Every finding on record at Burlington House Rehab & Alzheimer's Care Center

Based on observation and staff interview, the facility failed to maintain a safe and comfortable air temperature on the 400 unit. This had the potential to affect the 47 residents residing on the 400 hall. The facility census was 96 residents. Findings include: Observation on 08/03/26 at 10:15 A.M. of the 400 unit revealed there were multiple cooling units on each hallway and in the common areas. Interview on 08/03/26 at 1:09 P.M. with Social Services Designee (SSD) #411 confirmed the cooling units have been on the 400 unit since the beginning of summer and have maintained a fairly comfortable temperature. SSD #411 stated she was not aware of the specifics of why the air conditioning was not working on the 400-unit. Interview on 08/04/26 at 3:35 P.M. with the Director of Nursing (DON) confirmed the air conditioner on the 400-unit hallways and common areas has been out for several months but that they have been able to maintain adequate temperatures with the cooling units they have in place. The DON stated resident rooms are cooled by a different system, so the resident rooms remained cool. Observation on 08/06/26 at 1:19 P.M. of the 400 unit revealed the air temperature in the hallways and the common areas on the 400 unit felt extremely warm. Observation on 08/06/26 at 2:00 P.M. with the Administrator revealed the air temperatures throughout the 400-unit hallways and common areas ranged from 80 to 84 degrees Fahrenheit (F). Interview on 08/06/26 at 2:01 P.M. with the Administrator confirmed several of the air temperatures in the 400-unit hallways and common areas were out of the acceptable range. Observation on 08/06/26 at 4:03 P.M. revealed temperature outside room [ROOM NUMBER] on hallway two was 85 degrees F and the area outside of room [ROOM NUMBER] on hallway three was 84 degrees F. All three hallways on the 400-unit and the common areas felt extremely warm. Interview on 08/06/26 at 3:28 P.M. with Corporate Nurse (CN) #513 confirmed the facility would bring in additional cooling units from another facility to try to get the temperatures in the 400-unit back in range. This deficiency represents noncompliance investigated under Complaint Number 3107079.

Based on observation, staff interview, review of Safety Data Sheets (SDS), and review of the facility policy, the facility failed to ensure hazardous chemicals were properly stored. This had the potential to affect 28 independently mobile and cognitively impaired residents residing on the west and south units. The facility census was 106 residents. Findings include:1. Observation on 03/17/26 at 9:21 A.M. revealed there was an open container of wipes labeled Sani-Cloth Plus Germicidal Disposable Cloth located on the floor under a desk at a nurses' station on the west unit. The label on the wipes indicated they should be kept out of reach of children and could be hazardous to humans and domestic animals. There was also an open container of wipes labeled Sani-Hands Instant Sanitizing Wipes. The label on the wipes indicated they should be kept out of reach of children unless under adult supervision and to obtain medical help or contact a poison center immediately if swallowed.Interview on 03/17/26 at 9:29 A.M. with the Executive Director (ED) confirmed the open containers of wipes on the west unit should have been locked up.2. Observation on 03/17/26 at 9:34 A.M. revealed there was an open container of wipes labeled Sani-Cloth Plus Germicidal Disposable Cloth located in an unlocked cabinet in the hallway outside of the activities area on the south unit. Interview on 03/17/26 at 9:34 A.M. with Licensed Practical Nurse (LPN) #373 confirmed the open container of wipes was being stored in an unlocked cabinet. LPN #373 further confirmed she did not have a key to lock or unlock the cabinet.3. Observation on 03/17/26 at 9:37 A.M. revealed there were two open containers of wipes labeled Sani Hands Instant Sanitizing Wipes in the nurses' station on the south unit. There was also an open container of wipes labeled Clorox Healthcare Bleach Germicidal Wipes in the nurses' station on the south unit. The label on the wipes indicated they should be kept out of reach of children and could be hazardous to humans and domestic animals.Interview on 03/17/26 at 9:46 A.M. with the ED confirmed the wipes in the south unit nurses' station should have been locked up.4. Observation on 03/17/26 at 9:48 A.M. revealed there was an open spray bottle labeled Ecolab Lemon Lift Heavy Duty Kitchen & Bathroom Cleaner with Bleach in an unlocked cabinet under the sink in a south unit dining area. The label indicated it was for industrial use only and should be kept out of reach of children and should not be ingested. There were also an open container of wipes labeled Sani-Cloth Germicidal Disposable Cloth and an open container labeled Clean-n-Mean Waterless Hand Cleaner in an unlocked cabinet above the sink. The label on the hand cleaner indicated it was for external use only, should not be used in the eyes, and should be kept out of the reach of children.Interview on 03/17/26 at 9:59 A.M. with the Director of Plant Operations (DPO) confirmed the items in the unlocked cabinets in the south unit dining area should have been locked up.Review of the SDS for Sani-Cloth Plus Germicidal Disposable Cloths revealed the wipes could cause eye irritation and mild skin irritation.Review of the SDS for Sani-Hands Instant Sanitizing Wipes revealed the wipes could cause serious eye irritation, might cause respiratory irritation and might cause drowsiness or dizziness.Review of the SDS for Clorox Healthcare Bleach Germicidal Wipes revealed the wipes should be kept out of reach of children and users should avoid contact with eyes and skin and wear appropriate personal protective equipment. Review of the SDS for Ecolab Lemon Lift revealed it should be kept out of reach of children and could cause serious skin and eye irritation. Review of the SDS for Waterless Hand Cleaner revealed this product would pose a health hazard if ingested or if it contacted the eye. Review of the facility policy titled Hazardous Materials Storage undated revealed hazardous materials may include but are not limited to cleaning and disinfecting products (wipes, liquids, sprays.) When not in immediate use, hazardous materials should be stored in a secure storage unit or container.This deficiency represents noncompliance investigated under Complaint Number OH2748667.

Based on interview and closed and open record reviews and facility policy review, the facility failed to ensure a resident was free from sexual abuse. This affected one resident (Resident #81) of one resident reviewed for sexual abuse. The facility total census was 97. Findings included: Closed record review for Resident #81 revealed the resident was admitted to the facility on [DATE] and discharged on 04/23/25 to home. Diagnoses for Resident #81 included Alzheimer ' s, dementia, heart disease, depressive disorder, and psychosis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and required partial assistance with toileting and supervision with ambulation. There were no functional impairments. The resident resided on the memory secured unit in room [ROOM NUMBER]. The resident had a guardian. Resident #81 had an emergency room visit on 03/30/25 and returned on 03/30/25. Record review of Resident Perpetrator, (RP) #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #11 include dementia, hypertension, anxiety disorder, PTSD, diabetes, and heart failure. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and required supervision with feeding himself and partial assistance with hygiene. The resident required partial assistance with transfers and used a wheelchair for ambulation. The resident had a guardian. Review of physician orders for Resident #11 revealed an order for progesterone at 5 milligrams for hypersexuality started on 11/02/24 and for progesterone increased to 10 milligrams on 03/04/25. There was a physician order for one-on-one staff monitoring towards female residents beginning on 03/30/25. The resident resided on the memory secured unit. There was a room move on 03/30/25. Review of the nurse progress notes dated from 03/30/25 at 3:30 P.M. revealed Registered Nurse, (RN) # 43 was notified Resident #81 entered the bathroom of RP #11 and RP #11 and had his hand inside Resident #81's brief. The residents were separated. Resident #81 had a head-to-toe assessment with no injury noted, skin clean and dry and intact. Resident #81 was peaceful and displayed no signs of agitation or distress. The physician, police and Power of Attorney were notified. Resident #81 was sent non-emergent to the hospital for a Sexual Assault Nurse Exam, (SANE) examination. Review of the facility investigation witness statement dated 03/30/25 of Licensed Social worker, (LSW), #48, revealed on 03/30/25 at approximately 10:45 A.M., Resident #81 was observed standing in RP #11 bathroom with her pants at her ankles and brief pulled up. RP #11 was in a wheelchair and had his hand inside Resident #81's brief. The residents were separated with no resistance. Resident #81 and RP #11 had no response to questioning of the incident. The police were notified and filed a report. Review of the police report dated 03/30/25 at 1:17 P.M. revealed LSW #48 reported at 10:30 A.M. she passed by RP #11 room and observed Resident #81 standing in the bathroom with the briefs intact and pants at ankles. RP #11 was seated in wheelchair with his hand down front of Resident #81's brief. LSW #48 observed no movement, and neither residents were speaking or making any sound, with blank facial expressions. The police advised the guardian to permit Resident #81 to have a SANE examination. Review of the hospital emergency department report dated 03/30/25 at 3:50 P.M. revealed the SANE examination was completed. Resident #81 had some excoriation of the perineum, likely from the use of a diaper. Review of SANE nurse documents dated 03/30/25 at 5:28 P.M., SANE nurse #200 verified LSW #48 report of seeing Resident #81 standing in the bathroom doorway with her pants around her ankles and the assailant's, RP #11, hand in her depends. Neither nursing home resident involved recalling the incident. Resident #81 did not appear in distress and respirations appeared unlabored. Resident #81 appeared clean and well-groomed upon RN #200 arrival. A large area of redness with associated tenderness was observed to the external genitalia, groin, and buttocks, consistent with incontinence associated dermatitis. There was a scant amount of thick white secretions observed to the left labia minora. The SANE RN #200 was able to evaluate the vulva and no lacerations, bruising, or bleeding was observed. There were no further findings. Review of the State Reportable Incident , (SRI) dated 03/30/25 and timed 2:55 P.M., revealed the facility completed a thorough investigation of the incident including witness statement, vulnerable resident skin assessments and staff education on resident abuse. Observations made on 04/02/25 at 11:16 P.M., 04/03/25 at 10:05 A.M., 04/03/25 at 5:55 P.M. and 04/07/2 at 9:25 A.M. and at 12:00 P.M., revealed Resident #81 was in no apparent distress related to the incident of 03/30/25. The resident was clothed, clean and had no odors. Observations made on 04/02/25 at 11:16 P.M. , 04/03/25 at 10:05 A.M. , 04/03/25 at 5:55 P.M. and 04/07/2 at 9:25 A.M. , revealed the FR #11 new room was at end of hall, two halls away from Resident #81 with one- on- one monitoring of Certified Nursing Assistants, (CNA) #100. Interview on 04/02/25 at 10:00 A. M. and on 05/12/25 at 1148 A.M., witness LSW #48 verified on Sunday, 03/30/25, at approximately 10:45 A.M. Resident #81 was standing, coming out of RP #11's bathroom doorway with outwear pants at her ankles and her brief pulled up at her waist. RP #11 was facing Resident #81, sitting in his wheelchair with his hand down her brief. There was no movement of the hand and he removed his hand immediately. There were no verbalizations and flat emotions of both residents. With assistance from RN #43, the residents were separated, assessed and responsible parties were notified. LSW #48 verified Resident #81 was independently ambulatory, able to take herself to the bathroom, and wandered into other resident's rooms. LSW #48 stated RP #11's usual behavior was to sit in his wheelchair at his doorway. Interview on 04/02/25 at 9:50 A.M., the SANE RN #200 verified she completed the examination of Resident #81 on 03/30/25, and there was no evidence of sexual penetration or injury. There was a reddened rash indicative of an incontinence dermatitis. Interview on 04/07/25 at 10:00 A.M RN #43 verified he was notified of the incident between Resident #81 and RP #11 by LSW #48 on 03/30/25 at approximately 10:50 A.M. RN #43 verified the LSW #48 reported RP #11 had his hand inside Resident #81's brief. The residents were separated and assessed with no injury noted. The police and guardian were notified and the guardian agreed to a SANE examination. Interviews on 04/02/25 at 1:40 P.M., the Administrator and Director of Nursing, (DON) verified Resident #81 and RP #11 had physical contact in RP #11 room on 03/30/25 at approximately 10:45 A.M. , discovered by LSW #48. RP #11 had his hand inside Resident #81's brief. Review of facility policy titled Ohio Abuse, Neglect and Misappropriation , undated, revealed the facility intent is to prevent resident abuse. Sexual abuse is defined as non-consensual sexual contact of any type. This deficiency represents non-compliance investigated under Complaint Number OH00165513.

Based on observation and staff the facility failed to ensure a clean and sanitary environment in resident bathrooms. This affected two (Residents #25 and #27) of three residents reviewed for physical environment. The facility census was 100 residents. Findings include: Observation on 09/16/24 at 9:12 A.M. with State tested Nurse Aide (STNA) #111 revealed a ceiling tile in Resident #25 and #27's bathroom had a large ring of discoloration of an unknown dark substance. Interview on 09/16/24 at 9:13 A.M. with STNA #111 confirmed the discolored ceiling tile in Resident #25 and #27's bathroom had been that way for a least a month and had occurred following a water leak. Observation on 09/17/24 at 11:00 A.M. revealed the ceiling tile in Resident #25 and #27's bathroom still had a large ring of discoloration of an unknown dark substance. Interview with on 09/17/24 at 11:00 A.M. with Maintenance Technician (MT) #81 confirmed the ceiling tile in Resident #25 and #27's bathroom was discolored, and he was going to treat the area with a commercial mold and mildew spray. This deficiency represents noncompliance investigated under Complaint Number OH00156321

Based on record review, observations, staff interviews, and review of facility policy, the facility failed to provide timely incontinence care. This affected one resident (#04) out of three reviewed for incontinence care. The facility census was 98. Findings Included: Review of medical record for Resident #04 was admitted [DATE]. Diagnosis included Alzheimer's disease, dementia, epilepsy, hemiplegia, and hemiparesis. Review of the Bowel assessment dated [DATE] revealed Resident #04 was incontinent of bowel and required to be checked and changed every two hours. Review of the Urinary Incontinence assessment dated [DATE] revealed Resident #04 was incontinent with multiple episodes daily. Resident #04 wore an incontinent brief and was required to be checked and changed every two hours. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #04 had a Brief Interview of Mental Status (BIMS) of 03 which indicated she was severely cognitively impaired. Resident #04 was dependent on staff for all activities of daily living (ADLs). Review of the plan of care dated 04/18/24 revealed Resident #04 was at risk for complications associated with episodes of urinary incontinence and was at risk due to self-care performance deficit related to dementia, Alzheimer's disease, and weakness. Interventions included two or more staff required for toileting, check the resident every two to three hours and as needed (PRN) for incontinent episodes, provide incontinence and perineum (peri) care after each incontinent episode, remind resident to go to bathroom every two to three hours, and report changes in bladder status to the physician. Numerous observations of Resident #04 on 05/29/24 starting at 9:56 A.M., revealed the resident was located in the lobby by herself and near the south hall nurses station dressed, covered in blanket and seated in a Geri-chair. At 10:20 A.M., Activity Aide #800 took the resident to the Music Hall dining room for activities. At 11:53 A.M., Activity Aide #800 took the resident to the dining room for lunch. At 12:22 P.M., Resident #04's daughter arrived and wheeled the resident to her room to assist with lunch. Interview with Resident #04's daughter on 05/29/24 at 12:25 P.M. revealed she visited the resident daily before noon to assist in her mother's meal. Resident #04's daughter stated when she arrived today, she asked the staff to check and change the resident because she smelled like urine. Resident #04's daughter indicated staff reported they would check and change the resident after 2:00 P.M. Observation of Resident #04 on 05/29/24 at 2:00 P.M. revealed Resident #04's daughter pushed the resident from her room to the dining room and exited the facility. Observation of incontinence care for Resident #04 on 05/29/24 2:20 P.M. by State tested Nursing Assistant (STNA) #390 and Registered Nurse (RN) #395 revealed the resident's incontinence brief was saturated with urine and bowel. Resident #04 had no skin issues. Interview with RN #395 at the same time, revealed he was tasked with caring for Resident #04 as the STNA during the day shift (7:00 A.M. to 7:00 P.M.) due to staffing issues. RN #395 verified he had not checked and/or changed Resident #04's incontinence brief since arriving at 7:00 A.M. RN #395 indicated the resident should have been checked and/or changed every two hours. Interview with STNA #390 on 05/29/24 at 2:22 P.M. revealed she was also tasked with caring for Resident #04 during the day shift. STNA #390 verified she had not checked and/or changed Resident #04's incontinence brief since arriving at 7:00 A.M. Interview with STNA #370 on 05/29/24 at 4:12 P.M. revealed she was tasked to care for Resident #04 during the night shift (7:00 P.M. to 7:00 A.M.) which started on the evening of 05/28/24. STNA #370 stated she last cared for Resident #04 at 5:45 A.M. which included changing her incontinence brief. STNA #370 stated she left for the day at 6:00 A.M. Review of the facility policy titled Routine Resident Care undated revealed it was the policy of this facility to promote and provide routine daily care by a certified nurse assistance that can maintain proper body position and alignment for all residents, implement and maintain program for skin care, maintain a bladder and bowel training program, toileting, provide care for incontinence with dignity and maintaining skin integrity, and providing therapeutic interventions for cognitively impaired residents. This deficiency represents non-compliance investigated under Complaint Number OH00153822 and Complaint Number OH00153607.

Based on [NAME] record review, observations, staff interviews, review of facility documents and policy review, the facility failed to provide resident's with a clean and sanitary environment. This affected four (#06, #10, #48, #80) out of four residents reviewed for the physical environment. The facility census was 99. Findings include: 1. Record review for Resident #06 revealed he was admitted to the facility on [DATE]. His diagnoses included, diabetes mellitus (DM)2, lymphedema, essential primary hypertension, anxiety disorder, adjustment disorder, heart failure, major depressive disorder, and chronic kidney disease stage 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 03/28/24, revealed Resident #06 had severely impaired cognition. Further review for the MDS assessment revealed he required maximum assist with toileting and bathing. Interview and observation on 04/30/24 at 2:30 P.M. with the housekeeper (HK) #90 confirmed she had cleaned Resident #06's room at an earlier time on 04/30/24. HK #90 confirmed the presence of brown splatter up the wall and onto the ceiling. HK #90 confirmed the brown substance all along the floor of the bathroom and dried on the toilet seat and around the toilet. HK #90 stated she thought the unknown brown substance on the toilet seat and around the toilet was feces. HK #90 stated she is unable to clean any brown substance and the task of cleaning unknown brown substances was the nursing staff's job. 2. Record review for Resident #10 revealed he was admitted to the facility on [DATE]. His diagnoses included, asthma, cachexia, osteoarthritis, dementia, and anxiety. Review of Resident #10's most recent MDS assessment, dated 03/11/24, revealed he required assistance from staff with toileting and bathing. Record review for Resident #10 revealed he was severely cognitively impaired. Interview and observation on 04/29/24 at 9:59 A.M. with Housekeeping Manager (HKM) #89 confirmed Resident #10's room had a very strong foul odor. HKM #89 confirmed the presence of brown water and splashed brown substance all around the toilet seat. HKM #89 confirmed Resident #10's toilet seat had several active flying gnats on and around the toilet seat. 3. Record review for Resident #48 revealed she was admitted to the facility on [DATE]. Her diagnoses included, Alzheimer's disease, hyperlipidemia, essential primary hypertension, hypokalemia, anxiety disorder, and major depressive disorder. Review of Resident #48's most recent MDS assessment, dated 03/18/24, revealed she was severely cognitively impaired. Further review of the MDS assessment revealed Resident #48 required assistance from staff with toileting and bathing. Record review for Resident #48 revealed an order for a pressure reducing mattress, dated 10/02/23. Observation of Resident #48's room revealed a mattress was on its side along the wall of the room. Resident #48's bed side table had a sticky substance on the top and splattered down the front. Resident #48's bathroom trash can was soiled and had brown splatter running down the sides of the trash can. Resident #48's toilet seat was dirty, soiled, and had numerous gnats flying around the toilet seat and on the toilet seat. Interview and observation on 04/19/24 at 9:46 A.M. with HKM #89 confirmed Resident #48's room had an extra mattress leaning up on the wall. HKM#48 confirmed that Resident #48 had a sticky substance all over the bed side table and running down the top drawer. HKM #48 confirmed the bathroom trash can had an unknown brown substance running down the bathroom trash can and the toilet had a unknown brown liquid in the toilet bowl. HKM #48 confirmed the soiled toilet seat had gnats flying around the toilet and around the bathroom. 4. Record review for Resident #80 revealed she was admitted to the facility on [DATE]. Her diagnoses included, bipolar disease, anxiety disorder, Alzheimer's disease, essential primary hypertension, dementia, and borderline personality disorder. Review of the most recent MDS assessment, dated 02/23/24, revealed she had impaired cognition. Further review of the MDS assessment revealed Resident #80 required supervision from staff with toileting and bathing. Interview and observation on 04/30/24 at 2:30 P.M. interview with HK #90 confirmed she had cleaned Resident #80's room. HK #90 confirmed the bathroom had a smudged brown substance all around the toilet and on the toilet seat was feces. HK #90 stated she was unable to clean feces from resident's bathrooms. Interview on 04/30/24 at 3:00 P.M. with the Administrator confirmed the housekeeping staff is expected to clean the feces from the toilet, however, nursing staff clean the feces from the floor. Review of the facility control treatments revealed the facility was treated from gnats in the dining area and kitchen area on 12/04/23, 01/15/24, 01/25/24, 02/29/24, 04/16/24, and 04/13/24. Further review of the pest treatments did not reveal any treatments of resident rooms for gnats. Review of the facility policy titled, Pest Control, dated 09/15/21 revealed, the facility will establish a regimented time each month for spraying and to eliminate pests in the facility. Review of the facility in-service policy titled, Seven Step Daily Washroom Cleaning, dated 01/01/200, revealed the policy was created to show housekeeping employees the proper method to sanitize a washroom or bathroom in a long-term care facility. Commodes includes the tank, the seat, the bowl and the base. The policy stated to use a separate rag and a germicide solution and to wipe every area of the commode.

Based on medical record review, review of a facility self-reported incident (SRI), observations, staff interviews, review of personnel files and policy review, the facility failed to ensure a resident was free from physical abuse. This affected one (#15) out of two residents reviewed for abuse. The facility census was 99. Findings include: Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Her diagnoses included, hydrocephalus, osteoarthritis, schizo affective disorder, hypothyroidism, hyperlipidemia, major depressive disorder, anxiety disorder, dementia, and essential primary hypertension. Review of the most recent Minimum Data Set (MDS), dated [DATE], revealed Resident #15 had severe cognitive impairment. Further review of the MDS assessment for Resident #15 revealed she required maximum assistance from staff with toileting, bathing, and personal hygiene and was dependent on staff for medication management. Review of Resident #15's behavior care plan initiated on 03/10/23 revealed she was care planned for a behavior problems that included, increased agitation, verbal aggression, refuses care, refuses medication, refuses showers, refuses skin checks, physical aggressive toward staff, refuses to wear incontinence supplies, throws objects at others, refuses to be seen by wound care, refuses to go on appointments, and physical aggression toward other residents. The facility listed the following interventions for Resident #15's behaviors, administer medication as ordered, approach in a calm manner, behavioral health consult as needed, communicate with resident, consult with pastoral, psychological services, support groups, encourage active support by family, minimize potential for disruptive behaviors by offering tasks that divert attention, encourage resident to participate in activities of choice, encourage resident to maintain as much independence and control with depictions making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, attempt to determine underlying causes, observe and anticipate resident's needs, and encourage resident to express her feelings. Review of Resident #15's progress notes dated 04/25/24 as a late entry for 04/24/24 revealed the Administrator received a call from Resident #15's private care giver related to the facility care provided to Resident #15 by the facility staff and will be in a later time to provide more information and a video of the incident. Further review of the progress notes reveled on 04/24/24 the Administrator and Director of Nursing (DON) met with the Resident #15's care manager and she reported concerns of care not being provided in the way the family would prefer. Documentation revealed the family refused to send Resident #15 out for evaluation and treatment until 04/29/24. The family requested Resident #15 to be sent to the emergency department for evaluation and treatment related to the allegation of abuse and falls. Review of hospital records for Resident #15 dated 04/29/24 revealed was seen in the emergency room and was discharged from the hospital with a diagnosis of fall, agitation, and complicated urinary tract infection (UTI). Resident #15 was given a new order for an antibiotic. Review of the facility SRI, revealed the facility opened an investigation regarding physical abuse on 04/24/24 at 1:23 P.M. and closed the report on 04/30/24 at 8:53 P.M. The SRI revealed a personal care giver of Resident #15 called the Administrator on 04/24/24 and reported an allegation of abuse to Resident #15 by two facility State tested Nurse Aides (STNA) #95 and #96 on 04/24/24. The report stated STNA #95 struck Resident #15 with a pillow, held her hands down, and caused Resident #15 to hit her head. As a result of the investigation the facility notified the police and substantiated the allegation of abuse. The investigation revealed Resident #15 was evaluated at the hospital on 04/29/24 and returned with a diagnoses of urinary tract infection. The SRI documented Resident #15 had no injuries or outcome from the incident. Observation on 04/30/24 at 2:08 P.M. of Resident #15 revealed there was no signs of abuse noted. Attempts to interview Resident #15 revealed the resident was not interviewable. Interview on 05/02/24 at 8:57 A.M. with the Administrator, Regional Nurse (RN) #91, and the facility [NAME] President of Risk Management (VPRM) #94 revealed the Administrator reported on 04/24/24 she received a call from Resident #15's personal care giver and she reported she will arrive at the facility and provide information related to care provided to Resident #15 from two STNA's (#95 and #96). The Administrator stated she immediately suspended STNA #95 and #96 and contacted the police department and filed a report. The Administrator stated the personal care giver arrived at the facility around 1:00 P.M. and provided a video of the abuse incident to the facility. The Administrator stated the video revealed the two STNA's (#95 and #96) were rough when they provided personal care to Resident #15. The Administrator confirmed the care provided by STNA #95 and #96 to Resident #15 was not consistent with the facility standards. The Administrator stated Resident #15 is resistive to care and this is care planned for Resident #15. The Administrator stated Resident #15 will swat, hit, kick and try to bite staff when the staff attempt to provide personal care to Resident #15. The Administrator confirmed the facility has provided education to the staff to walk away from the resident's if they are resistive to care and try another care giver or other attempts. The Administrator confirmed STNA #95 and #96 should have left Resident #15 and consulted with other staff members in an attempt to try again if she was resistive to care. The Administrator confirmed the video tape of the care provided to STNA #95 and #96 to Resident #15 appeared as though STNA #95 and #96 had attempted to restrain Resident #15 and had tossed a pillow at Resident #15's head during care. The Administrator confirmed the facility initiated a SRI regarding abuse which was substantiated. The Administrator confirmed STNA #95 and #96 were terminated from employment with the facility due to the incident involving Resident #15. The Administrator confirmed Resident #15 was assessed once the facility became aware of the incident and there was no injuries or outcome from the abuse incident. Observation on 05/02/24 at 11:30 A.M. with the VPRM #94 of the video footage dated 04/24/24 revealed care was being provided to Resident #15 by two STNA's #95 and #96. STNA's #95 and #96 were standing over Resident #15 while providing care. Resident #15 pushed at STNA #95 and #96 and struck out toward the staff members. STNA #95 threw a pillow at the resident, hitting her in the face. Resident #15 pulled the pillow off her face. STNA #95 then picked up a clean incontinence brief and hit the resident in the hand. Resident #15 continued to strike out and tried to bite the staff. STNA #96 stood at the foot of the bed and watched. STNA #95 then held both of Resident #15's hands down on her chest the resident tried to sit forward, and pressure was applied to keep the resident lying down. STNA #95 then put her right hand on the Resident #15's forehead and continued to hold Resident #15's hands down while STNA #96 changed the residents incontinence brief. Review of STNA #95's personnel file revealed the STNA was hired on 12/15/22. STNA #95 was in good standings with the Nurse Aide registry and received resident rights and abuse training. There was no other documented concerns regarding abuse in STNA #95's personnel file. Review of STNA #96's personnel file revealed the STNA was hired on 04/23/23. STNA #96 was in good standings with the Nurse Aide registry and received resident rights and abuse training. There was no other documented concerns regarding abuse in STNA #96's personnel file. Review of the facility policy titled, Ohio Abuse, Neglect & Misappropriation, dated 09/02/16 revealed the intent of the facility to provide resident centered care that meets the psychosocial physical and emotional needs and concerns of the residents. Further review of the facility policy revealed the intent of the facility is prevent the abuse, mistreatment, or neglect of residents.

Based on record review and staff interview, the facility failed to ensure a valid Preadmission Screening and Resident Review (PASARR) was completed upon admission to the facility. This affected one (#06) out of one resident reviewed for PASARR. The facility census was 99. Findings Include: Record review for Resident #06 revealed he was admitted to the facility on [DATE]. His diagnoses included, diabetes mellitus (DM)2, lymphedema, essential primary hypertension, anxiety disorder, post traumatic stress disorder (PTSD), adjustment disorder, heart failure, major depressive disorder, and chronic kidney disease stage 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 03/13/24, revealed Resident #06 had severely impaired cognition. Further review for the MDS assessment revealed he required maximum assist with toileting and bathing. Review of the PASARR Review for Resident #06 dated 03/13/24 revealed the facility failed to identify Resident #06's mental health diagnoses of major depressive disorder. Interview on 05/02/24 at 8:18 A.M. with the facility Social Worker (SW) #42 confirmed Resident #06's PASARR dated 03/13/24 was not completed correctly and the residents diagnoses of major depressive disorder was not assessed.

Based on record review, staff interviews and policy review, the facility failed to ensure residents with compromised nutrition status were weighed weekly as ordered. This affected three (#70, #33, and #85) of nine residents reviewed for nutrition. The facility census was 99. Findings include: 1. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia, unspecified obesity, major depressive disorder, and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment completed on 04/11/2024 revealed Resident #70 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the care plan dated 11/04/2022 revealed Resident #70 had potential for altered nutrition, had weight loss, needs for supplementation, and had inconsistent meal intakes. Interventions included identify resident preferences notify provider/family of unplanned weight loss, obtain daily weights as needed, offer substitutions if meal is declined, provide Med pass supplement twice daily as ordered, and provide assistive devices/assistance/diet as ordered. Review of the medical record revealed Resident #70 had physician orders for regular diet, regular texture with thin liquids. Additionally, Resident #70 had an order for weekly weights dated 02/16/2024. Review of the medical record revealed weights were obtained on 02/05/2024 (176.6 pounds), 03/05/2024 (173.8 pounds), 03/22/2024 (173.5 pounds), and 04/03/2024 (172.0 pounds). During an interview on 05/01/24 at 7:46 A.M. Registered Nurse (RN) #36 verified Resident #70's weekly weights were not being completed as ordered. RN #36 stated it looked like when the order was entered, there was no prompt for weekly weights triggered to document in Resident #70's Medication Administration Record (MAR). During a telephone interview conducted on 05/01/24 at 10:05 A.M. Dietitian #98 confirmed Resident #70's weekly weights were not being done as ordered. 44069 2. Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included the following: Alzheimer's Disease with early onset, pure hypercholesterolemia, major depressive disorder, moderate protein-calorie malnutrition, orthostatic hypotension, anemia, and anorexia. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident was assessed to require supervision for eating, moderate assistance for oral hygiene and transfer, and maximal assistance for toileting, bathing, dressing, personal hygiene, and bed mobility. Review of the care plan dated 08/31/21 revealed Resident #33 had the potential for nutritional problems related to Alzheimer's Disease, hypertension, hypercholesterolemia, major depressive disorder, protein-calorie malnutrition, dysphagia, hyperlipidemia, and anemia. Interventions included administering medications as ordered, identifying resident food and beverage preferences, monitor meal intake, provide assistance with meals as needed, and obtain, monitor, and record weights per facility protocol. Review of the weights documented for Resident #33 revealed a weight of 141 pounds on 02/07/24, 137 pounds on 03/07/24, 122 pounds on 04/05/24, and 127 pounds on 05/01/24. Review of the active physician orders revealed an order dated 02/16/24 for weekly weights. Interview on 05/01/24 at 10:14 A.M. via phone with Registered Dietician #98 confirmed weekly weights were not being obtained as ordered for Resident #33. 3. Review of the medical record for Resident #85 revealed an admitted [DATE]. Diagnoses included the following: dementia, vitamin B 12 deficiency anemia, and unspecified protein-calorie malnutrition. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident was assessed to require supervision for eating, oral hygiene, toileting, dressing, personal hygiene, and transfer, moderate assistance for bathing, and was independent for bed mobility. Review of the care plan dated 12/01/23 revealed Resident #85 had the potential for nutritional problems related to dementia, hypertension, mood disorder, vitamin B 12, and unspecified protein-calorie malnutrition. Interventions included identifying resident food and beverage preferences, monitoring meal intake, providing meals per diet order, and providing supplements per order. Review of the active physician orders revealed an order dated 02/16/24 for weekly weights. Review of the weights documented for Resident #85 revealed a weight of 163 pounds on 02/05/24, 164 pounds on 03/05/24, 164 pounds on 03/31/24, 155 pounds on 04/03/24, 154 pounds on 04/30/24, and 164 pounds on 05/01/24. Interview on 05/01/24 at 10:14 A.M. via phone with Registered Dietician #98 confirmed weekly weights were not being obtained as ordered for Resident #85. Review of the undated facility policy titled Resident Height and Weight revealed weights would be obtained monthly or as ordered by the physician or practitioner.

Based on record review, staff interview and review of medication information, the facility failed to ensure residents were free from unnecessary psychotropic medications when the facility administered antipsychotic medications without an adequate indication of use. This affected two (#66 and #349) of five residents reviewed for unnecessary medications. The facility census was 99. Findings include: 1. Review of the medical record for Resident #66 revealed an admitted [DATE] with diagnoses of Alzheimer's Disease, dementia with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and malignant neoplasm of unspecified site of right female breast. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 is cognitively impaired and frequently incontinent of bowel and bladder. Resident #66 has no range of motion impairment in upper and lower extremities, requires touch assistance with eating, oral hygiene, toileting, bathing, bed mobility, transfers, and ambulation, and moderate assistance with dressing. Review of hospital documents for Resident #66 revealed a hospital admitted [DATE], with diagnoses of acute encephalopathy, altered mental status, and dementia associated with other underlying disease with behavioral disturbance. Resident #66 was living with a sister in a home environment at the time of hospitalization and had an order written on 12/01/23 for Seroquel 25 milligrams (mg) by mouth three times daily. It was reported on 01/18/24 that Resident #66 had not been taking the medication as ordered while at home. Review of the physician orders revealed Resident #66 had an order written on 01/24/24 for Seroquel (Quetiapine Fumarate) oral tablet 25 mg-give one tablet by mouth three times a day for depression. On 02/23/24, the order was changed to Seroquel (Quetiapine Fumarate) 25 mg-give one tablet by mouth every morning and at bedtime for dementia with behavioral disturbance, psychosis. Interview on 05/02/24 at 10:50 A.M. with Director of Nursing #38 confirmed Resident #66 is being administered Seroquel for a diagnosis of dementia with behavioral disturbance, psychosis which is not a clinically indicated diagnosis. Review of the 2021 [NAME] Pocket Drug Guide for Nurses revealed Seroquel (Quetiapine Fumarate) has a Black Box Warning (BBW) of do not use in elderly patients with dementia related psychosis as there is an increased risk of cardio vascular (CV) mortality, including stroke or myocardial infarction. Further review revealed Seroquel (Quetiapine Fumarate) is indicated for treatment of schizophrenia, manic episodes of bi-polar disorder, depressive episodes of bi-polar disorder, and major depressive disorder. 2. Review of the medical record revealed Resident #349 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia with agitation, anxiety disorder, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #349 is cognitively impaired and occasionally incontinent of bladder and frequently incontinent of bowel. Resident #349 has no range of motion impairment in upper and lower extremities, requires moderate assistance with eating, oral hygiene, and dressing, maximal assistance with toileting and bathing, and supervision with bed mobility and transfers. Review of the physician orders for Resident #349 revealed an order for Risperdal oral tablet 0.5 mg. (Risperidone), give 1 tablet by mouth two times a day for dementia with behavioral disturbance. Review of the hospital documents for Resident #349 revealed an admitted [DATE] to psychiatric services with diagnoses of aggression aggravated, violent behavior, and dementia. It is indicated Resident #349 was receiving Risperdal 0.5 mg. by mouth two times a day for Alzheimer's dementia with behavioral disturbance prior to hospitalization . Review of the medical record for Resident #349 revealed a Consultant Pharmacist Medication Regimen Review dated 04/17/24 with recommendations in reference to a Celexa order. The facility was unable to provide a Consultant Pharmacist Medication Regimen Review for the Risperdal order and the indication for use. Interview on 05/02/24 at 1:47 P.M. with Regional Nurse #93 confirmed the facilities consultant pharmacist did not review the Risperdal order for Resident #349. Interview on 05/02/24 at 10:50 A.M. with Director of Nursing #38 (DON) confirmed Resident #349 is being administered Risperdal for a diagnosis of dementia with behavioral disturbance which is not a clinically indicated diagnosis. Review of the 2021 [NAME] Pocket Drug Guide for Nurses revealed Risperdal (Risperidone) has a Black Box Warning (BBW) of do not use in elderly patients with dementia as there is an increased risk of cardiovascular (CV) mortality and is not approved for this use. Further review revealed Risperdal (Risperidone) is indicated for treatment of schizophrenia, bi-polar 1 disorder, and bi-polar mania.

Based on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure a resident received timely assistance with missing dentures. This affected one resident (#51) of three residents reviewed for dental care. The facility census was 101. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnosis included, but not limited to, alcohol dependence with alcohol induced persisting dementia. Additional record review revealed the resident's payor source was Medicaid and the resident had a guardian. Review of the Minimum Data Set (MDS) assessment for Resident #51 dated 03/25/23 revealed resident was cognitively intact and required supervision and set up help with activities of daily living (ADLs.) Review of the June 2023 monthly physician orders for Resident #51 revealed an order dated 07/20/20 for resident to have dental consult as needed. Review of the care plan for Resident #51 dated 10/07/20 revealed the resident had oral/dental health problems related to poor oral hygiene, and abnormal mouth tissue. Interventions including the following: monitor, document and report to physician as needed any oral/dental problems needing attention, provide mouth care, coordinate arrangements for dental care, transportation as needed/as ordered. The care plan did not include documentation regarding the presence or absence of dentures. Review of nurse progress note for Resident #51 dated 01/25/23 revealed the resident's guardian set up an outside appointment for resident to meet with a neuropsychologist. Review of nurse progress note for Resident #51 dated 02/06/23 revealed the resident went out of the facility for an appointment. The resident's guardian took him to the appointment and would bring the resident back. An additional progress note dated 02/06/23 for Resident #51, revealed the resident arrived back to the facility from the appointment, and guardian brought resident back to the facility. Review of nutritional assessments dated 03/28/23 and 06/27/23 for Resident #51 revealed they did not include documentation regarding the presence or absence of the resident's dentures. Review of the care conference note for Resident #51 dated 04/18/23 revealed the facility held a meeting with resident, guardian, and the facility staff present. The note did not include documentation regarding resident's missing dentures. Review of social service progress note dated 06/01/23 per Social Service Designee (SSD) #172 revealed she and the Administrator spoke to Resident #51's guardian about his dentures. Resident got lower dentures in 2022 and insurance would only cover dentures every [AGE] years. Guardian was made aware of this. SSD #172 contacted the dentist, and the dentist would reach out to the guardian as well on how to go about replacing resident's dentures. Review of the dental prior authorization for Resident #51 dated 06/16/23 revealed there would be no charge to replace resident's upper denture. Replacement of the lower denture would cost $1200. Interview on 06/28/23 at 12:21 P.M. with the Administrator confirmed she started working with the facility at the end of March 2023 and that sometime near the end of May 2023 Resident #51's guardian told her the resident's dentures were missing. Administrator confirmed SSD #172 told her the dentures got lost when resident went out to a doctor appointment with the guardian. Administrator confirmed in June 2023 the facility got a quote from the dentist on the cost of replacing the dentures. Administrator confirmed the lower dentures cost $1200 and Medicaid would not cover this. Administrator confirmed it was her understanding that the resident/guardian were responsible for paying for the dentures because they got lost when resident was out of the facility with the guardian. Observation on 06/28/23 at 12:52 P.M. of Resident #51 revealed he was edentulous and had no dentures in his mouth or in his room. Interview with Resident #51 at the same time confirmed his dentures got lost a few months ago and he did not remember where or how they got lost. Resident #51 confirmed he was embarrassed by not having teeth and he was upset that the facility had not helped him replace his dentures. Interview on 06/28/23 at 2:41 P.M. with the Director of Nursing (DON) and SSD #172 confirmed Resident #51 was admitted to the facility in 2020 and had upper and lower dentures. SSD #172 confirmed Resident #51 went to a neurology appointment with the guardian on 02/06/23 and when he returned, he had no dentures in his mouth. DON confirmed the facility called the doctor's office, and they did not have Resident #51's dentures. SSD #172 confirmed the facility called the guardian and she did not know what happened with the dentures. The guardian said she had not transported him back to the facility but did not provide information regarding who transported the resident back to the facility. DON confirmed the guardian was upset about the resident's dentures at the care conference on 04/18/23, but it was the guardian's responsibility to replace the dentures since the resident lost them when he was out of the facility. Interview on 06/28/23 at 4:15 P.M. with the Administrator and the DON confirmed Resident #51's payor source was Medicaid and he was admitted with upper and lower dentures. Resident #51's dentures were noted to be missing on 02/06/23 after resident returned from a doctor appointment. The referral to the dentist was dated 06/16/23. The resident's record had no documentation regarding the reason for the delay in referral to the dentist nor the potential effect on the resident of having his teeth missing for several months. The facility had no documentation of investigation regarding how and when the dentures got lost. Review of the undated facility policy titled Denture Loss or Damage revealed dignity and self-esteem may be compromised when the resident does not have their dentures. Speech or communication may also be compromised. For these reasons and more it is imperative that missing dentures be replaced in a timely manner. Dentures that are reported broken or lost shall be replaced with the assistance of facility staff. A referral will be made within three days of the missing or broken dentures reported. Social Service will place a referral for a dental consult within three days. If a referral does not occur within three days, the facility must provide documentation that the resident was assessed for the ability to eat and drink adequately while waiting for dental services and the reason for the delay. An investigation will be performed to determine if loss or damage of the denture was the result of facility neglect or mishandling. The facility will replace broken or lost dentures at the cost to the facility if the investigation reveals that the facility was negligent and/or irresponsible with handling and that the resident had that denture on admission. This deficiency represents non-compliance investigated under Complaint Number OH00143672.

Based on medical record review, observations, staff interview, review of witness statements, review of the police report, review of information from Google Maps, review of a weather report, review of the facility investigative files, review of in-service education, and policy review, the facility failed to complete thorough investigations following resident elopements to prevent additional elopements from occurring. Additionally, the facility failed to update residents' elopement assessments and care plans following elopements. Lastly, the facility failed to identify like-residents at risk for elopement to ensure appropriate interventions were in place to potentially prevent the same actions, situations, and/or practices from occurring in the future. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] at an unknown time when Resident #306, who resided on the west hall, exited the facility's secured unit on the south hall through a thirty second egress alarmed door, which lead to an exterior door to exit the building. Resident #306 was found at 2:40 A.M. approximately three-fourths of a mile away from the facility, which was approximately a 14-minute walk. The Immediate Jeopardy continued when Resident #306 exited the secured unit through the same alarmed door on [DATE] at approximately 8:15 A.M. when Maintenance Supervisor (MS) #370 saw Resident #306 walk by the maintenance window and started running down the driveway. Furthermore, the Immediate Jeopardy continued when Resident #86 exited the secured unit through a thirty second egress door on [DATE] without floor staff's awareness. Moreover, the Immediate Jeopardy continued when Resident #86 exited through a thirty second egress door on [DATE], without staff's awareness, and was found one tenth of a mile from the facility by Receptionist #380. Additionally, the facility failed to follow their elopement policy and did not review and update Resident #86's elopement risk assessment and care plan. This affected two (#86 and #306) of seven residents reviewed for elopement. Lastly, the facility failed to ensure residents who required the use of a mechanical lift were transferred safely with the assessed amount of staff. This affected one (#32) of 13 residents reviewed for transfers. The facility census was 101. Findings include: On [DATE] at 3:46 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #427 were notified Immediate Jeopardy began on [DATE] at an unknown time when Resident #306 eloped from the facility and was found approximately 14 minutes later around 2:40 A.M. Resident #306 was found by Licensed Practical Nurse (LPN) #341 walking down the side of a two-lane busy road with no sidewalks or streetlights approximately three fourths of a mile away from the facility. Resident #306 was wearing black pants, a red t-shirt, and shoes. The temperature in the area was approximately 55 degrees Fahrenheit (F). Resident #306 refused to go back to the facility with staff, and police were called for assistance. Upon Resident #306's return to the facility, the facility had not updated his elopement care plan to prevent recurrence. Additionally, the facility had not identified like-residents to ensure appropriate interventions were in place to potentially prevent future elopements. The Immediate Jeopardy continued when Resident #306 exited the facility without floor staff awareness on [DATE] and was found by MS #370 running down the driveway. Upon Resident #306's return into the facility, the facility had not updated his wandering observation tool to prevent recurrence. Additionally, the facility had not identified like-residents to ensure appropriate interventions were in place to potentially prevent future elopements. The Immediate Jeopardy continued when Resident #86 exited the secured unit through a thirty second egressed door on [DATE] without floor staff's awareness. The Immediate Jeopardy continued when Resident #86 exited through a thirty second egress door on [DATE] without staff's awareness and was found one tenth of a mile from the facility by Receptionist #380. The facility failed to follow their elopement policy and did not review and update Resident #86's elopement risk assessment and care plan. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the DON/Unit Manager (UM)/Designee ensured all residents were accounted for and began to obtain statements from all staff on duty. On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Wandering assessments were updated for all residents, the elopement binders were reviewed, updated, and elopement drills were held. On [DATE], the DON/UM/Designee ensured all residents were accounted for and began to obtain statements from all staff on duty. On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Elopement binders were reviewed, updated, and elopement drills were held. On [DATE], the DON/UM/Designee ensured that all residents were accounted for and began to obtain statements from all staff on duty. On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Elopement binders were reviewed, updated, and elopement drills were held. On [DATE], the DON/UM/Designee ensured that all residents were accounted for and began to obtain statements from all staff on duty. On [DATE], MS #370 assessed all doors and alarms for functionality without noted deficiency. On [DATE], the DON/UM/Designee completed staff education on elopement and completed an elopement drill. Wandering assessments were updated for all residents with no new elopement risks noted. Elopement binders were reviewed. discharged residents were removed from the elopement binders and any new admissions not previously added, were added to the elopement binders. The medical director was notified of each elopement and agreed with intervention to monitor one-to-one. On [DATE], the elopement binders were reviewed for accuracy. Resident #100 was added to the binder due to an elopement in February 2023. On [DATE], all wandering resident assessments were updated with no changes needed. All care plans were validated and updated with no changes needed. All elopement binders were validated with no changes needed. Wandering assessments are completed upon admission, quarterly, with change in condition, and upon any elopement event. Staff have been educated on elopement. Nurses have been educated on accurately completing wandering assessments, care planning, and timely completion of care plans. On [DATE], RDCO #427 provided education with the DON, the UM, and the Administrator on completing a thorough investigation including staff interviews/witness statements with all staff working the dates of the elopements. On [DATE], education was provided by the DON/Designee with all staff regarding elopement risk and facility policy. All newly hired staff will be educated. On [DATE], education was provided by RDCO #427/Designee with the licensed nurse to ensure wander observation tools are completed accurately. On [DATE], education was provided by RDCO #427 with the DON, UM #304, #310, and #314 and the Minimum Data Set (MDS) staff #375 on ensuring care plans are in place regarding those identified at risk. On [DATE], education was provided by RDCO #427 with the DON, UM #304, #310, and #314, the Administrator, Activity Director #322, Activity Staff #319, #329, #336, #337, and #338, Admissions Coordinator #385, and the Electronic Health Records Clerk #387 to ensure elopement binders are up to date with residents at risk for elopement. On [DATE], LPN #350, State tested Nursing Assistant (STNA) #369, Receptionist #380 and Maintenance Supervisor #370 stated they had been educated about elopements and responding immediately or as soon as it was safe to do so when alarms sounded. The Administrator/Designee will conduct elopement drills twice weekly on each shift for four weeks, then once a week on each shift for four weeks, then once a week on each shift every two weeks, then monthly for two months. The DON/Designee will audit the elopement binders on each unit to ensure that all residents in the facility are included twice a week for four weeks, then weekly for four weeks, then every other week for four weeks then random observation thereafter. The RDCO #427 will review the completeness of all elopement investigations to ensure that all staff were educated on elopements, elopement binders are updated, and wandering observation tools were completed and accurate. RDCO #427 will review all staff statements to ensure all staff on duty at the time of elopement have provided thorough statements. This audit will occur for all elopements for three months. All variances will be corrected upon discovery, and additional training/follow-up will be provided as deemed necessary. The DON/Designee will bring the results of the audits to the monthly Quality Assurance Performance Improvement (QAPI) meeting. The results of the audit will be reported, reviewed, and trended for a minimum of six months, then randomly thereafter for further recommendations. Although the Immediate Jeopardy was removed on [DATE], 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 was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #306 revealed an admitted [DATE] with diagnoses including dementia, schizophrenia, and Parkinson's disease. Review of the MDS assessment dated [DATE] revealed Resident #306 was severely cognitively impaired and required supervision with mobility. Review of the most recent wandering observation tool dated [DATE] revealed Resident #306 was not at risk for elopement. Further review of the medical record revealed the facility had not completed a wandering observation tool after the elopement on [DATE]. Review of the elopement care plan for Resident #306 updated on [DATE] revealed the resident was an elopement risk related to wandering behavior, diagnoses of Parkinson's, dementia, schizophrenia, and a history of elopement. Interventions included one-to-one supervision until further notice; care conference with the family to discuss a possible transfer ([DATE]), assess hunger, thirst, ambulation, and toileting needs ([DATE]), complete wandering evaluation upon admission/re-admission, quarterly, and as needed ([DATE]), evaluate for need of secured unit and notify medical provider as needed ([DATE]), notify medical provider and resident representative of behavior changes ([DATE]), provide diversionary activities as needed and redirect when appropriate ([DATE]), and provide structured activities at times of increased elopement risk, diversional tasks, redirection of ambulation pattern, and utilization of safe wandering areas ([DATE]). Review of the nurse progress note dated [DATE] at 3:58 A.M. revealed LPN #415 was alerted by State tested Nurse's Aide (STNA) #349 the door alarm on the south hall was triggered. LPN #415 and STNA #349 went through the alarming door and visualized the main exit door was ajar. LPN #415 and STNA #347 got into their vehicles and drove down the street. Resident #306 was found walking down Springdale Road towards [NAME] Road on the left side approximately a half a mile down the road. The police stopped and helped. Resident #306 was non-cooperative and resisted returning to the facility. Resident #306 was returned by the police. A head-to-toe assessment, neurological checks, vital signs, and nurse's notes were completed. The Director of Nursing (DON) and the family were notified. Review of LPN #341's statement (undated) revealed approximately an hour prior to the incident, Resident #306 was seen on the south hall using the phone. LPN #341 was on lunch when the incident occurred. LPN #341 was heading back from lunch when she saw Resident #306 walking on Springdale Road and called the facility to notify staff and to call the police. Review of STNA #347's statement dated [DATE] revealed at approximately 2:40 A.M., LPN #415 and STNA #420 from west hall came to the south hall to look for Resident #306. STNA #347 began to search for Resident #306. STNA #347 got into his car and drove around the facility looking for Resident #306 but had not found him. STNA #347 drove onto Springdale Road where LPN #341 and STNA #347 found him. STNA #347 did not know how Resident #306 exited the facility because STNA #347 was busy doing rounds and changing other residents. Resident #306 was resistive with staff when trying to bring him back to the facility and made STNA #347 bleed beneath his chin. Review of agency STNA #420's statement dated [DATE] revealed she was alerted by LPN #415 that STNA #349 stated the alarm was going off on the south unit. STNA #349 looked in Resident #306's room, but he was not there. All staff started looking in rooms and hallways and then moved outside of the facility. Resident #306 was found walking down the road. Review of agency staff STNA #425's statement (undated) revealed Resident #306 was walking up and down south hall towards nurse's station, and STNA #425 tried redirecting him to west hall, where he resided, but he refused. STNA #425 asked other staff to help redirect him. STNA #425 went to check on another resident on west hall and noticed Resident #306 was not in his room. STNA #425 asked other staff if they had seen him, and the other staff said no. STNA #425 reported that was when staff started looking for him. Review of Registered Nurse (RN) #318's statement dated [DATE] revealed at 2:40 A.M. she was at north hall nurse's station when the phone rang. The call was from LPN #341 who reported Resident #306 from west hall was walking down Springdale Road, and she needed help to get him back to the facility. RN #318 reported LPN #303 went to help LPN #341 while she called emergency services to meet them on Springdale Road for assistance. RN #318 notified the DON and completed a head count on residents. Review of LPN #303's statement dated [DATE] revealed he received a call from LPN #341 that she found Resident #306 on the road on her way to lunch. LPN #303 went to the road to help bring Resident #306 back to the facility. While trying to bring Resident #306 back to the facility, the police stopped and brought Resident #306 back to the facility. Review of STNA #349's statement dated [DATE] revealed the door alarm on south hall was going off and STNA #349 went to turn off the alarm. STNA #349 went through the alarm door and noticed the door leading outside was open. STNA #349 looked around and had not seen any residents. STNA #349 saw Resident #306 on south hall before the alarm went off, and Resident #306 was nowhere to be found. STNA #349 alerted LPN #415 that Resident #306 got out of the facility. STNA #349 and LPN #415 went back through the door that was alarming and checked the maintenance room and parking lot. LPN #415 got into her car as well as STNA #347 to check the road. STNA #349 stated Resident #306 was found and brought back to the facility. Review of agency LPN #430's statement dated [DATE] revealed she heard door alarms sounding on south hall while she was unclogging a feeding tube in a resident's room. LPN #430 reported as she finished up with resident care, she witnessed LPN #415 and STNA #349 looking for Resident #306. LPN #430 had staff check all rooms and closets. LPN #430 went outside to check the grounds. LPN #415 and STNA #347 got into their cars to search for Resident #306. About twenty-five minutes later, the police and three staff members returned to the facility with Resident #306 in a police car. Review of the police report dated [DATE] revealed a call was placed at 2:43 A.M. for the well-being of Resident #306. On [DATE] at 2:45 A.M. police arrived on scene where Resident #306 was standing in the middle of the road. Staff were unable to get him back to the facility. Police assistance was needed, and Resident #306 was placed into a squad car. On [DATE] at 2:59 A.M. Resident #306 was escorted back to the facility. Review of the in-service provided to staff dated [DATE] revealed staff must immediately react to sounding door alarms. Staff must always investigate to ensure all residents were accounted for and safe. Door alarms may not be deactivated without ensuring all residents had been accounted for. Observations throughout the annual survey revealed the facility's secured door where Resident #306 resided was in working order and alarmed appropriately. Telephone interview on [DATE] at 9:39 A.M., with RN #318 revealed the other nurses went out and looked for Resident #306. RN #318 reported she completed a head count on her unit and notified the DON. RN #318 stated LPN #341 called into the facility and reported Resident #306 was on the road. Telephone interview on [DATE] at 10:09 A.M. with LPN #303 revealed he received a call from LPN #341, who was at lunch, that she saw Resident #306 walking down Springdale Road. LPN #303 reported he turned right out of the facility and met LPN #341 at the gas station. LPN #303 explained he tried to get Resident #306 in his car, but he refused. LPN #303 stated the police were notified and assisted with the return of Resident #306 back to the facility. Telephone interview on [DATE] at 3:31 P.M. with agency STNA #420 revealed she was working west hall where Resident #306 resided. STNA #420 reported Resident #306 got out of the south hall door. STNA #349 came and told LPN #415 that Resident #306 had gotten out of the facility. STNA #420 explained all staff started looking for Resident #306 on south unit, then checked the other units, and checked outside the facility. STNA #420 reported someone called the facility and said Resident #306 was walking down Springdale Road. Telephone interview on [DATE] at 3:36 P.M. with agency LPN #415 revealed Resident #306 was ambulatory on his own and typically walked from unit to unit at night. LPN #415 reported Resident #306 would walk to the south hall and would usually come back after 10 minutes. LPN #415 was working west hall on [DATE], where Resident #306 resided. LPN #415 heard the alarm going off on the south hall but could not recall how long the alarm sounded. STNA #349 notified LPN #415 that Resident #306 got out of the building. LPN #415 and STNA #347 got into their cars and drove in opposite directions down the road looking for Resident #306. LPN #415 reported the streets were very dark at that time. LPN #415 went the opposite direction of where they found Resident #306. Telephone interview on [DATE] at 8:14 A.M. with STNA #349 revealed she saw Resident #306 prior to entering a resident's room to provide care. STNA #349 reported when she came out of the resident's room, the door alarm had been sounding. STNA #349 turned off the alarm and went through the alarming door to see the door to the outside was ajar. STNA #349 looked around and in Resident #306's room but had not seen him. STNA #349 alerted LPN #415 that Resident #306 was missing. STNA #349 and staff looked for Resident #306. LPN #415 and STNA #347 got into their cars and headed down the road. Telephone interview on [DATE] at 8:23 A.M. with agency STNA #425 revealed Resident #306 exited the building when she was providing resident care. STNA #425 reported LPN #341 called into the facility and said Resident #306 was on the street. STNA #425 could not recall any other pertinent information about the incident. Telephone interview on [DATE] at 5:55 P.M. with LPN #341 revealed she had seen Resident #306 prior to the incident wearing different clothes. LPN #341 reported she went to lunch at approximately 2:00 A.M. LPN #341 stated she was on her lunch break when she saw Resident #306 walking down Springdale Road. LPN #341 noticed a man walking down the side of the road with black pants, a red t-shirt, and shoes on. LPN #341 slowed down because she was surprised to see someone walking in a short-sleeved shirt because it was chilly. LPN #341 slowed down and realized it was Resident #306. LPN #341 put on her hazards and yelled his name, but she said he didn ' t slow down or look her way. LPN #341 called into the facility and notified staff that Resident #306 was walking down Springdale Road and to call the police. LPN #341 reported when other staff arrived on scene, she left because she had a passenger in her car. LPN #341 explained the Assistant Director of Nursing (ADON) called her on [DATE] to obtain her statement regarding the incident on [DATE] because the facility misplaced her original statement. Review of the nurse progress note dated [DATE] at 8:32 A.M. revealed Resident #306 exited through the south hall door. RN #314 was notified Resident #306 possibly got out of the facility. RN #314 immediately went out to the parking lot where Resident #306 was with the Maintenance Supervisor (MS) #370. Resident #306 was assisted back to his room. Resident #306 was assessed from head-to-toe without injury noted. The daughter was notified, and Resident #306 was placed on one-to-one supervision. Review of the in-service provided to staff dated [DATE] revealed staff were trained regarding elopement prevention and elopement management. Review of the former Business Office Manager (BOM) #431's statement dated [DATE] revealed she was walking into work around 8:20 A.M. when she saw Resident #306 running out of the maintenance door on the side of the building. As former BOM #431 started towards him, MS #370 immediately followed Resident #306 trying to redirect him. Resident #306 continued to run. Former BOM #431 continued to move towards him to prevent him from going further away from the facility. MS #370 was able to reach him, and Resident #306 stopped running. RN #314 came out to the parking lot and escorted Resident #306 back into the facility. Review of MS #370's statement dated [DATE] revealed at approximately 8:20 A.M., he heard the alarm go off next to the maintenance door. MS #370 saw Resident #306 walking down the sidewalk toward Springdale Road. MS #370 caught up to Resident #306 and was able to redirect him toward the entrance of the facility. Interview on [DATE] at 3:18 P.M. with MS #370 revealed he had not recalled the door alarm going off, but he looked out the window and saw Resident #306 by the south door outside of the facility. MS #370 reported that by the time he got up from the desk and over to the door, Resident #306 was running down the hill on the driveway. Resident #306 was fully clothed but had no shoes, only socks on. MS #370 was shocked Resident #306 did not fall. MS #370 revealed Resident #306 made it approximately 40 to 50 yards from the facility. MS #370 stated the former Executive Director #440 and former BOM #431 met him out in the parking lot for assistance with Resident #306. MS #370 could not recall if any floor staff assisted. Interview on [DATE] at 1:39 P.M. with RDCO #427 verified Resident #306's wandering observation tool was not updated after the elopement on [DATE]. Review of an online map per google maps revealed the gas station near where Resident #306 was found on [DATE] was approximately 0.7 miles from the facility and approximately a 14-minute walk. Review of the online weather resource https://www.accuweather.com/en/us/[NAME]/45243/september-weather/2214995?year=2022 revealed the air temperature was 55 degrees F for the morning of [DATE] for the city in which the facility was located. 2) Resident #86 was admitted on [DATE] with diagnoses including dementia, hereditary neuropathy, hypertension, disorientation, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #86 had severe cognitive deficits and required supervision with locomotion. Review of the wandering observation tool dated [DATE] revealed Resident #86 was not a risk for elopement. Review of the next wandering observation tool dated [DATE] revealed the resident was an elopement risk. Review of the wandering observation tool dated [DATE] revealed the resident was an elopement risk. Review of the wandering observation tool dated [DATE] revealed it was completed with incorrect information revealing the resident was not an elopement risk. Review of a nursing note dated [DATE] at 3:51 P.M. revealed RN #343 was notified by staff Resident #86 was out in the parking lot walking. Resident #86 was seen by the receptionist at that time and was assisted back to the unit by staff and assessed with no injuries. Notifications were made and one-to-one supervision was initiated. Review of the investigation related to the elopement on [DATE] revealed there was no timeline to determine the root cause of how Resident #86 eloped. Resident #86 had no updated plan of care with interventions to prevent elopement. Review of STNA #329's witness statement dated [DATE] revealed two Residents (#16 and #103) were at the south ambulance entrance door touching the door which set off the alarm at the time. Resident #91 informed STNA #329 that Resident #86 was outside. Everyone began looking for Resident #86. Review of a physician order dated [DATE] revealed Resident #86 was placed on increased supervision one-to-one until [DATE] every shift for resident safety. Review of RN #389's witness statement dated [DATE] revealed Resident #91 informed her and another staff member that Resident #86 was outside. RN #389 immediately addressed the situation, running outside to get him. Resident #86 was standing by the cars in the parking lot. No alarms were going off when first notified of the incident. Resident #86 was redirected back to the facility without difficulty. Review of STNA #320's witness statement dated [DATE] revealed she had seen Resident #86 at the south door trying to leave the unit, STNA #320 redirected Resident #86 away from the door and he walked towards the west unit. Review of the former Licensed Social Worker (LSW) #428's witness statement dated [DATE] revealed following the incident, the south ambulance door was alarming with no staff around. LSW #428 and maintenance disarmed the door and ensured the door was locked. Review of STNA #363's witness statement dated [DATE] revealed she saw Resident #86 on the north unit trying to open the door and she redirected him back to his unit. Review of LPN #429's witness statement dated [DATE] revealed Resident #86 kept pushing on the door trying to open it and she asked him to stop pushing on the door. Review of Receptionist #380's witness statement dated [DATE] revealed she was walking past her desk and saw Resident #86 outside and got help. A follow-up interview on [DATE] at 11:57 A.M. with RDCO #427 verified there was no wandering observation tool completed related to the elopement on [DATE] until [DATE]. Review of the nursing note dated [DATE] at 7:40 P.M. revealed Resident #86 was found in the parking lot by Receptionist #380 with a coat, hat, and shoes on. Resident #86 was alert, verbal, and redirected back into the building with no behaviors. Resident #86 was placed on increased one-to-one supervision. Review of the investigation related to the elopement dated [DATE] revealed the incident was not thoroughly investigated and there was no timeline of events to determine a root cause. Review of Receptionist #380's witness statement dated [DATE] revealed she was taking her trash out and walked around the front of the facility and spotted Resident #86 walking towards the end of the driveway. Review of STNA #348's witness statement (undated) revealed she was providing care to Resident #54 and heard the back door alarm. After STNA #348 finished providing care she checked outside, reset the alarm, and informed the nurse. Review of Nurse Practitioner (NP) #430's note dated [DATE] revealed Resident #86 was seen for follow-up due to dementia with wandering behaviors/elopement. Resident #86 was an [AGE] year-old male with dementia and eloped from the facility over the weekend. Resident #86 was found in the parking lot and redirected back to the facility without difficulty. The plan was to continue one-to-one supervision and follow-up with the psychiatrist as needed for behaviors. Observation and interview on [DATE] at approximately 9:00 A.M., the door on the south unit was alarming continuously and when the surveyor questioned what the noise was, RN #399 stated it was the door alarm and it alarmed all the time because it was broken, and the facility can ' t seem to get it fixed. Observation on [DATE] at 12:15 P.M. with MS #370 revealed the door beyond the keypad 30 second egress door on the south unit, was opened, leading to an open outdoor area. The door was opened and immediately sounded a loud alarm, which sounded for 30 seconds. After 30 seconds, the alarm silenced automatically. No staff were observed to respond to the alarm. MS #370 verified no staff responded to the alarm. Observation on [DATE] at 12:18 P.M. with MS #370 revealed the keypad 30 second egress door on the south unit was pulled and immediately alarmed. The door continued to alarm and was pulled for 30 seconds and then released. The door continued to alarm for an additional three minutes before STNA #325 arrived at the door to respond to the alarm. MS #370 verified staff had not responded to the alarming door for over three minutes. Interview on [DATE] at 12:15 P.M. during observation with MS #370, he reported all egress doors when the alarm was set off was a 30 second delay before the door would open. Interview on [DATE] at 12:18 P.M., two STNAs #302 and #325 stated they could hear the alarm at the nurse's station. STNAs #302 and #325 said there were not enough staff to concentrate on all the door alarms. Interview on [DATE] at 12:30 P.M. with STNA #348 she said she was working on [DATE] when Resident #86 eloped from the building. STNA #348 was in a room two rooms down from the door he eloped from performing care on Resident #54 when she heard the door alarm sound. STNA #348 stated she finished care before checking the alarm which was approximately five minutes. After resident care was completed, she went to the door and looked outside, did not see anyone, reset the door alarm, and went back to work. STNA #348 reported there was not enough staff to check on Resident #86 frequently. Interview on [DATE] at 1:14 P.M. RDCO #427 stated the expectation was for staff to respond to the door alarms as quickly as possible. Follow-up interview on [DATE] at 2:22 P.M., RDCO #427 stated if staff were in the middle of caring for a resident, the expectation would be to immediately ensure the resident was in a safe position, respond to the door alarm, and then return to complete their task. Interview on [DATE] at 1:45 P.M. with Receptionist #380 she stated it was getting close to the end of her day on [DATE] so she bagged up her trash, took it out to the dumpster in the back, walked around to the front of the facility and noticed Resident #86 more than halfway down the driveway that was about a tenth of a mile that led to a busy two-lane road without sidewalks and a blind curve. Receptionist #380 stated she started yelling his name to get him to stop, redirected him back inside, and called the DON right away. During an observation on [DATE] at 1:50 P.M. with Re [TRUNCATED]

Based on observation, interview, review of manufacturer recommendations, and policy review, the facility failed to ensure expired medications were removed from the medication carts. This affected two medication rooms out of two observed, and two medication carts out of three carts observed for expired medications. This had the potential to affect all residents who reside in the facility. The facility census was 101. Findings include: Observation on 04/24/23 at 1:22 P.M. of the west unit cart one with Licensed Practical Nurse (LPN) #315 revealed there was one bottle of stool softener that expired on 10/2022, a bottle of calcium carbonate (a supplement) expired on 11/2022, and a bottle of senna plus (a laxative) that expired on 03/2023. Observation on 04/24/23 at 1:23 P.M. with LPN #315 revealed three vials of tuberculin serum were opened and undated. Interview on 04/24/23 at the time of the observation with LPN #315 verified the expired medications. Observation on 04/24/23 at 1:25 P.M. with LPN #426 of the Mount [NAME] medication cart revealed one bottle of geridryl (antihistamine) expired on 03/2023 and the north wing medication room revealed one vial of tuberculin serum with an open date of 01/12/23. Interview on 04/24/23 at 1:25 P.M., during the observation with LPN #426 verified the medications were expired. Interview on 04/24/23 at 1:30 P.M., with the Assisted Director of Nursing (ADON) #314 verified the medications had expired and were not removed from the carts or rooms. Review of the policy titled Storage of Medications Policy, dated 08/2020 revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory and disposed of according to procedure for medication disposal, and reordered from the pharmacy if a current order exists. Review of the manufacturer recommendation for tuberculin revealed the vial should be discarded after 30 days of opening.

Based on record review, observations, and staff interviews, the facility failed to ensure dietary staff were competent to fulfill their responsibilities. This had the potential to affect 100 residents who received food from the kitchen. The facility identified one resident (#24) who did not consume any food from the kitchen. The facility census was 101. Findings include: Interview on 04/19/23 at 5:49 P.M. with Culinary Aide #342 revealed he would put his hand in the water from the dishwasher and make an educated guess regarding the temperature. Review of a performance evaluation for Culinary Aide #346 completed on 11/07/22 indicated Culinary Aide #346 had an N for no on the evaluation for testing of parts per million (PPM) for the low temperature dishwasher. Review of a performance evaluation for Culinary Aide #342 completed on 11/08/22 indicated Culinary Aide #342 had an N for no on the evaluation for testing of PPM for the low temperature dishwasher. Interview on 04/20/23 at 3:04 P.M. with Cook #372 revealed he was not aware of how to test PPM. Interview on 04/20/23 at 3:13 P.M. with Culinary Aide #342 revealed he was unaware of how to test the PPM for the dishwasher. Interview on 04/20/23 at 3:15 P.M. with Culinary Aide #346 revealed he was unaware of how to test the PPM for the dishwasher. Observation on 04/20/23 at 3:24 P.M. of Cook #372 revealed he used a green colored bucket for sanitizing solution. Observation on 04/20/23 at 3:27 P.M. of Cook #372 revealed he tested a bucket filled with sanitizing solution with a test strip that showed the solution read at 7.81 milliliters per liter. Interview with Cook #372 at the time of the observation indicated the recommended level was 1.17 milliliters per liter. Interview on 04/20/23 at 4:31 P.M. with Mobile Dietary Manager #435 revealed he felt the dietary staff needed additional training regarding their assigned responsibilities. Mobile Dietary Manager #435 stated green buckets should be used for general purpose cleaning and red buckets should be used for sanitizing solution. Mobile Dietary Manager #435 revealed the facility was using Sink & Surface Cleaner Sanitizer Test Strips from Ecolab. Interview on 04/25/23 at 10:47 A.M. with Culinary Director #353 revealed he conducted staff evaluations every six months for dietary employees. Culinary Director #353 indicated he would follow-up with a dietary employee if that employee had not successfully met all competencies on the evaluation. Culinary Director #353 stated he had no documentation of any follow-ups he had conducted with dietary staff as needed based on their performance evaluations. Review of the facility's list of residents who do not receive food from the kitchen revealed Resident #24 did not receive food from the kitchen. Review of the Ecolab Sink & Surface Cleaner Sanitizer Test Strips How-To Guide, dated 2020, revealed the approved dilution range of the test strips were between 2.11 and 4.30 milliliters per liter.

Based on record review, observations, staff interviews, review of facility policies, and review of manufacturer guidelines, the facility failed to ensure the refrigerator was functioning properly, foods were covered and dated, and the chemicals used for sanitation were at the recommended level. This had the potential to affect 100 residents who receive food from the kitchen. The facility identified one resident (#24) that did not consume any food from the kitchen. The facility census was 101. Findings include: Observations on 04/17/23 from 6:35 P.M. to 6:45 P.M. of the walk-in refrigerator revealed undated fruit cocktail, undated ricotta cheese, and an uncovered and undated metal container of sausage. The attached walk-in freezer had an undated bag of frozen ravioli, and two plastic sealable bags of an unknown frozen meat that was undated. Interview with Culinary Aide #455 at the time of the observations confirmed the undated and uncovered items in the refrigerator and freezer. Observation on 04/19/23 at 11:59 A.M. of the walk-in refrigerator revealed a metal container of uncovered chicken breast, which was confirmed by Healthcare Services Group District Manager #450 at the time of the observation. Observation on 04/19/23 at 12:00 P.M. of the walk-in refrigerator revealed the temperature was 60 degrees Fahrenheit (F), which was confirmed by Healthcare Services Group District Manager #450 at the time of the observation. Interview on 04/19/23 at 12:30 P.M. with Maintenance Technician #362 confirmed the walk-in refrigerator had been turned off. Interview on 04/19/23 at 1:30 P.M. with Healthcare Services Group District Manager #450 revealed the refrigerator had been off at least two to three hours for the temperature to be that high. Observation on 04/20/23 at 4:31 P.M. of a sanitizing bucket revealed the test strip indicated the sanitizing concentration was between 5.86 and 7.81 milliliters per liter. Interview with Mobile Dietary Manager #435 at the time of the observation confirmed the level should be between 2.11 to 4.30 milliliters per liter. Review of the facility's list of residents who do not receive food from the kitchen revealed Resident #24 did not receive food from the kitchen. Review of the Ecolab Sink & Surface Cleaner Sanitizer Test Strips How-To Guide, dated 2020, revealed the approved dilution range of the test strips were between 2.11 and 4.30 milliliters per liter. Review of the Healthcare Services Group policy titled Equipment, revised 09/2017, revealed all food service equipment would be clean, sanitary, and in proper working order. Review of the Healthcare Services Group policy titled Food Storage: Cold Foods, revised 04/2018, revealed all perishable food items would be maintained at a temperature of 41 degrees Fahrenheit or below. The policy also revealed that all foods would be stored wrapped or in covered containers and would be labeled and dated.

Based on record review, staff interview, and policy review, the facility failed to have a developed Quality Assurance and Performance Improvement Plan (QAPI). This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the facility QAPI program revealed the facility had not developed a QAPI plan for review. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the facility had no documentation of a developed QAPI plan. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the QAPI program is ongoing, comprehensive, and encompasses the full range of services offered by the facility.

Based on record review, staff interview, and policy review, the facility failed to develop and implement action plans to improve performance or address concerns as part of their Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the facility QAPI program revealed the facility had no documentation regarding any performance improvement plans initiated to addressed identified concerns. Interview on 04/26/23 at 2:54 P.M. with the Director of Nursing (DON) revealed the facility had addressed concerns such as falls and wound management in their clinical meetings. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the facility had no documentation related to performance improvement activities as part of their QAPI program. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed that the facility would track, investigate, and monitor adverse events that must be investigated every time they occur, and action plans will be implemented to prevent a recurrence. The policy also revealed the facility would respond to identified quality and safety concerns using a performance improvement plan developed by the QAPI committee.

Based on record review, staff interview, and policy review, the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of QAPI meeting minutes revealed the facility last conducted a QAPI meeting on 08/30/22. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the last documented QAPI meeting was on 08/30/22. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the facility would conduct a QAPI meeting every month where required members would be present, and any trends or other facility data that required review would be addressed.

Based on record review, staff interview, and policy review, the facility failed to ensure all staff were properly trained on the facility's Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the facility records revealed the facility had no documentation of staff training related to QAPI. Interview on 04/26/23 at 4:19 P.M. with the Administrator confirmed the facility had no evidence of QAPI training records for staff. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the facility staff would receive training on QAPI upon hire and annually.

Based on medical record review, family and staff interview, the facility failed to ensure resident assessments were completed accurately. This affected two residents (#59 and #50) of 21 residents reviewed for assessments. The facility census was 101. Findings include: 1. Review of the medical record of Resident #59 revealed an admitted [DATE]. The resident transferred to the hospital on 11/01/22 and readmitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, dementia, generalized anxiety disorder, hypotension, schizophrenia, and anorexia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had severely impaired cognition. The resident required extensive assistance for bed mobility and transfers. The resident was assessed as receiving tube feeding (K0510B) during the assessment period. Review of Resident #59's medical record revealed no evidence of Resident #59 receiving tube feeding during the assessment period. Interview on 04/18/23 at 1:17 P.M., Resident #59's responsible party stated Resident #59 had never received tube feeding, to her knowledge. Interview on 04/24/23 at 3:17 P.M., Registered Dietitian (RD) #400 verified tube feeding (section K0510B) was incorrectly checked as yes. RD #400 further stated Resident #59 definitely had not received tube feeding during that assessment period. 2. Review of the medical record of Resident #50 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia without behavioral disturbance, type II diabetes mellitus, osteoarthritis, iron deficiency anemia, and hyperlipidemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 had severely impaired cognition. The resident required supervision for ambulation. The resident was coded as having no significant weight changes during the assessment period. Review of Resident #50's weights revealed, on 04/11/23, Resident #50 weighed 125.5 pounds. On 03/02/23, Resident #50 weighed 135 pounds. On 02/03/23, Resident #50 weighed 135 pounds. On 01/14/23, Resident #50 weighed 135 pounds. On 01/03/23, Resident #50 weighed 140 pounds. On 12/03/22, Resident #50 weighed 145 pounds. On 11/03/22, Resident #50 weighed 145 pounds. On 10/04/22, Resident #50 weighed 165 pounds. On 09/05/22, Resident #50 weighed 165 pounds. Further review of Resident #50's weights revealed the resident experienced an 18.1 percent weight loss between 09/2022 and 03/2022. Interview on 04/24/23 at 3:13 P.M., RD #400 verified Resident #50 had a significant weight loss during the 6 months prior to the assessment reference date and verified she had not correctly coded for Resident #50's weight loss for the 6 month period.

Based on record review, staff interview, review of facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement physician-recommended interventions for residents with pressure ulcers, failed to thoroughly assess resident's skin and failed to identify pressure ulcers until they had already reached an advanced stage. This resulted in Actual Harm to Resident #105 who was admitted to the facility without pressure ulcers and developed an avoidable unstageable pressure ulcer to his right heel. This affected one (#105) of three residents reviewed for pressure ulcers. The facility census was 99. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE]. Diagnoses include inguinal hernia, emphysema, transient ischemic attack (TIA), cerebral infarction, atherosclerosis, vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), osteoarthritis, major depressive disorder, and hypertension (HTN). Review of the Minimum Data Set (MDS) assessment for Resident #105, dated 11/13/22, revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Resident #105 was coded as negative for the presence of pressure ulcers. Review of the pressure ulcer risk assessment for Resident #105 dated 11/07/22 revealed the resident was at risk for the development of pressure ulcers. Review of the admission skin assessment for Resident #105 dated 10/31/22 revealed there was an area to the resident's right heel. There was no further description of the area. Review of the nurse progress note for Resident #105 dated 11/01/22 revealed the resident's heels were soft and an order was given to apply skin preparation to resident's heels daily. Review of the weekly skin assessments for Resident #105 dated 11/07/22, 11/14/22, and 11/21/22 revealed the resident's skin was intact. Review of the care plan for Resident #105 initiated on 11/02/22 and updated on 11/28/22 revealed the resident was at risk for altered skin integrity related to need for assistance with ADL's, and fragile skin. Interventions included the following: administer medications and treatments as ordered, barrier cream post incontinent episodes, complete skin at risk assessment upon admission/readmission, complete weekly skin checks, ensure residents are turned and repositioned, monitor meal intake, monitor vital signs, peri care as needed to prevent skin breakdown. Review of the care plan revealed it did not include specific interventions to reduce or eliminate pressure to the heels such as to float the heels. Review of wound nurse practitioner (NP) #99 assessment for Resident #105 dated 11/28/22 revealed had an unstageable pressure ulcer to his right heel which measured 1.82 centimeters (cm) in length by 1.40 cm in width. The wound bed was covered with 50 percent (%) slough/eschar tissue. Further review of the note revealed the resident needed to wear heel boots while in bed as much as possible. NP #99 gave an order dated 11/28/22 to cleanse pressure ulcer to right heel with normal saline, apply Medihoney to wound bed and cover with border foam once daily. Review of the November 2022 Treatment Administration Record (TAR) for Resident #105 revealed the treatment to the right heel was signed off as ordered. There was no order for heel boots. Review of the December 2022 TAR for Resident #105 revealed there was an order dated 12/19/22 for the resident to float heels while in bed with soft boots. Order was signed off for 12/20/22 and 12/21/22. Resident #105 was discharged from the facility on 12/21/22. Interview on 01/26/22 at 2:22 P.M. with Licensed Practical Nurse (LPN) #230 confirmed she had completed the admission skin assessment for Resident #105. LPN #230 confirmed the area to Resident #105's right heel was not open. LPN #230 stated the area was a discolored area to the resident's entire right heel. LPN #230 confirmed she did not recall if she had reported the area to anyone. Interview on 01/26/22 at 2:34 P.M. with Registered Nurse (RN) #235 confirmed she had observed Resident #105's right heel on 11/01/22 and it was not discolored or open. RN #235 confirmed Resident #105's bilateral heels were soft and that's why the order for skin preparation was obtained. Interview on 01/26/22 at 11:02 A.M. with the Director of Nursing (DON) confirmed Resident #105 was admitted to the facility without pressure ulcers and developed an unstageable pressure ulcer to his right heel which was first identified on 11/28/22. The DON further confirmed the weekly skin checks performed by licensed nurses on 11/07/22, 11/14/22, and 11/21/22 revealed Resident #105's skin was assessed as intact with no new areas noted. The DON confirmed the wound NP #99 made the recommendation for soft boots to the resident's heels while in bed on 11/28/22 but the facility did not implement the recommendation until 12/20/22, the day prior to resident's discharge from the facility. The DON confirmed the pressure ulcer to Resident #105's right heel was not identified until it had reached a classification of unstageable with the presence of slough/eschar to the wound bed. Review of the facility policy titled Skin and Wound Care Management Overview dated 04/20/17 revealed the facility staff would prevent resident skin impairment and would promote the healing of existing wounds. The staff would identify and implement interventions to prevent and and treat potential skin integrity issues. The staff would evaluate, and document identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment. Application of treatment protocols would be based on clinical best practice standards for promoting wound healing. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence's. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPUAP guidelines dated 2014 page 115 revealed ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. This deficiency represents non-compliance investigated under Complaint Number OH00139054.

Based on medical record review, review of the hospital records, staff interviews, and review of the facility policies, the facility failed to provide a resident with timely care and treatment to a wound which was found on 07/31/22. This resulted in Immediate Jeopardy when Resident #10 was placed at a potential risk for serious life-threatening harm and injury when Resident #10 went without a physician ordered wound treatment and no wound team follow up from 07/31/22 to 08/07/22. Resident #10 developed maggots and gangrene on his right second toe resulting in [CONDITION(S)] (bone infection) and required a partial amputation to the right foot on 08/15/22. This affected one (#10) of three residents reviewed for wound care at the facility. The facility identified 13 residents with non-pressure related wounds currently residing at the facility. The facility census was 103. On 09/01/22 at 12:10 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) #74 were notified that Immediate Jeopardy began on 07/31/22 when the facility did not provide timely care and treatments to Resident #10's right second toe. There was no physician notification or new treatment ordered on 07/31/22 when the right second toe had an open ulcer. The wound team did not complete a weekly skin assessment on 07/28/22 due to Resident #10 having [CONDITION(S)] three times a week which required him to leave the facility. On 08/02/22, an unidentified nurse assessed the open area on Resident #10's right second toe and did not notify the physician and did not obtain a new treatment order for the open area. On 08/07/22, Licensed Practical Nurse (LPN) #350 assessed Resident #10's second toe after Resident #10 asked for LPN #350 to complete a dressing change on it. Resident #10's second toe had maggots on it and had a strong odor to it. Nurse Practitioner (NP) #250 was notified on 08/07/22 at 4:23 A.M. of maggots in Resident #10's toe wound, and NP #250 ordered to send Resident #10 to the emergency room (ER). NP #250 documented the limb was threatening, and Resident #10 was transferred out urgently. The hospital notes revealed Resident #10 had [CONDITION(S)], gangrene to the second and third toe, and required immediate surgery to prevent [CONDITION(S)] from spreading to save the limb. Resident #10 required partial amputation to right foot, intravenous antibiotics, and a wound vac (vacuum-assisted closure for wound healing) for the [CONDITION(S)]. The Immediate Jeopardy was removed on 08/09/22 when the facility implemented the following corrective actions: On 08/07/22, Resident #10 was sent to the hospital and did not return to the facility. On 08/09/22, the DON, Wound Nurse #100 and/or Designee completed a whole-house skin audit on every resident and every resident was assessed. There were no new skin issues discovered. Existing skin issues were reviewed to ensure there was a treatment order in place, and weekly skin assessments were completed. On 08/09/22, staff education was completed with licensed nurses regarding the facility's policy titled Skin Care and Wound Management Overview as it related to weekly skin assessments, interventions to prevent the development and worsening of wounds and identifying wounds and risk. Education was completed with licensed nurses regarding the facility's policy titled Physician Notification for Change in Condition Reporting as it related to change of skin condition, notification of physician for treatment and interventions and physician notification for change of condition policies. Ongoing education will be provided for agency staff who are new to the building. On 08/09/22, the DON/Designee will conduct a weekly skin check audit by visual assessment of all in-house resident's skin condition one time a week for four weeks, then once a week every other week for four weeks, then monthly for two months. On 08/09/22, the DON/Designee will complete an audit and observe three residents daily for four weeks, then three times a week every week for four weeks, then every other week for four weeks, then random observation thereafter to ensure interventions and treatments are in place per physician orders based on resident needs and care planned for the prevention of development and/or worsening of wounds. On 08/09/22, the DON/Designee will complete an audit and observe three residents daily for four weeks, then three times a week every week for four weeks, then every other week for four weeks, then random observation thereafter to verify that the physician has been notified of any change of skin condition and any identified concerns were immediately addressed. On 08/09/22, all variances will be corrected upon discovery, and additional training/follow up with be provided as deemed necessary. The DON/Designee will bring the results of the audits to the monthly Quality Assurance Performance Improvement (QAPI) meeting. The results of the audits will be reported, reviewed, and trended for six months, then randomly thereafter for further recommendations. Review of the facilities in-service sign-in-sheet for skin care and wound management and change in condition, and documentation of education revealed all licensed nursing staff were educated on 08/09/22. All resident head-to-toe assessments and audits of the physician treatment orders were completed for the past 30 days. Although the Immediate Jeopardy was removed on 08/09/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan, including their new policy, and are monitoring to ensure on-going compliance. Findings include: Review of Resident #10's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively impaired. Resident #10 required extensive one-person physical assistance for bed mobility, dressing, and bathing. Resident #10 utilized a wheelchair for ambulation. Review of the Podiatry Consults dated 01/24/22 at 2:45 P.M. revealed Doctor of Podiatric Medicine (DPM) #200 had tried to see Resident #10 but the resident had refused care at the visit. On 03/14/22 at 6:00 A.M., DPM #200 had not seen Resident #10 because he did not go to the facility this date. On 05/09/22 at 12:45 P.M. and on 07/11/22 at 12:45 P.M., DPM #200 had not seen Resident #10 because the resident was out of the facility at [CONDITION(S)] and was unavailable. Review of the physician's orders dated 07/11/22 through 08/07/22 revealed Resident #10 had treatment orders to his open areas on his right shin. There were no physician orders for a treatment to his right foot or toes during this time period between 07/11/22 and 08/07/22. Review of the plan of care dated 07/21/22 revealed Resident #10 had diabetes mellitus Type II. Interventions included to administer medications and insulin, podiatry consult and weekly skin checks. Resident #10 was also at risk for impaired skin integrity related to open area (venous ulcer) to his right shin and had a history venous ulcer to his right lower extremity. Interventions included to refer Resident #10 to wound nurse practitioner for weekly rounds, administer treatment as ordered, complete skin at risk assessments upon admission, readmission, quarterly and as needed, complete weekly skin checks, and evaluate existing wound daily for changes. Review of the skin and wound note dated 07/28/22 at 3:02 P.M. documented by Wound Nurse Practitioner #225 revealed Resident #10 was out of the facility at [CONDITION(S)] during wound care rounds. Resident #10's skin was not assessed. Additionally, there was no skin and wound assessment by Wound Nurse Practitioner #225 the week of 08/04/22. Review of the progress note dated 07/31/22 at 3:45 P.M. by an unknown agency nurse revealed Resident #10 informed the writer that he had an area noted to his right toes that was bleeding. Unknown agency nurse assessed the second and third toes and noted an open area. The second toe had a circular open area to the front of the toe and an area noted in between second and third toe. The area was cleansed, patted dry, band aid applied, and a message was left with the on-call physician. Resident #10 expressed his concern that he was a diabetic, so he was worried. The nurse administered the treatment to his right shin and there were no signs or symptoms of infection noted. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weekly skin assessment dated [DATE] at 12:31 A.M. by an unknown agency nurse revealed there were no new skin issues since the last documented skin check. Review of the weekly skin assessment dated [DATE] at 2:04 A.M. documented by an unknown agency nurse revealed Resident #10 had skin conditions or changed, ulcers, and injuries. Resident #10 had area identified on the right second toe that measured 1.0 centimeter in length by 1.5 centimeter wide by unable to determine depth (UTD) with moderate clear drainage. This was stated as a new non-pressure skin condition. A treatment was completed upon assessment and Resident #10's right foot was cleansed with normal saline, patted dry, covered with dry clean dressing and wrapped from toes to skin with kerlix. Review of Resident #10's medical record from 08/02/22 to 08/06/22 revealed there was no physician notification and no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 08/07/22 revealed Licensed Practical Nurse (LPN) #350 was asked by Resident #10 to do a treatment to his right leg and foot. LPN #350 performed the treatment on his right leg and foot, and LPN #350 noticed Kerlix was partially hanging off his right leg and foot. LPN #350 was told by Resident #10 that he was unsure when the last treatment was done to his right leg and foot. LPN #350 noticed a strong odor when doing the treatment and then called the on-call physician. Review of the progress note dated 08/07/22 at 4:23 A.M. with Nurse Practitioner (NP) #250 revealed NP #250 was notified on 08/07/22 at 4:23 A.M. of maggots in Resident #10's toe wound, and NP #250 ordered to send Resident #10 to the emergency room . NP #250 documented Resident #10 with known wound and live maggots were noted. The limb was threatening, and Resident #10 was transferred out urgently. Review of the hospital admission documentation dated 08/07/22 at 6:32 A.M. revealed Resident #10 had gangrene to the second toe on the right foot with some associated maggots in between his toes. A Doppler was completed to his bilateral lower extremities that was concerning for underlying vascular disease. Resident #10 had white blood cell count that was mildly elevated. An x-ray of the right foot demonstrated underlying [CONDITION(S)]. Resident #10 was started on intravenous antibiotics and contacted podiatry. Resident #10 was admitted to the hospital. Review of the hospital documentation dated 08/13/22 at 6:54 A.M. by Physician #400 revealed the right second toe had gangrene with maggots in addition to early gangrenous changes of the third toe. Review of the hospital's Operative Report dated 08/15/22 by DPM Surgeon #300 revealed the preoperative and postoperative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The operation performed was an incision and drainage of multiple abscesses with excisional debridement of necrotic soft tissue and bone on the right foot. An open trans metatarsal (partial) amputation of the right foot was completed. A wound vac with normal saline to be applied Tuesdays and Fridays due to the extent of the infection. Telephone interview on 09/01/22 at 10:20 A.M. with Medical Director (MD) #600 stated he was not aware of Resident #10's wound to his right toes until after Resident #10 was discharged to the hospital. MD #600 initially stated the agency nurse who discovered the wound called the on-call physician and received an order to place a dry dressing to be changed daily until Resident #10 could be seen by the wound team. However, the nurse did not transcribe the order onto Resident #10's medical record. Resident #10 was already being seen weekly by the wound team for a vascular ulcer to the right shin and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound NP (#225) was also aware that Resident #10 was supposed to be seen first because he had to leave for [CONDITION(S)] that morning. All residents were seen by podiatry every six months, and more frequently if there were specific concerns. Staff notified residents when the podiatrist was coming and put them on the list if they wanted to be seen. The facility could not force them to be seen if they did not want to see the podiatrist. Skin assessments were scheduled weekly for every resident and treatments were completed according to orders. Ideally what should have occurred in this situation, the nurse should have notified the on-call physician and initiated treatment orders until Resident #10 could be assessed by the wound team. MD #600 stated if he had been notified; he would have ordered a daily dressing with either Santyl or Medi-honey applied to be covered with a dry dressing. Nursing would have been expected to assess the wound and document the wounds characteristics daily. The agency nurse, unidentified, put a dry dressing on the wound, but did not implement a treatment order. The nurse manager, unidentified, was mainly to blame because she should have looked at the wound the next day, knowing the resident's condition, and made sure the orders were in place. Staff assumed the wound team would follow. Interview on 09/01/22 at 2:56 P.M. with Wound Nurse Practitioner (NP) #225 stated she was seeing Resident #10 for his right shin that would not heal. Wound NP #225 stated no one at the facility had notified her of Resident #10 having any new skin issues to his right foot or toes. Wound NP #225 stated Resident #10's wounds would not heal properly because of the [CONDITION(S)]. Wound NP #225 stated the facility would get his wound to heal up, then [CONDITION(S)] caused it to stretch and reopen at the shin. Wound NP #225 stated that [CONDITION(S)] asked for additional days because of [CONDITION(S)] and water retention. Interview on 09/08/22 at 1:18 P.M. with LPN #350 revealed Resident #10 had come to her on 08/07/22 to have his treatment done on his right foot. LPN #350 stated she looked in the electronic chart to find no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #350 stated when she undressed the right foot, the kerlix was hanging off the right foot, and she had found Resident #10 had many maggots. LPN #350 stated there were so many maggots that some fell off his right foot, and she killed them with sterile gauze dressings. LPN #350 explained to emergency medical service not to take the dressing off the right foot of the resident, because LPN #350 did not want to embarrass the confused, nice resident. During a telephone interview on 09/12/22 at 1:35 P.M. with Wound NP #501 she stated she took over Wound NP #225's assignment on 07/28/22. Wound NP #501 stated Resident #10 was not on her list of residents to see on 08/03/22. Wound NP #501 stated she missed Resident #10's treatment to his shin on 08/03/22. Wound NP #501 stated it was probably her fault for not seeing Resident #10's wound on 08/03/22. Wound NP #501 verified she was unaware of Resident #10's new area to his second right toe. Review of the facility's policy titled Skin Care and Wound Management Policies and Standard Procedures, last reviewed on 05/30/19, revealed to review and select the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Physician Notification for Change in Condition Reporting, last reviewed on 08/01/16, revealed it was the facility's policy to promote resident centered care by using evidence-based practice for notification of providers for changes in conditions and when to report signs symptoms to the physician, nurse practitioner, and/or physician assistant. The nurse will report change in conditions based on the following criteria for reporting to the physician/provider, which included any wound that will not stop bleeding or that exposes subcutaneous tissue would require reporting immediately. Non-immediate would be the next office day which included any minor recent wound now developing redness, swelling, or pain. This deficiency substantiates Complaint Numbers OH 941 and OH 951.

Based on observation, record review, and staff interview, the facility failed to provide nutritional supplementation as recommended by the Registered and Licensed Dietitian (RD, LD), and ordered by the physician, to improve the nutritional status of a resident identified with significant weight loss. This resulted in actual harm when Resident #36 was identified as having a 7.99 percent (%) significant weight loss in one month and did not receive nutritional interventions as ordered. In addition, the facility failed to provide nutritional interventions as ordered and identified on a second resident's (#20) care plan that placed the resident at risk for more than minimal harm. This affected two (#36 and #20) of seven residents reviewed for Nutrition. The facility census was 94. Findings include: 1. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility completed an admission minimum data set assessment (MDS 3.0) of Resident #36's cognitive and physical functional status dated 09/12/19. The 09/12/19 assessment identified the resident as having poor cognitive skills and requiring the extensive assistance of one staff person to eat. The resident's weight was documented as 102 pounds (lbs.) and height was 61 tall. Review of Resident #36's physician orders [REDACTED]. The resident was also ordered to receive the following nutritional supplements as ordered: med pass 2.0 supplement 240 milliliters, three times a day, ordered on [DATE], fortified pudding at lunch and supper ordered 09/24/19, frozen nutritional treat in the afternoon, ordered 09/24/19, nutritional juice drink with meals ordered 10/03/19. A diet order change was implemented on 11/01/19 for a pureed consistency diet with nectar consistency liquids. Review of Resident #36's weight history revealed the resident weight was 102.6 lbs. on 09/30/19, and when weighed on 10/30/19, the resident's recorded weight was 94.4 lbs. This represented a loss of 7.99 percent (%) of the resident's body weight in a 30-day period. Review of Resident #36's comprehensive plan of care, reviewed and revised on 10/24/19, revealed a current plan of care to address the resident's nutritional problem. The care plan developed by RD, LD #150 identified the resident as having a significant weight loss over the past 30 days, and having increased nutrient needs for weight stability. The goal was for the resident to maintain her weight within normal limits for the resident, with no signs or symptoms of malnutrition, and consuming 50-100% of her meals daily through the next review date. Interventions included providing and serving her diet as ordered, providing and serving supplements as ordered included med pass 2.0, 240 ml's three times a day, super (fortified) pudding at lunch and dinner daily, and super (fortified) cereal at breakfast. The nutritional interventions did not include the physician ordered frozen nutritional treat in the afternoon, or nutritional juice drinks with meals. Review of Resident #36's dietary progress noted revealed an entry by RD, LD #150 on 10/24/19. RD, LD #150 documented she spoke with nursing regarding the resident's recent significant weight loss. The resident had a 5% weight loss over the last 30 days. Resident #36 had also recently had hip surgery, so RD, LD was trying to determine if appetite loss was related to that, or if there were other reasons for appetite loss. Resident's intake was varied, but she takes her med pass supplement well daily. Resident #36 required some assistance with feeding. RD, LD #150 added [MEDICATION NAME] 15 milligrams daily (to stimulate appetite) related to varied weight loss and varied intake and would continue to monitor weight and intakes. Review of Resident #36's (MONTH) and (MONTH) 2019 medication administration records (MARs) revealed nursing staff were checking off daily the resident was provided with the fortified pudding every day during the lunch time meal. None of the other physician ordered nutritional supplements were noted on the MARs with the exception of the med pass supplement which was being provided. Resident #36 was observed on 11/04/19 at 12:35 P.M. through 1:05 P.M. during the lunch meal. She was eating in the unit dining room, sitting with other residents. The resident was served a pureed diet with nectar thick liquids. The resident ate very slowly, took small bits, and chewed for an extended period of time with each bite. She consumed 25%-50% of the meal served. There were no nutritional supplements of any kind served with her meal. Resident #36 was observed during the evening meal in the unit dining room on 11/05/19 at 5:56 P.M. The resident was feeding herself a pureed diet with nectar thick liquids. The resident stated her lunch was good. There were no nutritional supplements of any kind served with her meal, and her tray card did not specify any nutritional supplements were to be served with her meal. Resident #36 was observed during the lunch meal in the unit dining room on 11/06/19 at 12:56 P.M. feeding herself a pureed diet with nectar thick liquids. There was a State tested Nurse Aide (STNA) sitting across from her, STNA #44. STNA #44 reported nursing provided residents with supplements unless it was the frozen one frozen nutritional treat, the special pudding (fortified pudding), or the special juice drink (nutritional juice drink), as those come from the kitchen with the resident ' s meals. STNA #44 verified Resident #36 was not provided with any nutritional supplements with her lunch and verified the tray card did not specify the resident was to have any nutritional supplements. During an interview conducted with RD, LD #150 on 11/07/19 at 11:02 [NAME]M., she stated the resident's orders regarding the supplements, which were supposed to come from the kitchen, had not been entered into the meal tracker systems, thus they were not added to the tray card to notify dietary staff to place the items on the resident's tray. RD, LD #150 stated the only supplement the resident would have been receiving was the med pass nutritional supplement that was ordered and provided by nursing staff during medication administration. She verified the resident was not receiving any of the ordered and care planned nutritional supplements other than the med pass supplement provided by nursing. RD, LD #150 communicated that if nursing staff were marking the resident as receiving the fortified pudding with lunch daily, that was not an accurate reflection of what had occurred. An interview was conducted with the Director of Nursing on 11/07/19 at 11:59 [NAME]M. regarding the observations of Resident #36 not receiving her nutritional supplements as ordered, including the fortified pudding, and documented from nursing staff the resident had been receiving it daily in the (MONTH) and (MONTH) 2019 MARs. She verified it was not appropriate for nursing staff to check off the resident had received the fortified pudding, when they in fact did not. 2. Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The facility completed an admission MDS assessment of Resident #20's cognitive and physical functional status dated 08/30/19. The 08/30/19 assessment identified the resident as having significant cognitive impairments and being able to feed himself with only supervision by staff. The resident was assessed as being 5'10 tall and weighing 131 lbs. Review of Resident #20's physician orders [REDACTED]. The resident was also to receive fortified pudding with lunch and supper ordered 09/25/19, a frozen nutritional treat in the afternoon ordered 09/25/19, nutritional juice drink with meals three times daily ordered 10/03/19. Review of Resident #20's weight history revealed that he weighed 130.5 lbs. on 08/25/19 and weighed 135.2 lbs. when weighed on 11/05/19. Review of Resident #20's comprehensive plan of care initiated 08/27/19, current through 03/03/20, revealed a plan of care to address the resident's nutritional needs. The plan of care developed by RD, LD #150 specified the resident had a nutritional problem related to recent weight loss, visible wasting (hollow cheekbones, visible collar bone, loss of fat pads under eyes) and low body mass index of 19.5, indicating risk for being underweight. The goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight within normal limits for his height, no signs or symptoms of malnutrition, consuming 50-100% of meals, and tolerate supplements as ordered, through the next review date. Interventions included, providing and serving his diet as ordered, and providing the following supplements as ordered: med pass 2.0, 240 ml's three times a day, frozen nutritional treat in the afternoon, super (fortified) pudding at lunch and dinner, and nutritional juice drink three times a day with meals. Resident #20 was observed on 11/05/19 at 6:06 P.M. in the unit dining room finishing eating his supper meal and drinking coffee. He had consumed greater than or equal to 75% of the meal served. The resident did not have any supplements, and his tray card did not indicate that he was to have any supplements with his meal. An interview was conducted with STNA #75 who stated Resident #20 does not get any supplements, he eats pretty well, and the facility gives supplements to resident's who don't eat well. An interview was conducted with LPN #42 on 11/06/19 at 11:18 [NAME]M. LPN #42 stated the med pass supplement was provided by nursing and nurses document the amount consumed in the MAR. LPN #42 stated as for other items like nutritional pudding frozen treat or nutritional juices, they come up on resident trays from the dietary department, and nursing check the MAR indicated [REDACTED]. Resident #20 was observed on 11/06/19 at 12:22 P.M. eating lunch in a unit dining room. The resident was served a regular diet with milk and juice, and no nutritional supplements. Activity Staff (AS) #303 stated supplements were provided by nursing or dietary, not when served their meal on the unit. AS #303 verified she served the resident his food, he did not have any supplements, and his tray card did not specify the resident was to have any supplements. An interview was conducted with Dietary Manager (DM) #113 on 11/06/19 at 12:26 P.M. revealed DM #113 was present in the unit dining room where Resident #20 was eating his lunch. DM #113 stated the dietary staff in the kitchen put nutritional supplements including fortified pudding, frozen supplement, and nutritional juice drinks on the resident ' s meal trays, and nursing provides the med pass supplement during med pass. An interview was conducted with Licensed Practical Nurse (LPN) #56 on 11/06/19 at 12:48 P.M. LPN #56 was supervising the dining room where Resident #20 was eating lunch. LPN #56 stated the resident received a med pass supplement only, which was provided by nursing. LPN #56 stated if they did get anything else like a frozen supplement, it would come from the kitchen. LPN #56 verified the resident did not get any supplements with his meal. Review of Resident #20's (MONTH) and (MONTH) 2019 MARs revealed nursing staff were documenting daily the resident was being provided with fortified pudding at lunch and dinner each day, frozen nutritional treat in the afternoon, and nutritional juice drink with meals three times daily. However, none of those nutritional supplements had been provided to the resident at meal time as the ordered supplements had not been added to his tray card. Nursing staff were documenting the resident was provided with the med pass 2.0 supplement three times daily and were recording how much he consumed. A nurse had documented the resident received all the physician ordered supplement designated to come from the kitchen during the noon meal on 11/06/19. An interview was conducted with RD, LD #150 on 11/06/19 at 2:41 P.M. stated the ordered supplements which were to be provided to Resident #20 by the dietary department had not been added into the meal tracker systems, which would result in the resident not being provided with the supplements. She stated dietary staff would not have known to add the supplements to Resident 20's meal tray. An interview was conducted with the Director of Nursing on 11/07/19 at 11:59 [NAME]M. regarding the observations of Resident #20 not receiving his nutritional supplements as ordered, including the fortified pudding, frozen treat, and nutritional juice drink, and that nursing staff had been checking off the resident had been receiving it daily in the (MONTH) and (MONTH) 2019 MARs. She stated that it was not appropriate for nursing staff to be checking off the resident received the supplements when they did not.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility self-reported incident (SRI) including investigation, observations, staff and resident interviews and review of facility Abuse, Neglect, and Misappropriation policy, the facility failed to ensure a resident was free from physical abuse. This resulted in actual physical harm when Resident #5 was physically abused by Resident #7 and subsequently required hospital evaluation and three sutures to a [MEDICAL CONDITION]. This affected one (#5) of four residents reviewed for abuse. The facility census was 96. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed severely impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility, toileting, personal hygiene, limited assistance was required with transfers, and supervision with eating and locomotion. Resident #5 did not require any mobility devices. Review of care plan dated 07/07/17 revealed Resident #5 had a potential for mood problems related to disease process (Alzheimer's, dementia with behaviors, [MEDICAL CONDITION] disorder and [MEDICAL CONDITION]), and medication side effects. Resident #5 may have difficulty communicating wants/needs related to [DIAGNOSES REDACTED]. Resident #5 had a history of [REDACTED]. Resident #5 also required a secured unit due to [DIAGNOSES REDACTED]. Behaviors exhibited included episodes of wandering on the unit with potential for poor decision-making abilities and poor safety awareness. Review of nursing progress note dated 01/27/19 at 7:24 P.M. revealed Resident #5 picked up another residents' glasses and walked away. The other resident followed Resident #5 and struck Resident #5 in the forehead with a plastic coffee cup. Resident #5 was assessed for injury and had a four centimeter (cm) by three cm bruise with a one cm laceration to the forehead. Resident #5 was placed on one to one observation, family and physician were notified, and Resident #5 was transported to the hospital for further evaluation. Resident #5 returned to the facility at 10:02 P.M. laughing and in good spirits, accompanied by family, with three sutures to the forehead. On 01/28/19, Resident #5 was evaluated for psychiatric hospitalization , was unable to recall the incident on 01/27/19, and did not meet criteria for hospitalization . Review of hospital after visit summary dated 01/27/19 revealed Resident #5 was diagnosed with [REDACTED]. Follow up care revealed to remove sutures in five to seven days. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly MDS dated [DATE] revealed intact cognitive skills for daily decision making, supervision was required with all activities of daily living (ADL's) except for extensive assistance with toileting and personal hygiene. A cane/crutch was utilized for mobility. Review of care plan dated 07/15/17 revealed Resident #7 was at risk for fluctuations in mood/behavior related to [DIAGNOSES REDACTED]. Resident #7 required a secured unit due to poor safety awareness secondary to [DIAGNOSES REDACTED]. Review of care plan dated 06/07/18 revealed Resident #7 had the potential to demonstrate verbally abusive behaviors related to dementia. While on outings, Resident #7 could have verbal outburst if not given immediate gratification for wants. Interventions dated 06/07/19 included to intervene before agitation escalated and guide Resident #7 away from source of distress. Intervention dated 09/30/18 included to encourage Resident #7 to ask for assistance if another resident had his/her belongings. Review of nursing progress note dated 01/27/19 at 7:33 P.M. revealed Resident #7 was on the floor by another residents' chair with his legs extended and Resident #7 was holding his/her hands on their head. Resident #7 reported hitting his/her head on chair. The incident was witnessed by State tested Nursing Assistant's (STNA's). Resident #7 was assessed for injuries and had a half cm bruise to the back of head. First aid provided, notifications made, neurological checks initiated, and Resident #7 was placed on one to one observation pending transfer to hospital for psychiatric evaluation. Review of nursing progress note dated 01/28/19 at 4:20 A.M. revealed Resident #7 returned from the hospital, was medically cleared, and did not meet criteria for psychiatric admission. Review of post fall risk assessment dated [DATE] revealed Resident #7 reported another resident took his/her glasses and this resident pushed Resident #7 upon attempting to retrieve the glasses. Review of facility SRI dated 01/27/19 revealed on 01/27/19 at 6:50 P.M. residents were eating dinner in the dining room when Resident #5 picked up Resident #7's eyeglasses off the table. Staff were in route to intervene when both residents began pushing each other and Resident #7 struck Resident #5 in the forehead. Both residents were placed on one to one supervision until transferred to the hospital for evaluation. Both residents were evaluated by psychiatry, medications were reviewed, and dining room seating was changed. Review of facility investigation witness statements for SRI dated 01/27/19 by STNA #20 revealed Resident #7 walked towards Resident #5 and yelled to put his/her glasses down. Resident #5 attempted to back Resident #7 away and Resident #7 was hitting Resident #5 in the head with a cup. Staff responded immediately but both Residents fell to the floor prior to the arrival of staff. Review of undated witness statement by STNA #35 revealed while cleaning up the dining room from dinner, Resident #7 was observed walking towards Resident #5 telling this resident to give back the glasses. Resident #7 pushed Resident #5 whom pushed back. Resident #7 then hit Resident #5 numerous times in the forehead. Both residents fell to the floor by the time staff was able to intervene. Review of witness statement dated 01/27/19 by STNA #44 revealed while feeding another resident, Resident #7 yelled don't take my glasses. Upon turning around, Resident #7 was observed swinging a coffee cup and hitting Resident #5 in the head and Resident #5 was on top of and hitting Resident #7. Residents were separated by staff and the nurse was notified. Review of witness statement dated 01/27/19 by STNA #47 revealed while assisting another resident eat, Resident #7 was heard arguing with another resident about a pair of glasses. The other resident began hitting Resident #7 while Resident #7 hit the other resident several times in the head with a cup. The other resident fell on top of Resident #7 and staff responded and separated the two residents. Observation on 03/02/19 at 12:17 P.M. revealed Resident #7 was seated at a table in the common area of the south unit, laughing and interacting appropriately with other residents. Interview with Resident #7 on 03/02/19 at 12:20 P.M. denied any conflicts with other residents or anyone hurting him/her at the facility. Resident #7 denied ever hitting another resident at the facility and reported one fall related to a little misunderstanding with another resident as the other resident had a dementia problem. Resident #7 reported kindly attempting to get glasses back from another resident whom took them, when the other resident pushed him/her, this other resident fell on top of him/her and was hitting him/her. Resident #7 reported still having a coffee cup in his/her hand, as they were in the dining room, and used the cup to get the other resident off. Staff were in the dining room at the time of the incident and pulled the other resident off from on top of Resident #7. Observation on 03/02/19 at 3:19 P.M. revealed Resident #5 was in the west common area playing bingo independently with activities. Interview with Resident #5 after the activity revealed a confused mental status and inability to answer simple questions. Resident #5 ambulated independently without assistive devices and returned to the south unit verbally directed by another resident. At 3:40 P.M., Resident #5 was observed independently roaming around the south unit. Interview on 03/02/19 at 4:17 P.M. with the Administrator reported on 01/27/19 Residents #5 and #7 were eating dinner in the dining room when Resident #5 got up and took Resident #7's eyeglasses. Both residents started yelling at each other, Resident #7 got up to retrieve the eyeglasses, both residents pushed each other, fell to the floor, and Resident #7, whom still had a coffee cup in his/her hand, hit Resident #5 in the forehead. The incident was witnessed by staff present in the dining room, whom immediately responded, but the incident happened within seconds. After the incident the residents were assessed for injuries, both residents were transferred to the hospital for further evaluation and returned to the facility. The Administrator confirmed Resident #5 required suturing to a [MEDICAL CONDITION]. Dining room seating was changed and now both residents seek each other out. Skin audits were completed on all residents, staff and other residents were interviewed without any abnormal findings. All staff received education and behavior monitoring was being conducted on all units. Interview on 03/20/19 at 9:52 A.M. with STNA #35 reported during dinner on 01/27/19, Resident #5 wandered into the dining room and started talking to Resident #7 while Resident #7 finished eating. Resident #7 yelled those are my glasses. Due to the angry tone and loudness, all the staff looked over. Both residents were standing next to each other. Resident #7 was aggressive and pushed Resident #5 while attempting to grab the pair of glasses. Resident #7 had a coffee mug and hit Resident #5 in the forehead with it. Both residents then fell to the floor. Staff immediately responded and while attempting to separate the two residents, Resident #7 again hit Resident #5 in the forehead with the coffee mug. Resident #5 was fighting back. Interview on 03/20/19 at 10:04 A.M. with STNA #44 reported during dinner on 01/27/19 Resident #7 yelled at Resident #5 to give him/her their glasses. When STNA #44 turned around, Resident #5 was on top of Resident #7 on the floor and Resident #7 was hitting Resident #5 in the forehead with a coffee cup. Staff immediately responded and separated the two Residents who were assessed for injuries by the nurse. Review of facility Abuse, Neglect and Misappropriation Policy revised 02/01/17 revealed it was the intent of the facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property. The definition of abuse included the willful infliction of injury. Physical abuse included hitting, slapping, pinch, kick or flicking with fingers or striking in any manner that is demeaning. As a result of the incident, the facility took the following actions to correct the deficient practice by 02/28/19: · Immediately following the incident on 01/27/19, Residents #5 and #7 were assessed for injuries and were maintained on one-to-one staff supervision while at the facility for 24 hours. · On 01/27/19, skin audits were completed on all residents whom resided on the south unit by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #88. There were no other concerns identified regarding abuse. · On 01/27/19, Resident #5 was transported and evaluated at a local hospital and received treatment for [REDACTED]. · On 01/28/19, Resident #5 was evaluated for psychiatric hospitalization . · On 01/28/19, Resident #7 was transported and evaluated at a local hospital. · On 01/29/19, an audit tool was developed by the Administrator to include monitoring meals for escalating behaviors by the Administrator, DON, ADON #88, Staff Development Coordinator (SDC) #102, and Social Service Designee (SSD) #109, Maintenance Director (MD) #115, Human Resource (HR) #121, Business Office Manager (BOM) #121, and Registered Nurse (RN) #130 of two meals, three times a week for one month and then monthly. Audits of dining room meals were completed on 01/29/19, 01/31/19, 02/01/19, 02/03/19, 02/05/19, 02/06/19, 02/09/19, 02/10/19, 02/12/19, 02/16/19, 02/17/19, 02/19/19, 02/20/19, 02/24/19, 02/26/19 and 02/28/19. Audits were reviewed by the Administrator during daily morning meetings and no additional concerns were identified regarding abuse. · On 02/01/19, all nursing staff had received training by the DON, ADON #88, SDC #102, and SSD #109 on abuse policies, preventing escalating behaviors, and dining room experience. · Observations of dining rooms on 03/02/19 at 8:49 A.M. and 9:01 A.M. and on 03/20/19 at 9:20 A.M. revealed residents received appropriate staff supervision. · Interviews on 03/02/19 with Licensed Practical Nurses (LPN's) #16, #17, STNA's #20, #21 and on 03/20/19 with STNA's #35 and #44 were able to identify types of abuse and procedures for escalating behaviors and abuse allegations. They reported they received training on abuse policies and procedures, escalating behaviors, and dining. · On 03/20/19, three (#6, #7 and #8) additional residents were sampled and reviewed for abuse. No concerns were identified. · On 03/20/19, review of the facilities SRI's revealed there were no further concerns identified regarding abuse. This deficiency substantiates Complaint Number OH 745.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on staff interviews, review of facility self-reported incident, review of law enforcement statement and record review, the facility failed to ensure one (#12) of three residents reviewed for injury of unknown origin received appropriate transfer from a wheelchair to a bed. Actual harm occurred when Resident #12 suffered a fractured fibula and tibia following an improper transfer by facility staff. This had the potential to affect all 90 residents residing in the facility who required assistance with transfers at the time of the survey. Findings include: Review of the closed medical record for Resident #12 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment and required a total two-person assist for bed mobility and was an extensive two-person assist for transfers. Resident #12 was coded as non-ambulatory and used a wheelchair. Review of the resident's plan of care for activities of daily living (ADL) self-care performance deficit revealed it was related to [MEDICAL CONDITION], limited mobility, and medications. This focus indicated a need for two-person assistance with transfers using the Hoyer lift. Review of the facility initiated Self-Reported Incident (SRI) Control Number 6 revealed an injury of unknown origin had occurred to Resident #12 on [DATE]. It was reported to the Director of Nursing (DON) on [DATE] that Resident #12 was sent to the emergency room due to the appearance of a displaced left lower leg and discoloration to the front of the foot. An interview with State tested Nursing Assistant (STNA) #183 revealed she had pivoted Resident #12 by herself from her wheelchair to her bed the night prior on [DATE]. Review of the facility's Occurrence Report completed on [DATE] at 5:30 A.M. by Licensed Practical Nurse (LPN) #125 revealed it was reported to the nurse the resident's left lower leg appeared to be displaced. Upon assessment, the resident's left lower leg was red, with purple discoloration noted to the front of her foot, scant blood to the right side of her ankle, and her foot was noted to be limp when calf was slightly elevated. The resident was sent out by emergency 911. The nurse noted the resident had been resting quietly all of night shift. The resident did not yell out or exhibit any visible signs or symptoms of pain or discomfort. The report listed Resident #12 as non-verbal and unable to give a statement. The report identified the root cause was staff did not follow the plan of care. A review of the law enforcement statement for Case #,[DATE], written by Detective #184 revealed STNA #183 reported Resident #12's injury on [DATE] at 5:30 A.M. The statement revealed the Administrator reported to the investigating officer, STNA #183 admitted she had transferred Resident #12 from her wheelchair to her bed by herself, without any assistance from staff. STNA #183 told the Administrator she had lifted Resident #12's legs onto the bed, took off her pants and bilateral inflatable Posey boots, and noted no reaction to pain with the transfer. The Administrator stated STNA #183 provided perineal care at 10:45 P.M., 1:30 A.M., and 5:30 A.M. The Administrator stated STNA #183 said when she went in at 5:30 A.M. to get Resident #12 ready for the day and went to place socks on Resident #12's feet, she noticed her left leg had some discoloration and a bruise had formed on the top of her foot. The Administrator stated STNA #183 notified Licensed Practical Nurse (LPN) #125 of the injury. Both the Administrator and the Regional Director of Operations #185 agreed in the interview with the detective that the injury to Resident #12 could have occurred during the transfer. The statement from the DON revealed she did not know how the injury had occurred, agreed the transfer could have caused the injury, and Resident #12 would not have caused the injury to herself. The detective's statement revealed in an interview with the surgeon who performed the orthopedic surgery on Resident #12, the leg injuries occurred from a twisting motion, causing a spiral fracture(s) and could have been caused by an improper transfer from a wheelchair to the bed. The surgeon stated the only other possible cause for the injury would be if there were side rails on Resident #12's bed and she was rolled from one side to another, causing her leg to get stuck. The surgeon stated there would not be a lot of force necessary to cause the injury due to Resident #12's medical history. In an interview on [DATE] with LPN #125, she revealed STNA #183 called her into Resident #12's room at 5:30 A.M. and showed her the injury, which she described as having bruising and the foot was off to one side like it was broken. LPN #125 agreed Resident #12 could not have caused the injury to herself. LPN #125 stated to the detective STNA #183 should have used the mechanical Hoyer lift to transfer Resident #12. LPN #125 stated the injury could have occurred during the transfer of Resident #12. In STNA #183's statement to the detective, she stated she put Resident #12's wheelchair next to the bed, faced Resident #12, put her arms under Resident #12's arms, picked her up, twisted to the side, and set Resident #12 on the bed. STNA #183 stated she then held under Resident #12's legs and back to transition her to the bed. STNA #183 demonstrated to the detective how Resident #12 was transferred. Once in bed, STNA #183 stated she removed both Posey boots, left her socks on, and did not notice any injury. STNA #183 reported to the detective she checked on Resident #12 several times throughout the night, but when she went to get Resident #12 ready for the day and went to change her socks, she observed Resident #12's foot hanging to the side, and immediately notified LPN #125. STNA #183 acknowledged to the detective she should not have transferred Resident #12 by herself and she required a two-person lift, she was supposed to use a standing lift, which required two-person to operate, even though one person could do it. STNA #183 stated Resident #12's feet were positioned between her feet as she lifted Resident #12 from the wheelchair. The detective's statement concluded the injury most likely was caused by STNA #183's failure to properly transfer Resident #12 and failure to follow policy on proper lifting procedure. Review of Resident #12's hospital medical record revealed a progress note on [DATE] at 10:13 A.M. written by the hospital admitting physician stated to admit Resident #12 for left tibial fibula fracture, with a [DIAGNOSES REDACTED]. A progress note on [DATE] at 11:33 A.M. by the orthopedic surgeon revealed a [DIAGNOSES REDACTED]. Review of the facility's investigation of Resident #12's injury of unknown origin, dated [DATE], revealed STNA #183 reported the injury of unknown origin to LPN #125, who was the nurse assigned to the SR. The Administrator interviewed all the staff who had been assigned to Resident #12 for the 24 hours prior to the discovery of the injury. STNA #183 admitted to lifting Resident #12 from the wheelchair to the bed by herself and without the use of a Hoyer lift. Administrator stated STNA #183 was immediately suspended pending the outcome of the investigation. STNA #183 ultimately resigned prior to termination by the facility. The investigation revealed Resident #12 required an open reduction with internal fixation of an open, spiral [MEDICAL CONDITION] tibia and fibula. Resident #12 was discharged from the hospital following surgery to another long-term care facility, where she expired four days later. A phone interview with LPN #125 on [DATE] at 9:35 A.M. verified she worked the night shift from [DATE] to the morning of [DATE] and Resident #12's nurse. LPN #125 stated Resident #12 was non-verbal and just laid in bed. LPN #125 stated STNA #183 called her to Resident #12's room, stating the Resident #12's leg did not look right. LPN #125 stated she looked at Resident #12's leg and foot, realized there was discoloration and deformity and she sent Resident #12 to the hospital. LPN #125 stated she heard STNA #183 tell the Director of Nursing (DON) she transferred Resident #12 by pivot by herself from the wheelchair to the bed. LPN #125 stated it was not usual for STNA #183 to transfer residents by herself, and she didn't know why the STNA #183 didn't get assistance with transferring that night. An attempt to interview STNA #183 during the survey was unsuccessful. An interview with the Administrator on [DATE] at 6:30 A.M. verified Resident #12 should have been transferred by a mechanical lift with another staff person to assist her. Interview with the DON on [DATE] at 7:28 A.M. verified STNA #183 transferred Resident #12 improperly. The DON verified Resident #12 should have been transferred by a mechanical lift with another staff person to assist her. As a result of this incident, the facility took the following actions to correct the deficient practice by [DATE]: · On [DATE], STNA #183 was suspended until she voluntarily resigned on [DATE], prior to termination by the facility. · On [DATE], the Administrator and the Director of Nursing conducted an entire in-house audit of all residents to ensure no unreported injuries. · By [DATE], the physical therapy department assessed all residents to ensure for proper transfer status and documented findings in the resident's medical record and on their Kardex. · By [DATE], all nursing staff were educated on the use of mechanical lifts, where to locate the information in resident's plan of care including transfer care, and all nursing staff had return demonstration of mechanical lift use prior to caring for any residents. · On [DATE], the Director of Nursing began audits of observing staff transfers being completed appropriately. This deficiency substantiated Control Number OH 328 and Complaint Number OH 315 and OH 288.