready to change the code status. Interview on [DATE] at 10:49 A.M. with the DON verified LPN #101 did not initiate CPR for Resident #9 when he was found unresponsive and that his order had not been changed to a DNR at the time he expired. The DON stated if a nurse found a resident who was a Full Code and unresponsive, she would expect the nurse to always initiate CPR. She stated the situation with Resident #9 was different because LPN #101 knew the family of the resident was considering a change in code status, which caught the nurse off-guard, so she called On-Call Physician #115 instead of initiating a code. Review of the undated facility policy titled, [MEDICAL CONDITION] Code Blue Policy, revealed if you discover someone who has suffered [MEDICAL CONDITION], the nurse should summon help while remaining at the person's side, know the status of a DNR, begin CPR, and continue until assistance arrives or takes over, call 911, page the building Code Blue, assign a person to guide squad personnel to the scene where trained personnel would respond with emergency equipment. Review of the Ohio Revised Code (ORC) Section 4723.36 titled, Determination of Death by Certified Nurse Practitioner or Clinical Nurse Specialist, revealed a registered nurse (RN) may determine and pronounce an individual's death, but only if the individual's respiratory and circulatory function are not being artificially sustained and, at the time of the determination and pronouncement of death is made, the RN is providing or supervising the individual's care through a licensed hospice care program or any other entity that provide palliative care. Review of the Ohio Administrative Code (OAC) [DATE] titled, Pronouncement of Death, revealed a physician holding a current certificate to practice medicine or surgery or osteopathic medicine may pronounce a person dead without personally examining the body of the deceased on ly if a competent observer has recited the facts of the deceased 's present medical condition to the physician and the physician is satisfied that death has occurred. According to the OAC [DATE], an LPN is not permitted to pronounce an individual's death. Review of the facility staffing schedule for the early morning of [DATE] revealed RN's #109 and #110 were working at the time of Resident #9's death. However, there was no indication that either RN had any involvement in the resident's assessment of condition when being found unresponsive. Further review of Resident #9's medical record revealed the resident was not receiving hospice and/or palliative care during his stay at the facility.

Based on review of medical records, personnel files, a Self-Reported Incident (SRI) and the facility's investigation, and interviews with staff, the facility failed to ensure staff carried out activities that promoted each resident's dignity and failed to assist each resident to maintain and enhance his/her self-esteem and self-worth by taking inappropriate pictures of residents and posting them to social media. This resulted in actual harm when five (#50, #51, #52, #53, and #54) State tested Nurse Aides (STNAs) engaged in actions meant to humiliate six (#1, #2, #4, #5, #6, and #7) confused residents residing on the dementia unit by taking inappropriate pictures without permission and not in accordance with facility policy. These pictures were taken over a course of several weeks and each picture was posted on social media when taken, resulting in intentional humiliation and psychological harm of residents. These pictures displayed the residents in various states of receiving personal care which included: sitting on a toilet, being transferred with a mechanical lift, and lying in bed with their night clothes on. Additionally, some pictures were taken of a resident lying in bed with a staff member, while another picture was posted with a derisive comment. This affected six (#1, #2, #4, #5, #6, and #7) of 39 residents residing on the dementia unit of 86 residents residing in the facility. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent comprehensive assessment dated [DATE] indicated Resident #1 was severely cognitively impaired. Resident #1 resided on the dementia unit. Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent comprehensive assessment dated [DATE] indicated Resident #2 was severely cognitively impaired and she was rarely/never understood. Resident #2 resided on the dementia unit. Review of Resident #4's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent comprehensive assessment dated [DATE] indicated Resident #4 was severely cognitively impaired. Resident #4 resided on the dementia unit. Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent comprehensive assessment dated [DATE] indicated Resident #5 was severely cognitively impaired and she was rarely/never understood. Resident #5 resided on the dementia unit. Review of Resident #6's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent comprehensive assessment dated [DATE] indicated Resident #6 was severely cognitively impaired and she was rarely/never understood. Resident #6 resided on the dementia unit. Review of Resident #7's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent comprehensive assessment dated [DATE] indicated Resident #7 was moderately cognitively impaired. Resident #7 resided on the dementia unit. Interview with the Administrator on 03/14/16 at 10:15 A.M. revealed a facility SRI had been submitted to the state agency due to allegations of emotional and verbal abuse by staff taking pictures of residents residing on the dementia unit and then uploading them to a social media application on their cellular phones called Snap Chat. The Administrator stated all staff involved were immediately suspended pending an investigation. All staff involved and working on the day of discovery were escorted to the time clock and then out of the building. Five former STNAs, #50, #51, #52, #53 and #54 were involved in taking pictures of six residents (#1, #2, #4, #5, #6 and #7) of 39 residents residing on the dementia unit. All five STNAs were terminated on 03/07/16 as a result of the investigation. The Administrator stated five of the six residents were non-interviewable and the sixth resident was blind and was unaware of any pictures being taken of her. Review of the SRI submitted to the state agency on 03/04/16 revealed staff had possibly committed emotional/verbal abuse to six (#1, #2, #4, #5, #6 and #7) residents. STNA #31 was listed as a witness and STNA's #50, #51, #52, #53 and #54 were all listed as alleged perpetrators. Review of the SRI incident investigation revealed STNA #31 showed the picture of Resident #2 sitting in a chair with a clothing protector around her neck to her charge nurse, Licensed Practical Nurse (LPN) #20. The picture was captioned with the statement when the ice cream hits too hard. LPN #20 immediately took STNA #31's phone to the Director of Nursing (DON) office who then notified the Administrator. The administrative staff requested STNA #31 come to the DON's office. STNA #31 stated she had recently been sent the picture by a co-worker who was not working that day. STNA #31 stated she had saved a screenshot of the picture and proceeded to send it to the DON's company phone. After sending the picture, STNA #31 then deleted it from her phone. STNA #31 informed the DON and the Administrator she was afraid if the co-workers involved with taking the pictures were to find out she had been the one to bring it to administration's notice, they would retaliate against her as she frequently worked with them. Review of the facility investigatory interviews revealed the DON and Administrator first interviewed STNA #51 on 03/04/16 at 6:08 P.M. who denied having received any Snap Chat pictures of residents. Three hours later, the Administrator and the DON re-interviewed STNA #51 and told him his name had come up in other staff interviews implicating him as one of the aides sending photos of residents. STNA #51 again denied he had received any Snap Chat photos but admitted to sending STNA #33, a picture he had taken of Resident #1 in her bathroom sitting on the toilet. STNA #51 was then informed he was suspended pending an investigation into the incident and was escorted out of the building. Shortly after interviewing STNA #51 for the first time, the Administrator and DON interviewed STNA #54. STNA #54 admitted to having taken pictures of the residents as well as sending them to co-workers using Snap Chat. STNA #54 admitted to taking a picture of Resident #5 standing clothed in the hallway of her unit and of Resident #7 sitting fully clothed in a Hoyer lift. He had sent the pictures to STNA #50, STNA #52, and STNA #53. STNA #54 stated he had received a picture of Resident #5 from STNA #53 and a picture of Resident #7 from STNA #52. When asked how long this had been occurring, STNA #54 stated a few weeks. The Administrator and DON informed STNA #54 he was suspended pending an investigation and was escorted out of the building. The next person interviewed was witness STNA #30, who stated she had received photos of Resident #5 standing in the hallway fully clothed and looking at the camera. STNA #30 stated she had received the photos from STNA #52 and STNA #53. STNA #30 denied having taken a picture of a resident or sending any pictures to her co-workers. When asked why she had not reported the pictures she had received to someone, STNA #30 was unable to provide a reason why. The Administrator and DON interviewed STNA #50 who denied ever having received a picture of a resident. She was then in-serviced about the facility's cell phone policy. A short time later the Administrator and DON placed a second call to STNA #50 and told her, her name had come up during the facility's investigation. STNA #50 then admitted to having received pictures of Resident #5 and Resident #7 from STNA #51, STNA #52, and STNA #54. Upon further questioning, STNA #50 stated she had taken a picture of Resident #5 and STNA #52 lying in a spare bed in another resident's room. STNA #50 informed the Administrator and DON the picture taking had been going on for approximately one to two months. When asked why she had thought it was acceptable to take pictures of the residents, STNA #50 stated it was not hurting anyone and she did not think they would be caught. STNA #50 was informed she was being suspended immediately pending an investigation into the incident. The next person interviewed by phone was STNA #52 who stated she had received pictures via Snap Chat of Residents #5, #7, #4, and #6. She stated Resident #5 had been clothed and standing in the hallway. Resident #7 was lying in bed fully clothed. Resident #4 was sitting fully clothed on her walker in the hallway. Resident #6 was lying in bed wearing her pajamas. The pictures of Resident #5 and Resident #6 were sent to her by STNA #53 and the pictures of Resident #4 and Resident #7 were sent to her by STNA #54. STNA #52 admitted she had taken pictures of Resident #5 and Resident #6 and sent them to STNA #53 and STNA #54. When asked why she thought taking pictures of the residents was acceptable, STNA #52 stated she did not know why she had thought it was acceptable. STNA #52 was then suspended by the DON pending the outcome of their investigation. The next phone interview conducted by the Administrator and DON was with STNA #53 who stated she had received Snap Chat photos of Resident #5 and Resident #7. Resident #5 was clothed and looking at the camera and Resident #7 was clothed and was a picture of her face. STNA #53 stated she had received Snap Chat pictures from STNA #50, STNA #52, and STNA #54. STNA #53 stated she had also taken pictures of Resident #5 and sent them to STNA #50, STNA #52, and STNA #33 and she had also taken pictures of Resident #7 and sent them to STNA #54. When questioned about why taking pictures of the residents was acceptable she replied she had not thought it through. The DON then informed STNA #53 she was suspended pending further investigation. The next phone interview was conducted by the Administrator and DON with witness STNA #34 who stated she had received Snap Chat pictures of Resident #5 and Resident #7. One picture of Resident #5 was with STNA #52 cuddling together in bed as well as one with the resident standing in the hallway. The picture of Resident #7 was of her sitting in her wheelchair. The picture of Resident #5 was sent to her by STNA #50 and the pictures of Resident #7 were sent to her by STNA #52 and STNA #53. STNA #34 denied having ever sent any pictures of residents. When questioned why she had not told anyone about the pictures she had received, STNA #34 stated she did not think anyone could do anything about it since as soon as you looked at the photo it was deleted so she had no proof to present. The DON and Administrator received a return call from witness STNA #32 who stated she had not told them the truth earlier in the evening when asked if she had ever received a Snap Chat picture of a resident. STNA #32 stated she had been scared to tell them the truth earlier. STNA #32 stated she had received a Snap Chat picture of Resident #2 walking in the hallway fully clothed. The picture had been sent to her by STNA #53. She denied ever having sent one. The facility investigation revealed on 03/05/16 the facility began contacting the responsible parties for all involved residents. The families were unaware staff had been taking pictures of their family members and were concerned about the type of pictures taken. Several of the family members requested to see the pictures and were told by the facility they did not have any copies of them. Interview with STNA #33 on 03/14/16 at 11:37 A.M. revealed she had first received a photo of Resident #5 a few months ago. She recognized the resident because of the clothes she had on. STNA #33 stated she did not remember what exactly the picture had been of but thinks it was of the resident walking down the hallway. STNA #33 stated she did not show the picture to anyone because she did not think anything about it. The next picture she received was of Resident #1 on 03/04/16. She did tell the DON she had received it when questioned during the investigation. Interview with STNA #32 on 03/14/16 at 2:07 P.M. revealed she had received a picture of Resident #2 several months ago. She stated she did not think much about it because as soon as she opened the picture it was deleted and there was no way to get it back. STNA #53 had sent the picture to her. STNA #32 stated she had never seen anyone taking pictures of the residents. Interview with STNA #30 on 03/15/16 at 11:12 A.M. by phone revealed the first time she had received a Snap Chat photo was a few months ago. She received several photos of Resident #5. She did not tell anyone about it and was unsure why she did not tell anyone. STNA #30 stated as soon as she opened the photo it was deleted. Interview with STNA #35 on 03/15/16 at 11:30 A.M. by phone revealed she received the first Snap Chat photo around the end of December 2015 or early January 2016. She received a total of three pictures but did not identify which residents were involved. All three pictures showed the residents were fully clothed. One picture was of a resident walking down the hall, another one was of a resident sitting on the couch watching television, and the last one looked like a selfie. STNA #35 stated she did not tell anyone about the pictures because the residents were fully dressed so it was not abuse. She stated the first time she was questioned about the pictures she denied having received any as she was unsure of what the consequences would be but later on did inform the DON she had received them. Interview with STNA #31 on 03/15/16 at 2:05 P.M. revealed she received a picture of Resident #2 wearing a clothing protector approximately one month prior to notifying LPN #20. STNA #31 stated she had not told anyone earlier as she was not sure who she should tell and because she did not want to get anyone in trouble. She stated STNA #53 had sent her the picture. STNA #53 had the picture on her cell phone and also showed her other pictures of the residents. STNA #31 stated she had taken a screen shot of the photo which is why she was able to show it to LPN #20. She was unsure why she showed it to LPN #20 when she did but stated they had just been talking and she showed it to her. After she showed LPN #20 the picture, the nurse took STNA #31's phone to the DON to show her the picture. STNA #31 stated she knew it was wrong to take the pictures but she had to work with the five former aides all the time and was afraid of retaliation if she told anyone. Interview with LPN #20 on 03/15/16 at 2:38 P.M. by phone revealed the day STNA #31 had shown her the picture of Resident #2 was the first time she had been made aware of staff taking pictures of the residents. Upon seeing the Snap Chat picture LPN #20 stated she freaked out a bit and then immediately took it to show the DON. LPN #20 stated she works full time on the dementia unit on the evening shift. The five involved aides also worked evening shift on the dementia unit. She never saw any of the aides involved taking pictures of the residents. Interview with the DON on 03/15/16 at 2:50 P.M. revealed she could show the picture to the surveyor on the facility owned phone but was unable to forward it due to phone security issues. Observation of the picture of Resident #2 revealed the resident was wearing a clean clothing protector, her face was expressionless, and the caption read when the ice cream hits too hard. The DON confirmed the families of the residents involved were told no photos were available to show them due to potential privacy violations. The DON stated the facility provides annual education as well as new employee orientation education regarding privacy of the residents, Health Information Portability and Accountability Act (HIPAA) information that anything regarding the residents was private, the facility's Code of Conduct as outlined in the Employee Handbook, and workplace violence. All staff are required to attend these in-services and sign they have received the information. The DON stated STNA's #50, #51, #52, and #53 all had attended the annual in-service in July 2015. STNA #54 had not attended the in-service as he began working at the facility after the in-service was completed. STNA #54 did receive the information in orientation and signed that he had received the information. Review of the personnel files for STNA's #50, #51, #52, #53, and #54 revealed each employee had signed the documents acknowledging they had received a copy of the Employee Handbook, a copy of the Code of Conduct, HIPAA information, resident rights, a copy of the Commitment to Support the Mission and Values Statement of the facility, a copy of the Employee Confidentiality and Non-Disclosure Agreement, a copy of the facility's social media policy, and abuse/neglect/misappropriation training. All five personnel files contained a termination noticed dated 03/07/16 for violation of company policies and substandard work. Review of the facility's policy titled Social Media Policy effective 01/17/12 revealed employees are personally responsible for any information they share on a social networking site. They are responsible for everything posted on the Internet as it provides a permanent record of their actions which they are held personally accountable. Employees are accountable for following the policies in the Employee Handbook relating to conduct, HIPAA violations, resident rights, and respect. Employees are not permitted to post pictures, videos or audio recordings of any resident, family member, or staff. This substantiates complaint number OH 037.

Based on observation, record review, interview, Material Safety Data Sheet review, review of the steam table manufacturer's guidelines, review of the General Dose Preparation and Medication Administration policy, review of the an Equipment Safety policy and review of documentation from the American Burn Association and Centers for Disease Control, the facility failed to ensure a safe environment when medication carts were observed unlocked, chemicals were observed not secured, a steam table and running dishwasher were observed unattended, and a stove was observed unattended. This presented potential opportunities for residents to experience severe harm, i.e., unobserved medication ingestion, chemical burns/poisoning and thermal burns. This resulted in Immediate Jeopardy for 55 residents (Resident #1, #3, #5, #6, #7, #9, #10, #12, #15, #17, #18, #19, #20, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #36, #37, #38, #48, #49, #50, #51, #53, #54, #55, #58, #59, #61, #62, #64, #66, #68, #69, #71, #72, #74, #75, #76, #78, #79, #80, #81, #82, #84, #90, #91 and #92) identified by the facility as independently mobile and cognitively impaired. The facility census was 88. On 01/21/15 at 2:10 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) #3 were notified Immediate Jeopardy began on 01/21/15 at 10:02 A.M. when the medication cart serving the 400 Hall was observed unlocked, with nine residents in the Solarium and no staff within view. At 10:32 A.M., the 200 Hall bathroom, which had a push button lock, could be pulled open freely. Inside were four locked cabinets surrounding a sink, and the sink counter which contained the key to the cabinets. Once unlocked, the cabinets contained 12 disposable razors, a large bottle of Cen-Kleen IV (a hospital-grade disinfectant that was labeled "Corrosive-Danger") and two spray bottles of Neutra-Stat HD (a detergent that was labeled "Danger"). At 10:50 A.M., the 100 Hall Soiled Utility closet, which had a push button lock, was pulled open freely. All chemicals were locked; however the biohazard bin was full of bags and sharps containers. At 11:05 P.M., the Wasen Hall kitchen was observed unlocked. Inside was a steam table, turned on, with visibly boiling water (the boiling point of water is 212 degrees Fahrenheit) and hot to the touch, a working gas stove and flat top grill, a dishwasher reading 164 degrees Fahrenheit with approximately 3 inches of standing water in the bottom, an unlocked drawer with seven sharp kitchen knives, and accessible Da-clean Ultra detergent (a cleaner) and Q-San sanitizer (a corrosive compound). The Immediate Jeopardy continued on 01/21/15 at 1:33 P.M., when the 300 Hall medication cart was observed unlocked with 12 residents in the dining area and no staff within view. On 01/22/15 at 4:59 P.M., the 200 Hall bathroom door was locked but pulled freely open. No chemicals were accessible; however a sharp cuticle clipper was accessible. At 5:21 P.M., the 300 Hall soiled utility room was observed with a push button lock in place, however it was able to be pulled open. Inside a mop bucket was accessible with approximately seven inches of a chemical, Neutra-Stat HD, inside the bucket. At 6:45 P.M., the therapy room on the Wasen Hall was observed unlocked. Inside there was a mock apartment for therapy use, with a working oven and stove, and knives in a cabinet. The Immediate Jeopardy was removed on 01/24/15 when the facility implemented the following the corrective measures ? On 01/21/15, the facility had a locksmith verify the push button locks to the 200 Hall bathroom and 100 Hall soiled utility room were functioning. The locksmith changed the lock to the Wasen Hall kitchen by ensuring it was unable to be left unlocked. ? On 01/21/15, the facility began in-servicing all nurses, aides, and Wasen dietary aides on "A Safe Environment at All Times", with a plan to complete the education by 01/23/15 for all affected staff. ? On 01/21/15, Licensed Practical Nurse (LPN) #4, LPN #5, and Dietary Aide #6 were suspended for three days, pending a full in-service on safe environment. ? On 01/21/15, all residents in the secured units where the medication carts were unlocked were monitored for 48 hours to ensure no medications were accidentally ingested. ? On 01/21/15 at 4:59 P.M., Dietary Aide #7 was knowledgeable regarding the in-service and ensuring a safe environment. ? On 01/22/15, the 200 Hall bathroom and 100 Hall soiled utility room push button locks were replaced with regular locking doors after continued malfunctioning. ? On 01/22/15, all push button locks and keyed doors had sensor alarms added to alert staff if they are opened, and 15 minute checks of all locked doors on units were initiated. The facility planned to continue those until the all locks on the whirlpool rooms, soiled linen rooms, supply closets, nourishment rooms, and nurses stations were replaced with electronic key pads. ? On 01/22/15, interview with State tested nursing assistant (STNA) #8 at 9:48 A.M., LPN #9 at 9:55 A.M., LPN #10 at 10:03 A.M., STNA #11 and STNA #12 at 1:14 P.M. confirmed knowledge of the in-service and how to ensure a safe environment. ? On 01/22/15 at 7:15 P.M., the therapy room was locked and a plan for the nurses on Wasen Hall to check out the therapist before leaving to ensure the therapy door is locked, the breaker for the stove turned off, and the knives locked up was implemented. ? On 01/23/15 from 6:35 P.M. to 6:51 P.M., all push button and keyed doors were observed locked, motion sensors functioning, and 15 minute checks were completed as ordered. ? On 01/23/15, interview with LPN #17 at 6:40 P.M., STNA #8 at 6:42 P.M., Facilities Manager #20 at 6:44 P.M., STNA #18 at 6:50 P.M., and STNA #19 at 6:52 P.M. confirmed knowledge of the in-service and how to ensure a safe environment. ? On 01/24/15 from 9:48 A.M. to 10:16 A.M., all push button and keyed doors were observed locked, motion sensors functioning, and 15 minute checks were completed as ordered. ? On 01/24/15, interview with Registered Nurse (RN) #14 at 9:53 A.M., RN #13 at 10:10 A.M., LPN #15 at 10:14 A.M., LPN #16 at 10:15 A.M. confirmed knowledge of the in-service and how to ensure a safe environment. ? From 01/23/15 through 01/27/15, the facility provided written evidence of 15 minute checks being completed for all doors with locking/push button and key lock mechanisms. The facility provided a plan to continue every 15 minute checks until all locks were replaced. As of 01/27/15, one of the locks had been replaced. ? From 01/23/15 through 01/27/15, the facility provided written evidence the therapy staff were signing out with nursing staff prior to leaving for the day to ensure the therapy room was properly locked and the breaker to the stove was turned off. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy), as not all door locks had been replaced and the facility was still in the process of implementing and evaluating corrective measures. Findings include: On 01/21/15 at 10:02 A.M., the 400 Hall (a secured dementia unit) solarium was observed. A medication cart was observed against the back wall, unlocked. Resident #12, #16, #26, #36, #46, #51, #66, #87 and #80, were in the Solarium with no staff present. Resident #50 was observed walking down the hall. The medication cart contained lancets, syringes, and many mediations, including blood pressure medications, anticoagulant medications, anti-psychotic medications, insulin, aerosol medications, and two chemotherapy drugs, which were stored in bags with neon yellow stickers, among all other medications for the 23 residents residing on the 400 Hall. On 01/21/15 at 10:16 A.M., an interview with LPN #4 confirmed the medication cart was unlocked with nine residents, including six residents who were independently mobile and confused. LPN #4 indicated she didn ' t realize she left the cart unlocked. On 01/21/15 at 10:32 A.M., the 200 Hall bathroom was observed with a push button lock, yet could be easily pulled open without inputting a code. Inside the bathroom was a sink flanked by four cabinets on the back wall, directly in view. The key to the cabinets was attached to a small piece of wood and was lying on the sink counter. When opened, the top left cabinet contained 12 disposable razors and shampoo, soaps, and perfumes. The top right cabinet contained shampoos and soaps. The bottom right cabinet contained a spray bottle of Neutra-Stat HD detergent that said " Danger " . The bottom left cabinet contained a bottle of Neutra-Stat HD as well as a large container of Cen-Kleen IV, a hospital grade disinfectant, which read "Corrosive" and "Danger". No staff was observed in the area and multiple residents were in the hall. On 01/21/15 at 10:43 A.M., an interview with LPN #9 confirmed the bathroom was accessible despite the push button lock. She revealed maybe maintenance had turned off the locking mechanism, as the bathroom was scheduled to be renovated soon. She revealed the key to the cabinets was usually in the nurse ' s medication cart or in the top of the cabinet. She closed the door and was able to open it without inputting the code five of nine times attempted. On 01/21/15 at 10:50 A.M., the 100 Hall soiled utility room was observed with a push button lock, but was pulled open easily without inputting a code. Inside, all cabinets were locked. However, the trash, soiled linen and biohazard bins were full. Facility Manager #20 revealed all locks are checked nightly and he denied the locks were faulty, despite being able to gain access without inputting a code. On 01/21/15 at 11:05 A.M., an observation of the Wasen Hall kitchen revealed the door was unlocked and the kitchen was accessible. Upon entering the door, to the immediate right was a set of steam tables, with the lids hot to the touch and the water noticeably boiling when removed. The steam tables were turned on high and medium high. Further down the right side was a set of drawers, one which contained seven very sharp kitchen knives. A three compartment sink was next to the drawers, with Da-Clean Ultra detergent and Q-San sanitizer accessible under the open sink. Next to the sink was a dishwasher, which read 164 degrees, and when opened, steam immediately rose and approximately three inches of water was visible at the bottom of the dishwasher, within easy reach. Also in the kitchen was a flat top stove and gas oven, which both were able to be turned on to heat up. On 01/21/15 at 11:15 P.M., an interview with RN #14 confirmed the kitchen door was unlocked and should not have been. She confirmed the steam tables were on and had noticeably boiling water in them and were hot to the touch, that there was a working stove and oven, an unsecured drawer with sharp kitchen knives, accessible chemicals, and that the dishwasher temperature was at 164 degrees. RN #14 revealed the nurses do not check the kitchen door and that it is up to the kitchen aides. She also confirmed there were independently mobile, confused residents residing on the Wasen Hall. On 01/21/15 at 1:33 P.M., an observation of the 300 Hall medication cart revealed it was unlocked and there was no staff in view. Multiple residents were in the dining area, unsupervised. Resident #80 was observed walking around and tucking blankets in around other residents. The medication cart contained lancets, syringes, and many mediations, including blood pressure medications, anticoagulant medications, anti-psychotic medications, insulin, and aerosol medications, among the many other medications for the 20 residents residing on the 300 Hall. On 01/21/15 at 1:37 P.M., an interview with LPN #5 confirmed that she left the medication cart unlocked while she was in the nurse's office on the phone. She confirmed residents were in the same area, with no staff in view. LPN #5 confirmed the contents of the medication cart included lancet, syringes, blood pressure medications, anticoagulant medication, insulin, and anti-psychotic medications, among others. On 01/21/15 at 1:45 P.M., an interview with the DON revealed staff had been educated about locking medication carts and ensuring chemicals were locked. On 01/22/15 at 9:44 A.M., an observation of the 100 Hall soiled utility room revealed the locking mechanism was taped open. STNA #8 was standing in front of the hall which housed the soiled utility room door. She revealed that she was called into work to guard the door, as it was not working. On 01/22/15 at 9:55 A.M., LPN #9 revealed the soiled utility room door was not working when she started her shift, so the STNA was to be guarding the door so no residents could access the room until someone could replace the lock. On 01/22/15 at 4:53 P.M., an interview with Facility Manager #20 revealed he was planning on replacing the push button locks due to intermittent problems. He revealed the locksmith had come out on 01/21/15, and stated there was wear to the push button locks on the 200 Hall bathroom and 100 Hall soiled utility room, so on 01/22/15, between 10:30 A.M. and 11:30 A.M., those two locks had been replaced with keyed locks. Facility Manager #20 revealed that was the temporary plan until electronic keypads could be placed on the bathroom, nurse's station, and nourishment room doors. On 01/22/15 at 4:59 P.M., an observation of the 200 Hall bathroom revealed a keyed lock, however the door pulled easily open. The cabinets were locked, but a sharp cuticle clipper was observed in an open cabinet to the side of the tub. The DON and Administrator confirmed the door was able to be opened without the key, and implemented 15 minute checks and a sensor alarm to that door. On 01/22/15 at 5:21 P.M., an observation of the 300 Hall (secure dementia unit) soiled utility room revealed a push button lock. The door was easily pulled open without inputting a code. Inside the room, a mop bucket was in front of the sink, with approximately 7 inches of an orange-colored liquid inside and accessible. This chemical was diluted Neutra-Stat HD. The Administrator confirmed the soiled utility room was able to be opened without the code, and contained a potentially hazardous chemical. On 01/22/15 at 6:35 P.M., an observation of the therapy room at the end of the Wasen Hall revealed it was unlocked. Once entered, there were two offices, both which had keys in the locks. A double door to the outside was at the far end of the large room, and to the right was a door that lead to a mock apartment used in therapy. Inside was a working stove and oven, which when turned on were hot very quickly. Also, knives were observed in the corner kitchen cabinet. This room also had an alarmed door to the outside. On 01/22/15 at 6:54 P.M., the Administrator and ADON #3 confirmed the therapy room was supposed to be locked but the nurses on duty on Wasen thought therapy was still there. ADON #3 verified the stove became hot very quickly after the burner was turned on. They both confirmed the stove, oven, and knives were accessible to residents at that time and should not have been. Review of the facility policy, "General Dose Preparation and Medication Administration", dated 05/01/10, revealed facility staff should not leave medications or chemicals unattended and the facility should ensure that medication carts are always locked when out of sight or unattended. Review of the facility policy, "Equipment Safety", dated 2010, revealed that equipment should not be left on when unattended. Review of the January 2015 Maintenance log revealed resident door were checked twice a week and fire/storage doors were checked weekly. Bathroom and whirlpool doors were not included on the checklist. Review of the MSDS for the Neutra-Stat HD cleaner, last revised 07/20/06, revealed it was a quaternary ammonium liquid detergent. The concentrate is very irritating to the eyes and moderately irritating to the skin. Dilutions are irritating to the eyes and mildly irritating to the skin. If ingested, medical attention must be obtained immediately. Gloves should be worn when handling this material. Review of the MSDS for the Cen-Kleen IV cleaner, last revised 10/23/06, revealed it was a hospital grade disinfectant that burns the skin, eyes, and on ingestion. The precautions revealed "do not get in eye, on skin, or on clothing". Gloves, protective safety glasses, and an apron should be worn when handling the material. Review of the MSDS for the Q-San Sanitizer, last revised 01/05/07, revealed it was a liquid quaternary ammonium compound. The concentrate is corrosive to the eyes and very irritating to the skin. It causes eye damage, severe skin irritation, and may damage the mucous membranes if swallowed. If swallowed, medical attention must be obtained immediately. Gloves and safety glasses should be worn. Review of the MSDS for Da-Clean Ultra detergent, last revised 09/01/06, revealed it was an enzyme cleanser. The concentrate can be irritating to the eyes and if ingested can cause nausea and diarrhea. Gloves should be used when handling the product. Review of the Operators Manual for the steam table, a drop-in series heated well model 9560, by Randell, revealed the units are designed for 145 degrees to 175 degrees operation and 140 to 170 degrees product temperature. According to the American Burn Association, the severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140 degrees F, it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 degrees F, resulting in almost instantaneous burns that will require surgery. Since immediate removal of the hot liquid from the skin may lessen severity, splash and spill burns may not be as deep as burns suffered in a bathtub. According to the Center for Disease Control (MMWR Weekly, 09/18/09), adults over age 65 have a worse prognosis than younger patients after scald burns because of age-related factors and comorbid medical conditions, and they are subject to more extensive medical treatment. Compared with younger adults, older adults with scald-related burns are more frequently admitted to hospitals, experience longer intensive-care unit and hospital stays, and have increased hospital mortality. Review of the facility's incident log from 01/2014 through 12/2014, revealed no scald injuries and no medication-related injuries. No chemical injuries were noted. The Administrator confirmed there were no incidents related to chemicals, burns, or medication-related incidents. This deficiency substantiates Complaint Number OH 517.

Based on observation, record review, staff interview, facility policy review, and National Pressure Ulcer Advisory Panel guidelines, the facility failed to prevent, identify and treat pressure ulcers according to current clinical standards for four residents. This resulted in harm for Resident #8 when a Stage II pressure ulcer deteriorated to an infected, unstageable pressure ulcer and the resident developed an unstageable pressure ulcer on his heel. Harm occurred for Resident #52 when the resident developed bilateral heel unstageable pressure ulcers, one of which developed an infection with no change in treatment. Harm occurred for Resident #68 when the resident re-developed an unstageable pressure ulcer to the heel. Harm also occurred for Resident #11 when the resident was incorrectly assessed as excoriation and deteriorated to an infected, unstageable pressure ulcer. This affected four residents (Resident #8, #52, #68 and #11) of four residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. Findings include: 1. Review of the clinical record for Resident #8 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/29/14, revealed Resident #8 was severely cognitively impaired, required extensive assistance of two staff members for transfers and toilet use. The resident was assessed to be frequently incontinent of both bowel and bladder. Resident #8 was assessed as being at risk for pressure ulcers and had one Stage II pressure ulcer (defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguious filled blister). Review of the most recent Braden Scale assessment, completed on 01/22/15, revealed a score of 16, indicating Resident #8 was at risk for skin breakdown. Review of the pressure ulcer plan of care, dated 11/17/14 and last reviewed on 01/11/15, revealed Resident #8 developed a Stage II pressure area to the coccyx on 12/26/14 and an unstageable pressure ulcer that was a suspected deep tissue injury (SDTI) on 01/11/15. Interventions included a gel cushion to the wheelchair, a pressure reducing mattress to the bed, turn and reposition every two hours, elevate heels with pillow when in bed, added 01/11/15, and bilateral heel protector boots when in bed, added on 01/16/15. Review of the Wound Assessment sheets for Resident #8 revealed he had two pressure ulcers. A pressure ulcer to the coccyx was identified on 12/26/14 as a Stage II pressure ulcer with 100% granulation tissue. An assessment from 01/13/15 revealed the wound bed declined and was 100% slough (defined as necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy at times) and the depth was unable to be determined. According to the NPUAP guidelines, a Stage II pressure ulcer does not contain slough. Slough may be present in Stage III, Stage IV, or unstageable pressure ulcers. The pressure ulcer was identified as a Stage II on 01/13/15 and 01/21/15 on the Wound Assessment sheets, and crossed out after the start of survey. Review of the Wound Assessment sheets for Resident #8 revealed the resident had a pressure ulcer to the right heel/right medial foot identified on 01/11/15. This was identified as a purple area and the sheet had unstageable, suspected deep tissue injury noted and crossed out, and then the ulcer was labeled a Stage I on 01/11/15 and 01/21/15. On 01/21/15, the area was assessed and depth was unable to be determined. According to the NPUAP, a Stage I is intact skin with non-blanchable redness of a localized area usually over a bony prominence, and bruising indicated a suspected deep tissue injury (SDTI, defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). Review of a physician notification sheet, dated 01/11/15, revealed Resident #8 was found with a round closed purple area on the right medial foot. On 01/14/15, the facility requested an order for [REDACTED]. A second culture was requested on 01/25/15 due to continued drainage. Review of the coccyx wound culture, dated 01/23/15, revealed many gram negative rods and many gram positive cocci. The physician was notified and a referral for the wound clinic was ordered. Review of the nutrition assessment and plan for Resident #8, dated 12/29/14 revealed the resident had a pressure ulcer to the coccyx and was prone to and had a history of [REDACTED]. Per the NPUAP, the goal intake for people with pressure ulcers was between 30 to 35 Kcal per day. He was not receiving any additional supplementation. On 01/21/15 at 4:23 P.M., an observation of Resident #8 revealed he was in bed. Green heel boots were observed laying on the dresser next to the wall. The resident's heels were observed to be directly touching the mattress. On 01/22/15 at 9:17 A.M., an observation of Resident #8 revealed he was laying in bed with the heel boots not on and heels not elevated. On 01/22/15 at 11:05 A.M., Licensed Practical Nurse (LPN) #16 was observed performing a dressing change for Resident #8's coccyx and heel. The over bed table was not cleaned prior to laying out supplies. She removed the old dressing, and measured the area to be 1.5 centimeters (cm) in length by 3.5 cm width. The LPN was unable to determine the depth of the wound due to the presence of slough tissue. The LPN did not change her gloves after removing the old dressing and cleaning the wound. The LPN pulled gloves out from her pocket, completed cleaning and drying the wound and applied the Santyl with her gloved finger. LPN #16 then accepted a pen from LPN #22, which he had unclipped from his shirt, and after using it, handed it back to him, still wearing soiled gloves. When the dressing change was completed, she pulled up Resident #8's brief and sweatpants, which were so soiled with urine and feces that the brief had leaked out onto the sweatpants. LPN #16 then sat Resident #8 down in his wheelchair, in the dirty briefs, to complete his heel dressing change. She did not clean the over bed table in between dressing changes, laid out her supplies on it, then dropped the bottle of Skin Prep onto the floor, picking it up and placing it onto the over bed table with the rest of her supplies. LPN #16 confirmed not changing her gloves between dirty and clean for the coccyx, placing soiled briefs back on the resident, and dropping the Skin Prep on the floor and placing it back on the table with her other dressing supplies at 11:26 A.M. On 01/25/15 at 11:00 A.M., an observation of Resident #8 revealed he was laying in bed with the his heels directly on the bed and the heel boots not on. On 01/26/15 at 2:53 P.M., an interview with Assistant Director of Nursing (ADON) #3 revealed she was the in charge of assessing pressure ulcers. She confirmed that according to clinical standards in pressure ulcer staging, Resident #8's coccyx pressure ulcer should have been assessed as being unstageable (defined as a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III or IV) on 01/13/15 as it was covered in slough and the depth could not be determined. She verified his heel had always been a purple area, which was most consistent with a SDTI. She explained floor nurses initially assessed and staged the pressure ulcers, and she would correct that staging if needed when she next assessed the wound. ADON #3 confirmed the resident's wound declined from a Stage II to an unstageable and was clearly infected, as they had requested oral antibiotics from the physician. 2. Review of the clinical record for Resident #52 revealed the resident was admitted on [DATE] and most recently re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS 3.0 assessment, dated 01/06/15, revealed Resident #52 was severely cognitively impaired, and required extensive assistance of two staff members for transfers, bed mobility, and toilet use. The resident was frequently incontinent of both bowel and bladder, and was at risk for pressure. He was assessed as having two Stage II pressure ulcers, identified on 12/19/14. Review of the most recent Braden Scale assessment, dated 01/06/15, revealed he was at risk for skin breakdown. Review of the pressure ulcer care plan, dated 07/23/14, revealed on 12/29/14 the resident had two Stage II pressure ulcers to the left and right heels. Interventions included a pressure reducing mattress to the bed, treatments as ordered, elevate heels off the bed, keep the foot of bed raised at all times when in bed, a gel cushion to the wheelchair, heel lift boots, added 01/12/15, and a heel lift cushion to elevate heels when in bed, added 01/06/15. Review of the acute care plan related to Stage I pressure areas to bilateral heels, dated 12/21/14, revealed interventions including float heels while in bed, skin prep, monitor for signs of infection, heel lift boots, and Keflex, an antibiotic, was started on 01/03/15. Review of a Wound Assessment sheet revealed Resident #52 had an unstageable pressure ulcer to the right heel, identified on 09/12/14 upon readmission. It was noted to have healed on 10/05/14. Review of the Wound Assessment sheets revealed the pressure ulcer to Resident #52's right outer heel was identified on 12/19/14. The first assessment was on 12/21/14 and the wound was described as boggy and 100% eschar (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. Eschar may be loose or firmly adhered to the wound) and assessed as a Stage I. On 12/29/14, the pressure ulcer was again assessed as having 100% eschar and with a depth that was unable to be determined, and assessed as a Stage II each week, including on 01/22/15 during the survey. Review of the nursing note, dated 01/03/15 at 2:26 P.M., revealed Resident #52's left heel had a moderate amount of purulent drainage and a foul odor. The physician started the resident on an antibiotic for a wound infection. Review of the physician progress notes [REDACTED].#53 had a pressure ulcer to the left heel with a large blackened area with yellow/brown drainage. Review of the Nutrition Assessment for Resident #52, dated 01/06/15, revealed he was receiving 29 Kcal per day and had adequate intakes. No additional calories were ordered. On 01/21/15 at 4:18 P.M., an observation of Resident #52 revealed he was in his wheelchair, feet on the floor, and no gel cushion in place. State tested nursing assistant (STNA) #19 confirmed the resident's heels were on the floor and revealed the resident did not have a gel cushion for his chair and never did. On 01/22/15 at 9:17 A.M., Resident #52 was observed in his wheelchair in the dining area with no gel cushion. On 01/22/15 at 3:42 P.M., LPN #22 was observed performing a dressing change on Resident #52's heels. LPN #21 was also present observing the dressing change. The left heel was changed first, and was assessed to have 100% eschar tissue and a small amount of drainage. No concerns were noted with the dressing change until LPN #21 unclipped a pen from inside his shirt and handed it to LPN #22 to date her dressing. LPN #22 confirmed this break in infection control at 3:55 P.M. On 01/27/15 at 8:36 A.M., an observation of Resident #52 revealed he was in the dining area of the 300 unit, in his wheelchair with both heels resting directly on the metal foot pedals. The right foot was covered with a sock; however the left foot was uncovered, with the pressure area directly touching the metal of the foot pedal, and drainage accumulating on the floor beneath his heel. LPN #5 confirmed Resident #52's heels were not offloaded and resting on metal foot pedals, and drainage had accumulated on the floor beneath his left heel. On 12/26/15 at 2:53 P.M., an interview with ADON #3 revealed Resident #52's heel pressure ulcers began as fluid-filled blisters. The ADON confirmed it was two days from when the heels were first identified as simply blisters, according to the nursing notes, until the wound assessment was documented. She confirmed the heels could not be Stage I or Stage II as they were covered in eschar and no depth could be determined. 3. Review of the clinical record for Resident #68 revealed the resident was admitted [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS, dated [DATE], revealed Resident #68 was severely cognitively impaired and required extensive assistance of two staff members for transfer and bed mobility and extensive assistance of one for toilet use. The resident was frequently incontinent of both bowel and bladder. Resident #68 was at risk for skin breakdown and had three Stage II areas, only one present on admission and one that had worsened since the prior assessment. Review of the most recent Braden Assessment score, dated 12/19/14, revealed Resident #68 was at moderate risk for skin breakdown. Review of the pressure ulcer care plan, dated 12/09/14, revealed the resident was admitted with a Stage II pressure ulcer to the left buttock that healed on 12/30/14 and developed a Stage II pressure ulcer to the left lateral foot, healed on 01/07/15; an suspected deep tissue injury to the right hip, healed on 12/18/14; and three Stage I pressure ulcers to the left inner ankle, healed 12/23/14; to the left inner heel, healed 01/07/15; and, one to the right outer heel, healed 01/07/15. Interventions included a blue heel lift cushion, cozy [MEDICATION NAME] to the bed, gel cushion to the wheelchair, treatments as ordered, turn and reposition every two hours, and Zero-G heel boots to both feet while in bed for heel protection, added 01/09/15. Review of the acute care plan, dated 01/21/15, revealed an open area to the coccyx. Interventions included assessing and taking measurements, clean with normal saline and covering with a dressing, and keeping pressure off the coccyx area. Review of the Wound Assessment sheets revealed Resident #68 had a Stage II pressure ulcer to the coccyx, identified on admission on 11/26/14, which developed 10% slough on 12/06/14, and was still assessed as a Stage II. This area healed on 01/09/15. On 01/21/15, the area reopened and was a Stage II with 100% granulation tissue and macerated edges. Review of the Wound Assessment sheets revealed Resident #68 had a left heel pressure ulcer, identified on 01/18/15, with 100% eschar and an undetermined depth. This was assessed as unstageable. Review of the physician notification sheets revealed on 11/26/14, Resident #68 returned from the hospital with a open area to the left buttock. On 12/02/14, multiple pressure areas were noted, including a bluish area on the right hip, and areas on the left inner ankle, left lateral foot, left inner heel, right outer heel, all with bluish centers and assessed as Stage I pressure ulcers. On 12/05/14, the right hip area opened and the left buttocks was noted as not improving. On 01/19/15, a blood-filled blister was noted to the left outer heel. On 01/21/15, an open area was noted to the coccyx. Review of the Nutrition Assessment, dated 12/03/14, revealed he was ordered to receive 32 Kcal per day and was consuming less than half of what was offered. On 01/27/15 at 4:10 P.M., LPN #24 was observed changing Resident #68's dressings for the coccyx and applying skin prep to the heel. No concerns were noted with the dressing change, and all interventions were in place at that time. A purple area was noted surrounding scar tissue on the right hip, the site of a previous pressure ulcer, that measured 2.8 cm by 2.4 cm, and LPN #24 identified this as a new area. She confirmed the unstageable ulcer was found at an unstageable category. 4. Review of the clinical record for Resident #11 revealed the resident was admitted on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS 3.0 assessment, dated 10/22/14, revealed Resident #11 was severely cognitively impaired, required extensive assistance of two staff members for transfer and toilet use, was totally dependent on staff for ambulation, and needed extensive assistance of one for personal hygiene. The resident was frequently incontinent of urine and always incontinent of bowel. She was at risk for pressure with no open areas. Review of the most recent Braden Assessment score, dated 01/20/15, revealed Resident #11 was at high risk of skin breakdown. Her prior assessment, dated 10/21/14, revealed she was at moderate risk of skin breakdown. Review of the pressure ulcer care plan, dated 04/21/14, revealed interventions including a gel cushion to the wheelchair, a pressure reducing mattress, treatments as ordered, elevate heels off bed with a pillow, and turn and reposition every two hours. Review of the physician progress notes [REDACTED].#11 had two pressure ulcers, a Stage I and Stage II at the coccyx area. He noted the Stage II was healing on 12/23/14 and healed on 01/21/15. Review of the clinical record revealed a Skin Condition, excluding pressure areas, sheet for Resident #11's coccyx area. The area was identified on 10/28/14 as moisture damage/excoriation. On 12/11/14, the area was noted to have slough, and on 12/30/14 the area was noted to be 100% slough and the depth was unable to be determined. Review of the culture results for the coccyx wound, dated 12/09/14, revealed a moderate growth of [MEDICAL CONDITION] (MRSA). Review of the Nutrition Assessment, dated 01/20/15, revealed Resident #11 was receiving 41 Kcal per day and was consuming about half of what was offered. She was noted to have inadequate intakes. On 01/28/15 at 12:44 P.M., an interview with Medical Director #21 confirmed he assessed Resident #11 as having a Stage I and Stage II, as indicated in his progress notes. He was unaware the facility had assessed her coccyx as excoriation and confirmed an area with 100% slough was a pressure ulcer. On 01/27/15 at 2:53 P.M., an interview with ADON #3 revealed she was in charge of pressure ulcers in the facility. She revealed she was not a Certified Wound Nurse. She revealed a consultant wound nurse visited when the facility needed her. The ADON was unable to provide evidence the wound nurse had seen Resident #8, #52, #68 or #11. The ADON revealed the facility used skin prep treatment on all areas of eschar and unopened areas to dry them out. When asked for documentation supporting the use of skin prep on unstageable pressure ulcers, she supplied the Skin Prep manufacturers guidelines and a pressure ulcer protocol from the wound nurse consultant. Review of the facility's "Pressure Ulcer Policy: Definitions", dated 07/03, revealed definitions of Staging pressure ulcers not in accordance with current clinical standards. The policy did not explain or describe slough, did not explain what a suspected deep tissue injury was, or what an unstageable pressure ulcer was. Review of the Skin Prep manufacturer's guidelines revealed it was a barrier protection. It revealed it should not be applied to open or infected areas of the skin. It did not state it was useful in the treatment of [REDACTED]. Review of the pressure ulcer protocol, provided by the consultant wound nurse, revealed how to treat an unstageable pressure ulcer. Skin prep was not listed as a treatment, especially in areas with any drainage at all. This deficiency substantiates Complaint Number OH 517.

Based on observation, medical record review, policy review, M-Rail (bed rails) manufacturer guideline review, M-Rail Installation review, Incident Log review, review of the U.S. Food and Drug Administration ' s (FDA) bed rail entrapment guidelines, staff interview, and resident interview, the facility failed to ensure the resident ' s environment remained free of accident hazards for 23 of 23 residents utilizing bed rails which placed these residents at high risk for entrapment. This resulted in Immediate Jeopardy for Residents #3, #4, #10, #17, #18, #20, #27, #31, #32, #34, #58, #59, #64, #70, #79, #81, #83, #98, #99, #102, #103, #130, and #167. The Facility census was 87. On 12/18/13 at 9:45 A.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 12/17/13 when Resident #99 ' s M-Rail was observed not to have a horizontal cross bar and a large opening between the top of the bed rail and the mattress. The opening of the M-Rail measured 15 inches in height and 16 inches in width. Resident #99 had one M-Rail to the side of the bed that was able to be completely removed from the bed frame as the buckle, used to secure the strap, was missing. On 12/17/13, further observation revealed a total of 23 beds utilizing M-Rails, none of the 23 beds were secured per manufacturer guidelines, 19 of 23 M-Rails were observed to be loose with a gap between the rail and mattress that measured between four to 12 inches, 15 of 23 M-Rails were not equipped with horizontal cross bars resulting in an area between the mattress and top of the bed rail that measured 15 inches in height and 16 inches in width. Eight beds only utilized one M-Rail despite manufacturer instructions to utilize two M-Rails. The potential for harm or death from entrapment is more than likely with the large gaps between the mattress and top quarter side rails and the improper installation. The Immediate Jeopardy was removed on 12/18/13 at 12:25 P.M. when the facility provided documentation that all M-Rails were removed from the facility as of that time. This reduced the potential for imminent danger. No M-Rails were observed within the facility on 12/19/13. Although the Immediate Jeopardy was removed, The facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as no staff training had been completed. Findings include: Review of the medical records revealed Resident #3, #17, #18, #27, #32, #58, #64, #81, #83, #102, and #167 were cognitively intact for daily decision-making, Resident #4, #59, and #10 were moderately impaired for daily decision-making, and Resident #20, #31, #34, #70, #79,#98, #99, #103 and #130 were severely impaired for daily decision-making. All the above resident required limited to extensive assistance with bed mobility. Review of the medical records revealed side rail assessments were completed annually for Resident #10, #17, #32, #59, #64, #70, and #79 to assist with bed mobility. Quarterly assessments were not completed for Resident #3, #4, #18, #20, #27, #31, #34, #58, #81, #83, #98, #99, #102, #103, #130, and #167. Review of the medical records for Resident #3, #4, #10, #17, #18, #20, #27, #31, #32, #34, #58, #59, #64, #70, #79, #81, #83, #98, #99, #102, #103, #130, and #167 revealed no care plan for side rails. Review of the medical record revealed Resident #32 ' s weight on 12/10/13 was 329 pounds. On 12/17/13 at 1:35 P.M., observation of the 300 unit revealed Resident #20, #31, and #99 ' s M-Rails were not equipped with horizontal cross bars resulting in a large opening between the top of the side rail and the mattress that measured 15 inches in height and 16 inches in width. Resident #20, #99 and #130 ' s M-Rails were not properly secured and the webbing straps were not straight, parallel or securely strapped against the bed frame. The gap between the mattress and the M-Rail measured between four to 12 inches. Resident #99 ' s left M-Rail was able to be completely removed due to the buckle used to secure the strap against the bed frame was missing and the snap-lock spring button was missing allowing the side rail to move freely up and down. On 12/17/13 at 2:30 P.M., observation of the 400 unit revealed Resident #10 and #79 ' s M-Rails were not equipped with horizontal cross bars resulting in a large opening between the top of the side rail and the mattress that measured 15 inches in height and 16 inches in width. Resident #10, #79 and #103 ' s M-Rails were not properly secured and the webbing straps were not straight, parallel or securely strapped against the bed frame. The gap between the mattress and the M-Rail ' s measured between four to seven inches. On 12/17/13 at 7:55 A.M., observation with the DON verified Resident #3, #4, #10, #17, #18, #27, #32, #34, #58, #64, #79, #81,#98, #102, #103, and #167 M-Rails were not properly secured and the webbing straps were not straight, parallel or securely strapped against the bed frame. The DON verified the loose M-Rail made a gap between the mattress that measured between four to six inches. The DON also verified Resident #3, #17, #27, #32, #34, #58, #81 and #98 ' s M-Rails were not equipped with horizontal cross bars. The DON stated not all M-Rails had to have horizontal cross bars and verified the space created by M-Rails without the horizontal cross bars was large enough for a resident ' s head, arm or other body part. On 12/17/13 at 2:10 P.M., the surveyor demonstrated that the opening in the middle of the M-Rail and the mattress was large enough for her head. At the time of the demonstration, the DON verified the surveyors head easily went between the space created by the lack of the horizontal cross bar on the M-Rail and the mattress. On 12/17/13 at 2:15 P.M., interview with the DON revealed there was no known injury related to the use of M-Rails with or without horizontal cross bars. On 12/17/13 at 2:35 P.M., interview with Licensed Practical Nurse (LPN) #500 verified Resident #99 ' s left M-Rail was not secure. LPN #500 pulled on the M-Rail and the M-Rail was removed effortlessly. LPN #500 verified the M-Rails on the 300 and 400 unit were not properly secured and the webbing straps were not straight, parallel or securely strapped against the bed frame, and resident #10, #20, #79 and #99 ' s M-rails were not equipped with horizontal cross bars. On 12/17/13 at 4:00 P.M., interview with STNA #510 verified the M-Rails were adjustable in height, could be adjusted to meet the residents ' needs and could be removed by the nursing staff or maintenance. On 12/17/13 at 4:21 P.M., interview with STNA #509 verified not all M-Rails have horizontal cross bars stating it depends on the resident. STNA #509 verified she does not check the M-Rail straps daily and if she would notice a loose rail, she would inform the nurse. On 12/17/13 at 4:30 P.M., interview with Therapist #503 revealed M-Rails were used for mobility and were recommended for residents who needed assistance with bed mobility. Therapist #503 stated horizontal cross bars were only put on the M-Rails for residents with limited mobility, residents were assessed upon admission and quarterly for the appropriateness of M-Rails, and dependent resident would not have M-Rails. Therapist #503 also stated resident cognition was considered prior to implementation of M-Rails and stated the residents needed to be able to follow directions to use of M-Rails for mobility. On 12/17/13 at 4:43 P.M., during interview the DON stated " occasionally you ' ll see a resident with their arm through the space in the M-Rail but they get it right out. " On 12/18/13 at 7:29 A.M., interview with LPN #507 stated maintenance staff puts the M-Rails on the resident ' s bed and nursing " periodically " checks them once every three days to see if they were loose. LPN #507 verified the M-Rails were not checked daily to make sure they were secure, was unaware if two M-Rails with horizontal cross bars were needed for each bed and had not been trained on what should be assessed for the M-Rails. On 12/18/13 at 7:30 A.M., interview with LPN #508 stated she only looks to see if the M-Rails were on the bed, and if they " looked loose " . LPN #508 stated every resident with M-Rails had an order and nurses documented on the Treatment Administration Record that the rails were on the bed. LPN #508 verified she does not physically check to see if the straps were secured properly or if the rails were loose. On 12/18/13 at 7:30 A.M., interview with Registered Nurse (RN) #504 stated she was unaware of any M-Rails being loose and if a problem was noted she would report it to maintenance. On 12/18/13 at 7:34 A.M., interview with STNA #505 verified she was aware of loose M-Rails on the 200 unit. STNA #505 stated the M-Rail ' s has straps under the mattress attached to the bedframe and there was " no need to bother maintenance " and verified she would tighten the straps. STNA #505 stated the M-Rails were checked once a week to see if they were loose. On 12/18/13 at 7:55 A.M., observation of Resident #3 ' s low air loss mattress and M-Rails revealed both rails were loose. The gap between the low air loss mattress and the left side rail measured five inches. On 12/18/13 at 7:55 A.M., observation revealed Resident #3 ' s low air loss mattress and M-Rails revealed both rails were loose. The gap between the low air loss mattress and the left side rail measured five inches. On 12/18/13 at 7:55 A.M., interview with Resident #3 stated a few weeks ago she was transferring and holding on to the M-Rail when the M-Rail came loose and thought she was " going down. " Observation of Resident #3 ' s M-Rail at the time of the interview revealed a gap was produced between the mattress and the M-Rail by pulling on the rail and the gap measured more than five inches. On 12/18/13 at 8:07 A.M., interview with RN #506 stated the STNA ' s report to her if there are any loose side (bed) rails and she had not been informed of any loose M-Rails on the 200 unit in the past three months. On 12/18/13 at 3:12 P.M., interview with Director of Facility Maintenance (FM) #501 stated all M-Rails were removed from resident rooms and were placed in the Maintenance Garage off-site. FM #501 verified the M-Rails without the horizontal cross bars measured 15 inches in height and 16 inches in width. On 12/19/13 at 7:44 A.M., FM #501 revealed when requested by nursing, maintenance was responsible for the installation of the M-Rail. FM #501 stated sometimes on weekend and after hours the STNA ' s install the M-Rails on the beds. FM #501 stated the M-Rail had two different styles including the higher rail which included the horizontal cross bar and the shorter rail did not have a horizontal cross bar. FM #501 verified not all M-Rails were equipped with horizontal cross bars. FM #501 stated maintenance installs the rails according to manufacturer guidelines. If an M-Rail was loose, nursing makes a request and maintenance will fix it or replace it with a new. Once the M-Rail was installed the maintenance department ' s role was complete. FM #501 verified no monitoring of the M-Rails for proper installation, condition of the equipment, and staff training specific to the use of M-Rails had been completed. On 12/19/13 at 7:59 A.M., interview with Lead Maintenance staff #511 revealed sometimes the M-Rail package did not come with a horizontal cross bar; therefore, it was not installed. Lead Maintenance staff #511 verified the M-Rails without the horizontal cross bar was not installed per manufacturer guidelines. Lead Maintenance staff #511 stated there had been no problems with the M-Rails that he was aware of. On 12/19/13 at 8:03 A.M., interview with Maintenance staff #512 verified some of the older M-Rails did not have a horizontal cross bar, and placement of the horizontal cross bar was determined by the thickness of the mattress and if nursing wanted to side rail to be high or low. Maintenance staff #512 verified M-Rail manufacturer guidelines were available to them, no training on installation of the M-Rails was provided and the expectation was to install them according to the manufacturer guidelines. Maintenance staff #512 verified the manufacturer guidelines for the M-Rails were not followed. On 12/19/13 at 8:12 A.M., interview with FM #501 stated the M-Rail manufacturer guidelines indicated a weight limit of 300 pounds and it was the responsibility of nursing to inform maintenance if a resident exceeded the weight limit. FM #501 verified Resident #32 exceeded the weight limit of 300 pounds for use of the M-Rails and the rails should have boon removed. FM #501 verified the manufacturer guidelines for the M-Rails were not followed for the weight limit for Resident #32 and were not followed for proper installation for Resident #3, #10, #17, #18, #20, #27, #31, #32, #34, #58, #79, #81, #98, #99 and #102. Review of the incident and Accident Log (Dated August 2013 through December 2013) revealed no incidents involving side rails. Review of the Guidelines for M-Rail Usage policy (dated October 2012) revealed any resident not independent with bed mobility was to be considered for M-Rail usage to promote maximum independence. M-Rails were to have a physician's order [REDACTED]. The appropriateness for M-Rails was to be determined by the therapy department and/or nurse assessing the resident. The maintenance department was to apply the M-Rails per the manufacturer guidelines; rail height was to be determined by the thickness of the mattress and the needs/physical size of the resident. Each resident ' s physical mobility and the need for M-Rails were to be assessed at least every quarter or when there was a change in condition. Assessments used for determination to use M-Rails will include the Admission assessment, plan of care, MDS, State tested Nurse Aide (STNA) activity of daily living flow sheets, therapy quarterly screen, fall screens, Braden scale and input from staff and resident care conferences. Review of the M-Rail manufacturer guidelines (undated) revealed the M-Rail was an assistive balance handrail for beds to assist persons who were mobile, but required some assistance to move or sit up in bed, to help balance getting in and out of bed, and standing beside the bed or during transfers by the bed. The M-Rail was not intended to support the full weight of a person and was suitable for people who weigh up to 300 pounds. Warnings included entrapment between an assistive bedside handrail device and mattress can be serious and potentially life-threatening. Entrapment could occur when there was a gap between the side of the mattress and the assistive handrail. It was possible for a person ' s head, neck, arm(s), leg(s), or body to become wedged between the side of the mattress and the assistive handrail horizontal cross bars or vertical side bars. The mattress must be tight against the assistive handrail with no gaps at all times. This should be checked frequently-at least daily. For added safety, it was a recommendation by the manufacturer to install two M-Rails, one on each side of the bed, to assist with keeping the mattress in place with no gaps. The horizontal cross bars must be used at all times. The M-Rail was not intended for people with poor mobility or for people who were permanently bedridden. Extra safety measures and precautions must be used with higher risk patients. Review of the M-Rail Installation Instructions (undated) revealed the M-Rail was to be slid down between the mattress and the bed frame support. The long webbing was to be place across the bed frame and underneath, back to the M-Rail and through the buckle. The buckle was to be closed to secure the strap. The two webbing straps were to be tightened securely against the bed frame ensuring the webbing straps were straight and parallel. The excess webbing was to be removed. Review of the U.S. Food and Drug Administration ' s (FDA) bed rail entrapment guidelines, dated 03/10/06, revealed that the population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless or who have uncontrolled body movement. The FDA uses a head breadth dimension of 4 ? inches and the basis for its dimensional recommendations for side rails. They recommend 2 3/8 inches as an appropriate dimension for neck diameter. There are seven potential entrapment zones, with zone three being between the rail and the mattress. Zone three is the space between the inside surface of the rail and the mattress compressed by the weight of the patient ' s head. This space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. The FDA therefor recommends a gap of no more than 4 ? inches in this zone to prevent entrapment.