Every finding on record at Continuing Healthcare at Forest Hill

Based on record review, observations, interviews, and policy review, the facility failed to ensure food was served in form to meet residents' needs. This affected one resident (#2) of three residents reviewed for specialized diets. The facility census was 69. Findings include:Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia and dysphagia. Review of orders revealed Resident #2 had an order dated 09/23/24 for a regular diet and texture would be mechanical soft with pureed meats and thin consistency liquids. Review of a care plan dated 02/17/26 revealed Resident #2 had nutritional problems or potential nutritional problems related to presence of chronic disease, a mechanically altered diet, malnutrition risk, and need for supplements. Goals included being free from complaints of hunger or thirst and accepting food as desired and tolerated. Interventions included but were not limited to monitor/document/report to provider as needed for signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appearing concerned at meals; and provide and serve diet as ordered. Review of a minimum data set assessment dated [DATE] revealed Resident #2's cognition was severely impaired, she had no swallowing disorder signs and symptoms, and required maximum assistance for eating. Observation on 04/01/26 at 8:20 A.M. revealed Resident #2 was eating at a table in a common area and being fed by a certified nursing assistant (CNA) #102. Resident #2 had a bowl of oatmeal, scrambled eggs, and a bowl of what appeared to be mechanical soft ham. When asked what Resident #2's diet should be, CNA #102 stated she receives mechanical soft except her meat which is pureed. CNA #102 was asked if the ham appeared pureed or if it appeared chunky and she stated it appeared chunky and moved a chunk with her spoon. Resident #2's tray was sent back to request new meat. Review of a policy titled Pureed and Mechanical Soft Foods Production dated 09/08/21 revealed the pureed diet is for residents who have difficulty swallowing and/or residents who are unable to tolerate the mechanical soft diet. Food items are prepared using a food processor or blender and thickener can be added until the food achieves a pudding or mashed potato consistency. Pureed food should not have any pieces in it, does not require chewing, is not sticky and has no lumps. This deficiency represents non-compliance investigated under Complaint Number 2740471.

Based on observations, record review, policy review, and interview, the facility failed to implement infection control protocols for residents with orders for Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). This had the potential to affect ten (Residents #8, #20, #44, #45, #54, #59, #61, #67, #73 and #78) of 15 residents observed during meal service and one (Resident #9) of one residents observed during administration of medication through a feeding tube.Findings Include: Based on observations, record review, policy review, and interview, the facility failed to implement infection control protocols for residents with orders for Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). This had the potential to affect ten (Residents #8, #20, #44, #45, #54, #59, #61, #67, #73 and #78) of 15 residents observed during meal service and one (Resident #9) of one residents observed during administration of medication through a feeding tube.Findings Include:1. During observations of lunch delivery service on 01/12/26, Activity Assistant #75 was observed donning a gown and entering Resident #11's room at 12:38 P.M. No N95 mask, no eye protection and no gloves were donned prior to entrance. Signage posted outside the room indicated Resident #11 was on airborne/contact/droplet precautions. Review of the signage for airborne/contact/droplet precautions indicated prior to entering the room, hands should be cleansed and a gown, an N95 mask, eye protection and gloves should be donned. Upon exiting Resident #11's room, the surgical mask remained on and no hand hygiene was performed. Activity Assistant #75 proceeded to obtain a tray from the meal cart and fluids from a cart with fluids. At 12:41 P.M., Activity Assistant #75 proceeded to Resident #33's room (had signage for airborne/contact/droplet precautions) and entered without donning any eye protection, gown or N95 mask. Upon exiting Resident #33's room, no hand hygiene was performed and the surgical mask was not changed. Activity Assistant #75 resumed obtaining trays from the meal cart and fluids from the fluid cart. At 12:44 P.M., after being instructed by another staff member to don a gown, Activity Assistant #75 donned a gown and entered the room of Residents #47 and #49 (had signage for airborne/contact/droplet precautions). No N95 mask or eye protection was donned. Upon exiting the room, Activity Assistant #75 performed hand hygiene. On 01/12/26 at 12:47 P.M., Activity Assistant #75 verified she had not worn eye protection into any of the COVID identified rooms while delivering trays and stated N95 masks were not required as long as she had a surgical mask applied. Activity Assistant #75 verified she had not worn a gown into Resident #33's room and no hand hygiene was performed when exiting rooms for Residents #11 and #33.

Based on record review, interview, and observation the facility failed to ensure urologist follow-up appointments were scheduled for residents with an indwelling urinary catheter. This affected one resident (Resident #64) of one residents reviewed for incontinence. The facility census was 69.Findings include: Record review revealed Resident #64 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertension, chronic kidney disease, anxiety, and urinary tract infections.Review of Resident #64 hospital Discharge summary dated [DATE] revealed on 10/31/25 a foley catheter was inserted due to a bladder scan revealing 520 milliliter (ML) of urine in the bladder. No voiding trail was completed upon discharge, recommend outpatient urology follow up.Review of Resident #64's admission minimum data set (MDS) completed on 11/13/25 revealed a brief interview for mental status (BIMS) score of 15, and the resident had an indwelling catheter.Review of Resident #64's care plan initiated on 11/07/25 revealed the resident has an indwelling catheter and Resident #64 has an alteration in comfort related to the indwelling catheter.Review of Resident #64 orders revealed an order placed on 11/06/25 to maintain indwelling urinary catheter until follow up with urologist. The resident also had orders in place for catheter maintenance. Observation and interview on 01/15/26 at 10:15 A.M. revealed Resident #64 laying in bed with a indwelling urinary catheter containing urine to the left side of the bed. Resident #64 confirmed they do have an indwelling catheter but was unsure why.Interview on 01/15/26 at 1:40 P.M. with facility director of nursing (DON) confirmed Resident #64 does have an indwelling urinary catheter. The DON confirmed hospital discharge recommended to follow up with urology. The DON confirmed Resident #64 has not had a follow up appointment with urology and there is no appointment scheduled.

Based on record review, interview, observation, and policy review, the facility failed to ensure resident personal belongings were moved after a room change. This affected one resident (Resident #64) of two residents reviewed for personal property. The facility census was 69.Findings Include: Record review revealed Resident #64 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, obstructive and reflux uropathy, anxiety, urinary tract infections, and stage 4 chronic kidney disease. Review of Resident #64's admission minimum data set (MDS) completed on 11/13/25 revealed a brief interview for mental status (BIMS) score of 15.Interview on 01/14/26 at 1:36 P.M. with family representative of Resident #64 revealed during Christmas (December of 2025) Resident #64's family purchased a new leather recliner chair for the resident and a new blanket. The chair and blanket were delivered to her previous room (the resident had a room change during a hospitalization but after the chair was delivered). Resident #64 had slept in a recliner chair at home since her husband passed away around 1989, so they thought the chair may be better for her to sleep in. On 01/06/26 Resident #64 was sent to the hospital and discharged on 01/12/26 from the hospital back to the facility but not to the same room as it was being used for other residents. However, when arriving to the facility Resident #64 was missing some belongings, including the new recliner chair and new blanket.Observation and interview on 01/15/26 at 10:15 A.M. revealed Resident #64's previous room was occupied by Resident #80, and Resident #31. Outside of the room revealed an isolation precaution sign for COVID positive isolation with a personal protective equipment (PPE) cart supplying gloves, gowns, masks, and face shields. Upon entry to the room with PPE on Resident #80 and Resident #31 were laying in bed with a brown leather recliner chair in the middle of the two beds. Resident #80 and Resident #31 stated the recliner chair did not belong to either of them and it had been in the room since they moved in, they were unsure who it belonged to.Interview on 01/15/26 at 10:40 A.M. with Resident #64 revealed she was gifted a brown leather reclining chair for Christmas. Resident #64 stated she was unsure where it was as she didn't get to use it before going to the hospital and she would really like to have it back. Resident #64 stated she was unsure where it was at but thought maybe it was in her old room.Review of Resident #64's medical record revealed no documentation of the recliner chair on the resident's inventory list. Interview on 01/15/26 at 1:00 P.M. with Facility administrator revealed Resident #64 brown leather reclining chair was accidentally left in their previous room, they made room changes due to a COVID outbreak and during the swap the recliner chair was accidentally left in Resident #64's old room and where it still remained.Review of the facility personal inventory policy revised on 09/2023 and reviewed on 12/2025 revealed the facility attempts to accurately inventory residents property.

Based on resident interview, medical record review and staff interview with facility failed to ensure documentation of toileting was completed every shift in the medical record. This affected two (Residents #28 and #29) of two residents reviewed for toileting assistance. The facility census was 69. Findings include: 1. Review of Resident #28 ' s medical record revealed an admission date of 10/02/23 with diagnoses that included cerebrovascular accident, diabetes mellitus type II, and chronic obstructive pulmonary disorder. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 10/10/25 indicated Resident #28 had a modified independent cognition level and required maximum assistance with toileting. Review of Resident #28's care plans revealed an Activities of Daily Living (ADL) self-care deficit including need for toileting assistance. Review of the Certified Nurse Aide (CNA) toileting records revealed numerous shifts with no evidence documented of toileting assistance provided including 12/17/25 evening shift (PM), 12/18/25 day shift (AM), 12/21/25 PM, 12/31/25 AM and PM, 01/08/26 AM, 01/09/26 PM, 01/10/26 AM and 01/12/26 AM and PM. Further review of the medical record found no evidence of any complications related to toileting.On 01/12/26 at 9:45 A.M. interview with Resident #28 revealed there are times they are only toileted or checked and changed once a shift. 2. Review of Resident #29's medical record revealed an admission date of 10/04/23 with admission diagnoses that included diabetes mellitus type II, hypertension and chronic obstructive pulmonary disease. Further review of the medical record including the MDS 3.0 quarterly assessment with a reference date of 11/30/25 revealed Resident #29 had an independent and intact cognition level and required maximum assistance with toileting assistance. Resident #29's care plan revealed an ADL self-care deficit including need for toileting assistance. Review of the toileting records revealed numerous shift with no evidence of documented toileting assistance provided, 12/17/25 PM, 12/18/25 AM, 12/21/25 PM, 12/31/25 AM and PM, 01/05/26 PM, 01/08/26 AM, 01/09/26 PM, 01/10/26 AM and 01/12/26 AM and PM. Further review of the medical record found no evidence of any complications related to toileting.On 01/12/26 at 9:45 A.M. interview with Resident #29 revealed there are times they are only toileted or checked and changed once a shift.On 01/15/26 at 8:25 A.M. interview with the Director of Nursing verified lack of documentation provided for Resident #28 and #29 related to toileting assistance.

Based on record review, interview and policy review the facility failed to ensure residents did not receive unnecessary medications. This affected one resident (Resident #61) of 20 residents reviewed for medical record accuracy and one resident (Resident #69) of six residents reviewed for antibiotic use. The facility census was 69.Findings include: 1. Review of Resident #61's medical record revealed an admission date of 08/22/25. Diagnoses included anoxic brain damage, hypertension, epilepsy, insomnia, anxiety disorder, major depressive disorder, history of accidental methadone poisoning, and migraine. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and received anti-convulsant (seizure) and antidepressant medication.Review of a nursing note dated 12/15/25 at 2:15 P.M. indicated Resident #61 returned from a neurology appointment with orders to increase Baclofen to 20 mg twice daily, continue Keppra 1500 mg twice daily, continue Prozac 40 mg daily, start Vistaril 25 mg every 8 P.M., and continue Topamax 100 mg twice daily. The orders were transcribed onto the medication administration record (MAR).Review of the hand-written orders from the neurology appointment, signed by the neurologist and dated 12/15/25 revealed to increase Baclofen (muscle relaxant) to 20 milligrams (mg) twice daily, continue Keppra (seizure medication) 1500 mg twice daily, continue Prozac (antidepressant) 40 mg daily, start Elavil (antidepressant) 25 mg every day at 8 P.M. and continue Topamax (seizure medication) 100 mg twice daily. Review of the December 2025 MAR revealed the resident received Vistaril 25 mg at bedtime from 12/15/25 through and including 12/22/25.Review of a nursing note dated 12/22/25 at 10:02 A.M. indicated the neurologist's office was called to clarify orders. A voice message was left requesting a return phone call at their earliest convenience to request clarification of orders.A nursing note dated 12/23/25 at 1:40 P.M. indicated the neurologist office provided clarification on all orders except Elavil and staff were to wait to start the medication until the office called back with clarification.Review of Resident #61's MAR revealed the Vistaril was discontinued 12/23/25. Review of telephone communication through the Health System to the neurologist dated 12/23/25 revealed the neurologist was informed of the request for clarification of the Elavil. The physician response was dated 01/06/26 and an order was provided to start Elavil 25 mg every night at bedtime. The order was transcribed onto the MAR and started 01/07/26.Interview with the Director of Nursing (DON) on 01/13/26 at 3:03 P.M. revealed she was told two nurses reviewed the orders from 12/15/25 and believed the order was for Vistaril, not Elavil and was transcribed as Vistaril on the MAR (resulting in the resident receiving a medication not ordered by the neurologist). When staff received clarification, the Vistaril was discontinued by the neurologist but it took until 01/06/26 to receive clarification for the Elavil order.2. Review of Resident #69's medical record revealed an admission date of 03/17/25 with admission diagnoses that include vascular dementia, severe protein-calorie malnutrition and congestive heart failure. Further review of the medical record revealed a Minimum Data Set (MDS) 3.0 quarterly assessment which indicated the resident had severe cognitive impairment. Review of the progress notes revealed on 11/22/25 Resident #69 had a fall in the facility and was transferred to the emergency room for further evaluation due to shoulder pain. Nursing notes after return indicated Resident #69 was diagnosed with a urinary tract infection (UTI) and had a new prescription for cephalexin (antibiotic). Review of Resident #69's physician orders revealed on 11/22/25 the resident was prescribed the use of cephalexin 500 milligrams (mg) every eight hours for five days due to a urinary tract infection UTI. Review of the antibiotic assessment completed on 11/23/25 indicated Resident #69 did not meet requirements for use of an antibiotic. Documentation on the assessment further indicated the orders were from the emergency department, the resident's primary physician was notified and advised to await results of the urinary culture. Further review of the medical record found no evidence of any culture results obtained or records from the ER visit on 11/22/25.On 01/14/26 at 1:10 P.M. interview with Registered Nurse (RN) #22 verified Resident #69 did not meet criteria for antibiotic use and the resident's physician said to wait for the urine culture results however, the resident was seen by the nurse practitioner on 11/24/25 and continued on the antibiotic. The RN confirmed the facility was unable to obtain the urine culture results from the ER. Review of the facility policy Antibiotic Stewardship with a revision/update date of 05/2025 revealed no evidence indicating antibiotics are required to meet criteria for use. This deficiency represents noncompliance investigated under Complaint Number 2710158.

Based on medical record review, emergency medical service and hospital record review, interview, policy review and review of nursing standards of practice, the facility failed to ensure Resident #58 was free of unnecessary medication without adequate monitoring. This affected one (#58) of three residents reviewed for medication errors. The facility census was 61. Actual Harm occurred on 10/26/25 when Resident #58, a resident with a known low heart rate requiring cardiovascular medications to be held due (due to low heart rate) was administered four cardiovascular medications resulting in the resident becoming unresponsive one hour after medication administration. Resident #58 was transported to the emergency room by ambulance, where she was treated with intravenous fluids for hypotension (low blood pressure) a result of the medication administration. Prior to the administration of the medications, the facility failed to implement systems to ensure blood pressure monitoring was completed to prevent medication complications/adverse outcomes. Findings include:Review of the medical record for Resident #58 revealed an admission date of 08/20/20. Resident #58 had diagnoses including non-ST elevation myocardial infarction; dysphagia following cerebral infarction; essential hypertension; difficulty in walking, dysphagia; cognitive communication deficit, muscle wasting and atrophy, anxiety disorder, altered mental status and diverticulitis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating the resident was cognitively intact. A plan of care plan dated 08/27/25 revealed a focus of care for altered cardiovascular status due to a history of a non-ST elevation myocardial infarction (heart attack). Interventions included giving medications as ordered, monitoring side effects, monitoring vital signs as ordered/per protocol and notifying the physician of any significant abnormalities, which included rapid pulse, shallow, rapid or labored respirations, and low blood pressure.Review of the vital sign records for Resident #58, dated 10/25/25 at 9:40 P.M., revealed the resident had a pulse of 57 beats per minute (normal heart rate is considered 60-100 beats per minute). The resident's blood pressure was not assessed.Review of a progress note for Resident #58 dated 10/25/25 at 9:40 P.M. revealed Metoprolol Tartrate (a drug indicated for treatment of high blood pressure), ordered twice daily for the resident, with parameters to hold the medication if the pulse was less than 60, was held. The medication was held (at this time) due to the low pulse.Review of the vital sign records for Resident #58 dated 10/26/25 at 7:56 A.M., revealed a pulse of 70 beats per minute. The resident's blood pressure was not assessed at this time. Review of the Medication Administration Record (MAR) dated 10/26/25 revealed the resident was ordered and administered the following cardiovascular medications for blood pressure management during morning medication pass:Isosorbide Mononitrate ER (extended release) 60 milligrams (mg) by mouth, Amlodipine Besylate 10 mg one tablet by mouth, Metoprolol Tartrate 25 mg one tablet by mouth twice daily for hypertension and Lisinopril 20 mg one tablet. The medication order for the Metoprolol revealed to hold the medication if the resident's heart rate was less than 60. None of the medication orders included parameters for holding or administering the medication based on the resident's blood pressure.Review of a progress note dated 10/26/25 at 9:15 A.M. revealed the nurse was called to the resident's room by the Certified Nurse Aide. (CNA). The resident was sitting in her wheelchair with her head back, flaccid, not responding to voice commands or touch. The nurse sent the CNA to get another nurse. The residents' vital signs were taken. The resident had a change of mental status compared to baseline. The nurse practitioner (NP) was notified and 911 was called. Resident #58 was transferred to the hospital emergency room (ER) to be evaluated.Review of the vital sign record for Resident #58 dated 10/26/25 at 9:15 A.M., revealed the resident had a recorded pulse of 47 beats per minute and blood pressure of 110/60 documented. (Normal blood pressure is generally considered 120/80 millimeters of mercury (mm/Hg)).Review of Emergency Medical Transport documentation for Resident #58 dated 10/26/25 at 9:50 A.M., revealed the resident's heart rate was 73 and her blood pressure was 75/50 mm/Hg (hypotensive).Review of emergency room documentation for Resident #58 dated 10/26/25 revealed the resident arrived at the emergency room at 10:09 A.M., with a complaint of an unresponsive episode. At that time, her blood pressure was 83/50 and her heart rate was 69. At 11:56 A.M., the resident's blood pressure was 82/52 and her heart rate was 50. At 1:50 P.M., her blood pressure was 101/59, after administration of 1000 milliliters of normal saline intravenously at 12:16 P.M.Further review of the emergency room Record revealed the resident was discharged back to the facility with recommendation to have the primary care provider review the resident's blood pressure medications, which may have needed adjustment.On 11/17/25 at 12:13 P.M., an interview with Licensed Practical Nurse (LPN) #106 revealed if a resident had a medication which required vital signs to be taken prior to administration, the nurse would have to enter the vital measurement into the documentation prior to administration. However, there were no facility protocols for blood pressure or pulse monitoring for any residents receiving blood pressure medications, only those who had parameters listed.Review of standard of care for applying the nursing process to administering cardiovascular medications (Nursing Pharmacology [internet]; 2nd edition. https://www.ncbi.nlm.nih.gov/books/NBK594995/), revealed before administering cardiovascular medications, it was vital for the nurse to determine if the specific medication was safe for the client at that time. Because antihypertensives alter a client's blood pressure or heart rate, the nurse must assess blood pressure and heart rate prior to administering medications.Review of a facility policy titled Medication Administration and Documentation, updated 06/26/24, revealed it was the policy of the facility that every resident receives medication by a licensed nurse as prescribed by a licensed physician or other healthcare provider legally permitted to prescribe medications, safely, properly and in a timely manner. This same policy revealed it was expected the individual administering medications was familiar with the expected action, dosage and side effects of medications administered. If there was clinical data, such as vital signs, required for medication administration, this must be obtained prior to administration.This deficiency represents non-compliance investigated under Complaint Number 1353963.

Based on medical record review, policy review, review of medication error reports and interview, the facility failed to ensure medications were administered without significant error. Actual harm occurred on 06/06/25 when Resident #10, who had moderately impaired cognition and was dependent of staff to prepare and administer medications, received medications prescribed for another resident that included cardiac medications that lower the heart rate and blood pressure, medication to prevent platelets from clumping together, medication to treat gout and antianxiety medications. This resulted in the resident experiencing a change in condition requiring transport to the emergency room. The resident was subsequently admitted and treated for hypotension (low blood pressure) and bradycardia (low pulse) with intravenous fluids and an overnight hospital stay for monitoring secondary to the medication error after receiving incorrect medication that was prescribed for another resident. This affected one resident (#10) of two residents reviewed for medication errors. Findings include: Review of Resident #10's medical record revealed diagnoses including muscle wasting, osteoarthritis, hypertensive heart disease with heart failure, depression, Vitamin B12 deficiency anemia, pain, hyperlipidemia, and hypothyroidism. Resident #10 had no known allergies. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was usually able to make herself understood, was usually able to understand others, and was moderately cognitively impaired. Review of the monthly blood pressures recorded between December 2024 and June 2025 revealed the following: 12/04/24 was 127/72 millimeters of mercury (mm Hg) (normal blood pressure is 120/80 mm Hg). 01/01/25 was 134/78 mmHg 02/01/25 was 132/80 mmHg 03/02/25 was 126/74 mmHg 04/02/25 was 122/80 mmHg 05/03/25 was 163/88 mmHg Review of monthly pulses recorded between December 2024 and June 2025 revealed the following: 12/11/24 was 70 beats per minute (bpm) with normal range 60-90 bpm) 01/01/25 was 78 bpm 02/01/25 was 76 bpm 03/02/25 was 80 bpm 04/02/25 was 76 bpm 05/03/25 was 82 bpm Review of a medication error report dated 06/06/25 revealed Resident #10 received another resident's medications in the morning. Medications listed were Allopurinol, Buspar, ferrous sulfate, isosorbide mononitrate, losartan, metoprolol succinate, Plavix and Tylenol. The physician was notified at 10:15 A.M. The type of medication error was the wrong medication given due to failure to identify the resident. A nursing note dated 06/06/25 at 11:17 A.M. indicated Resident #10 received allopurinol (used to reduce uric acid production in the body), Buspar (anti-anxiety), ferrous sulfate (iron), isosorbide mononitrate (anti-anginal), losartan (angiotensin receptor blocker used to lower blood pressure), metoprolol succinate (beta blocker that affects the heart and circulation), Plavix (anti-platelet) and Tylenol. The doctor was notified with new orders were received to monitor vital signs and mental status. Neuro checks were initiated immediately, and an order was noted to send Resident #10 to the emergency room for an evaluation. A nursing note dated 06/06/25 at 12:45 P.M. indicated Resident #10 was administered the wrong medication. The note included vital signs were stable and no signs of altered mental status were noted. An eINTERACT Transfer Form dated 06/06/25 indicated the nurse practitioner ordered to send Resident #10 to the emergency room (ER) for an evaluation. Vital signs included temperature 97.3 degrees Fahrenheit, pulse 110 (bpm), respirations 18 and blood pressure 123/86 (mmHg). Oxygen saturation was 92% on room air (normal 92-100% on room air/without oxygen). Resident #10 was not on anticoagulants and had no known allergies. No changes were observed in mental status or functional status. The clinician was notified on 06/06/25 at 10:00 A.M. A nursing note dated 06/06/25 at 2:29 P.M. indicated Resident #10 left the facility via squad for the hospital at 12:25 P.M. A nursing note dated 06/06/25 at 2:30 P.M. indicated Resident #10 was being admitted to the hospital for overnight observation. Review of Resident #10's physician orders revealed none of the medications Resident #10 was administered in error on 06/06/25 were ordered for the resident. A hospital admission history and physical dated 06/06/25 revealed Resident #10 presented to the emergency room with hypotension (decreased blood pressure). The hospital record included, unfortunately she was given another resident's medication including allopurinol 200 milligrams (mg), Buspar 5 mg, Plavix 75 mg, isosorbide 60 mg, losartan 100 mg, metoprolol 100 mg, and Tylenol 650 mg. Resident #10 became lethargic, bradycardic, and hypotensive so Emergency medical services (EMS) was called. Upon examination, Resident #10 was easily awakened but spoke nonsensically which was reportedly her baseline. Resident #10 was able to move her extremities and denied any pain. On 06/06/25 at 3:30 P.M., a blood pressure (BP) of 81/45 and pulse of 56 was recorded. On 06/06/25 at 3:45 P.M. a BP of 99/54 and pulse of 48 was recorded. On 06/06/25 at 4:00 P.M. a BP of 87/55 and pulse of 47 was recorded. On 06/06/25 at 4:15 P.M. a pulse of 47 was recorded. A note indicated Resident #10 had hypotension throughout her ER stay but was improving with intravenous (IV) fluids. The bradycardia (low heart rate) was likely due to administration of the beta blocker medication (in error). The plan was to admit the resident for overnight observation and continue IV fluids. A hospital note dated 06/06/25 at 1:13 P.M. indicated Resident #10 presented via ambulance from the nursing home for complaints of hypotension and bradycardia with lethargy. Staff stated Resident #10 was accidentally administered medication ordered for a different resident. The medications included isosorbide, losartan and metoprolol. Hospital discharge records revealed admitting diagnosis of accidental medication overdose with multiple hypotensive medications. The resident presented (to the emergency room) with hypotension and bradycardia. A nursing note dated 06/07/25 at 1:09 P.M. indicated Resident #10 returned from the hospital. Resident #10 was in observation for lethargy and hypotension. Resident #10 received IV fluids for low blood pressure and pulse. On 06/25/25 at 2:50 P.M., the Administrator verified the medication error on 06/06/25 was identified before the nurse (LPN #130) administered Resident #10's medication to the other resident. The NP was notified, and Resident #10 was sent to the ER for evaluation. On 06/25/25 at 5:38 P.M., Licensed Practical Nurse (LPN) #130 verified the medication errors occurred after she failed to identify the correct resident prior to administering the medication. Review of the facility's Medication Administration and Documentation policy (revised 06/26/24) revealed medications may only be administered to the resident for whom they were prescribed. Prior to and during administration, the nurse must observe the 5 rights of medication administration including administering the medication to the right person. This deficiency represents non-compliance investigated under Complaint Number OH00166414.

Based on observation, record review, medication information review, policy review and interview, the facility failed to administer medication as ordered and/or in accordance with acceptable standards of practice. Three errors out of 28 opportunities were identified resulting in a 10.7% medication error rate. This affected one (Resident #5) of five residents observed for medication administration. Findings include: On 06/26/25 at 8:01 A.M., Licensed Practical Nurse (LPN) #100 was observed administering medication to Resident #5. Medications administered included two tablets of Potassium Chloride extended release (ER) 10 milliequivalents (meq) and one tablet of verapamil ER 240 milligrams (mg) (calcium channel blocker used to treat high blood pressure and angina). The tablets were crushed and added to other crushed medications. Review of Resident #5's physician orders revealed in addition to medication administered, Resident #5 had an order for PreserVision AREDS (multivitamin with minerals) one tablet in the morning. On 06/26/25 at 8:03 A.M., LPN #100 verified she crushed extended release tablets of potassium chloride and verapamil, stating Resident #5 could not consume the pills whole. LPN #100 stated her understanding was Resident #5 crushed the pills for consumption at home also. LPN #100 was unaware if anybody had inquired of the physician if alternate forms of the drugs were available or if alternates would be more appropriate. At 8:38 A.M., LPN #100 stated after speaking to Resident #5 she was willing to try to take the extended release tablets without crushing them. At 11:34 A.M., LPN #100 verified she had not administered the PreserVision AREDS tablet as ordered, stating she had none available on the medication cart. At that time, she inquired of LPN #110 if she had any on her medication cart. On 06/26/25 at 1:25 P.M., Registered Nurse (RN) #120 verified extended release tablets were not generally supposed to be crushed. RN #120 provided a hospital inpatient swallowing discharge summary for service provided to Resident #5 on 01/03/25 which indicated Resident #5 was taking pills crushed in applesauce/pudding (if crushable). Review of medication information from Medscape revealed consideration should be given to use liquid potassium if a resident had difficulty swallowing. Review of the verapamil extended release manufacturer guideline revealed tablets should be swallowed whole and not chewed, broken, or crushed. This deficiency represents non-compliance investigated under Complaint Number OH00166414.

Based on review of the facility Payroll Based Journal information, facility assessment, staffing schedule information and staff interviews the facility failed to ensure sufficient staffing levels were maintained to provide resident care and services. This had the potential to affect all 75 residents within the facility. Findings include: Review of the facility Payroll Based Journal (PBJ) data report for the third quarter (April 1 to June 30, 2024) revealed the facility had a one star staffing rating and low weekend staffing levels. The facility assessment with a reviewed date of 08/28/24 indicated a minimum staffing level plan of five to ten direct care nurses per day and seven to 14 State tested Nurse Aides (STNA) per day. The facility assessment indicated a daily average resident census of 71 to 78. Review of the facility staffing schedules for the dates of 05/10/24 to 05/12/24, 06/14/24 to 06/16/24 and 09/12/24 to 09/18/24 revealed the following dates and shift with low staffing levels: 05/12/24 (Sunday) census of 78 residents, dayshift one Registered Nurse (RN), four Licensed Practical Nurse (LPN), four CNA and night shift one RN, five LPN and three CNA for a total of two RN, nine LPN and seven CNA. 06/15/24 (Saturday) census of 68 residents, dayshift one RN, three LPN and three CNA and night shift one RN, one LPN and four CNA for a total staffing for the day of two RN, four LPN and seven CNA. 06/16/24 (Sunday) census of 68 residents, dayshift one RN, two LPN and five CNA and night shift two LPN and two CNA for a total staff for the day of one RN, four LPN and seven CNAs. 09/14/24 (Saturday) census of 78 residents, dayshift one RN, three LPN, four CNA and night shift one RN, two LPN and two CNA for a total staffing for the day of two RN, five LPN and six CNA. 09/16/24 (Monday) census of 78 residents, dayshift two RN, two LPN and three CNA and night shift three LPN and three CNA for a total staffing for the day of two RN, five LPN and six CNA. 09/18/24 (Wednesday) census of 79 residents, dayshift one RN, four LPN and three CNA and night shift two RN, three LPN and three CNA for a total staffing for the day of three RN, seven LPN and six CNA. On 10/22/24 at 6:11 A.M. interview with Licensed Practical Nurse (LPN) #532 revealed majority of time felt had enough staff but when dementia residents having behaviors it was difficult to provide care related to need for increased supervision. On 10/22/24 at 7:09 A.M. interview with CNA #610 revealed not enough staff because south wings has a lot of behaviors and lot of residents who required two assists. If there were only three aides it was hard to get help. On 10/22/24 at 7:18 A.M. interview with CNA #518 revealed not enough staff a lot of times there were three aides for the facility at night. Residents complain of wait times but if two aides were transferring a resident or giving a shower it left only the nurse to monitor the halls/call lights and often passing meds. Some nurses would help and answer call lights but some did not. It was difficult to say with certainty how long residents had to wait as staff did not always hear or see them when they were in rooms providing care to other residents but residents would complain how long it took. On 10/22/24 at 7:26 A.M. interview with LPN #524 indicated some nights it was difficult to provide care per residents' needs. There were generally two nurses working at night. Average number of aides on night shift was three. South wing had a lot of residents who required two assists related to dementia. Stated when two aides were tied up using the hoyer and she was passing medications on one hall a resident on the other hall could potentially have their call light going off for a while without staff knowing it. Residents did complain about wait time. She tries to help the aides when she can but that meant medications not being administered in a timely manner. Stated she worked three days a week and at least two of the three days she only had three aides in the facility. On 10/22/24 at 7:40 A.M. CNA #502 indicated most of the time there was not enough staff on night shift. Usually three to four aides for over 70 residents. Getting rounds done every two hours is difficult. When aides were giving showers call lights were going off and it could leave two halls uncovered. On 10/22/24 at 2:40 P.M. interview with the facility administrator and staffing scheduler #545 revealed minimum staffing schedules are four nurses and five CNAS on dayshift and two nurses and four CNA on night shift. The Administrator indicated the facility found this was insufficient staffing levels and have recently requested corporate office to approve increasing minimum staffing levels to four nurses and seven CNA on dayshift and three nurses and five CNA on night shift. Administrator verified the facility did not meet PBJ minimum staffing level requirements for the third quarter of 2024.

Based on medical record review, observation, interview, and policy review the facility failed to ensure residents call lights were readily assessable. This affected five residents (#47 Resident #3, #43, #48, #54) observed during the initial tour. Findings included: 1. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnosis including hunting disease, scoliosis, epilepsy, anxiety and depression. Observation on 10/21/24 at 4:11 P.M., revealed both of call lights in Resident #47's room were lying on the floor under the resident foot of bed. The resident was observed sitting in bed with back against the wall. There was a sign next to the door to remind the resident to use call light. Interview on 10/21/24 at 4:11 P.M., with the Administrator confirmed the call lights were on the floor. The Administrator placed the call lights next to the resident. Review of Resident #47's activity of daily living (ADL) deficit related to Huntington's plan of care dated 05/08/23 and revised 05/08/24 revealed to place call light within accessible reach and encourage resident to use bell to call for assistance. Review of Resident #47 fall plan of care dated 06/10/22 and revised 07/20/23 revealed to be sure the residents call light was within reach and encourage the resident to use it for assistance and as needed. The resident needs prompt response to all requests for assistance. Review of facility's policy titled Call Light Policy dated 04/2018 revealed the purpose of this procedure was the accessibility and response to the resident's request and needs. When the resident was in bed or chair be sure the call light was within easy reach of the resident. 28704 2. Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including cerebral infarction and anxiety disorder. On 10/21/24 at 9:41 A.M., observation revealed Resident #3 was laying in bed with her eyes closed. The call light was observed on the floor and not within reach. On 10/21/24 at 9:47 A.M., observation revealed Resident #3 was laying in bed awake and stated she was tired. Surveyor asked the resident if she knew where her call light was and she was unable to locate it and the call light was observed on the floor. The above was verified at the time of the observation by Laundry #573. 3. Medical record review revealed Resident #43 was admitted on [DATE] with diagnoses including pneumonia. On 10/21/24 at 9:45 A.M., observation revealed Resident #43's call light was looped around the 1/4 siderail attached to the bed closest to the door. Resident #43 was sitting in his recliner chair next to the window and the call light was not within reach. On 10/21/24 at 9:54 A.M., interview with Laundry #573 verified the above. 4. Medical record revealed Resident #48 was admitted on [DATE] with diagnoses Alzheimer's dementia. On 10/21/24 at 10:15 A.M., Resident #48 was laying in bed and her call light was observed on the floor wrapped in circle under a straight back chair. The resident stated she did not know where her call light was. On 10/21/24 at 10:21 A.M., the above observation was verified by Licensed Practical Nurse (LPN) #510. 5. Medical record review revealed Resident #54 was admitted on [DATE] with diagnoses including Creutzfeldt-[NAME] disease. On 10/21/24 at 10:27 A.M., observation revealed Resident #54 was laying in bed covered with a sheet with his call light on the floor and not within reach. LPN #510 verified the above at the time of the observation. Review of the policy: Call Light (April 2018) revealed the purpose o the procedure was the accessibility and response to the resident's requests and needs. General guideline included When the resident was in bed or chair, be sure the call light was within easy reach of the resident.

Based on observation, medical record review, policy review and interview, the facility failed to identify and address changes in weight, non-pressure skin conditions, and failed to follow physician orders. This affected two (#15 and #43) of two residents with non-pressure skin alterations, one (#35)resident reviewed for change of condition, and one (#3) of five residents reviewed for unnecessary medications. The census was 75. Findings include: 1. Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including hypertension, non-ST elevation myocardial infarction and obsessive compulsive disorder. Review of the Physician Orders (dated August 2024 and September 2024) revealed the following medications were scheduled to be administered in the A.M. with physician parameters that included to hold the medications if systolic blood pressure (SBP) was below a specific value or if the resident's pulse was less than 60 beats per minute: a. Hydralazine 25 milligrams (mg) hold if SBP was less than 100. b. Toprolol Tartrate 25 mg hold if SBP was less than 110. c. Isosorbide Monomitrate ER 60 mg hold if SBP less than 110. d. Lisinopril 20 mg hold if SBP less than 110. e. Amlodipine besylate 10 mg hold if SBP less than 110. Review of the electronic Medication Administration Record (MAR) (dated August 2024) revealed Resident #3's pulse was 55 on the morning of 08/08/24 and her SBP was 100 the morning of 08/11/24. Further review revealed hydralazine, toprolol tartrate, isosorbide monomitrate ER, lisinopril and amlodipine besylate were administered during the A.M. medication pass despite the SBP and pulse readings being below the physician ordered parameters. Review of the electronic MAR (dated September 2024) revealed Resident #3's pulse was 58 on 09/24/24 and lisinopril 20 mg was administered. Review of the electronic MAR (dated August, September and October 2024) revealed Resident #3's blood pressure was not checked prior to the administration of hydralazine for the P.M. dose administered between 11:00 A.M. and 2:00 P.M. daily. Review of the care plan: Hypertension (revised 11/09/22) revealed interventions included to give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. On 10/23/24 at 11:33 A.M., interview with regional Registered Nurse #714 verified physician parameters were not followed as ordered for Resident #3. 2. Medical record review revealed Resident #43 was admitted on [DATE] with diagnoses including pneumonia and hyperlipidemia. Review of the Baseline Care Plan (dated 09/18/24) revealed Resident #43 was at risk for skin alterations and interventions included to reposition frequently, encourage good nutrition and hydration, encourage mediation and treatment regimen and keep skin clean and dry. Review of Resident #43's assessments revealed a Skin Check Weekly - V 2 was completed on 10/19/24 with no skin impairments identified. On 10/21/24 at 9:54 A.M., observation of Resident #43 with Laundry #573 revealed a skin tear with active bleeding to the left hand. At the time of the observation, Resident #43 stated he did not know what happened and asked for a band-aid. The surveyor notified Licensed Practical Nurse (LPN) #510 who was standing at her medication cart at the end of the hall. On 10/21/24 at 10:28 A.M., observation revealed the resident's skin tear had dried and fresh blood coming from the left hand. Resident #43 was observed scratching his right forearm. On 10/21/24 at 10:45 A.M., Licensed Practical Nurse #510 was observed exiting Resident #43's room and verified she had just applied a band-aid to the resident's skin tear. On 10/22/24 at 11:04 A.M., observation revealed Resident #43 was sitting up in a straight back chair in his room. Two new circular areas approximately 0.4 centimeters in diameter were observed to the back of his left hand, as well as a linear scab between his left thumb and finger. Resident #43 also had a scant bleeding from an area to the right forearm. Resident #43 stated he did not know what had happened, but his skin did not itch. Review of the medical record revealed no treatment or assessments for the above skin impairments. Review of the progress note dated 10/23/24 at 9:10 A.M. revealed staff went in to assess a new skin area on Resident #43 with the wound nurse practitioner. Review of the care plan: Potential Impairment to Skin Integrity related to weakness and impaired mobility (dated 09/19/24) revealed interventions including avoid scratching, keep hands and body parts from excessive moisture, keep fingernails short, skin clean and dry. On 10/23/24 at 10:28 A.M., interview with regional Registered Nurse #714 verified skin impairments and treatments should be documented in the medical record. On 10/24/24 at 1:37 P.M., interview with the Director of Nursing verified Resident #43's skin impairments were not addressed timely. Review of policy: Wound Care (revised October 2021) revealed guidelines for the care of wounds to promote healing included recording documentation in the medical record of the type of wound care given and the name/title of the individual performing the wound care. 22653 3. Review of Resident #35's medical record revealed diagnoses including cognitive communication deficit, type two diabetes mellitus, chronic respiratory failure, cerebral infarction, anxiety disorder, depression, and atrial fibrillation. On 09/04/24 Resident #35 had a weight of 225.9 pounds recorded. Review of a nursing note dated 09/30/24 at 11:49 A.M. indicated Resident #35 was seen by a nurse practitioner related to cough and chest discomfort. New orders were obtained for a chest x-ray and cardiology consult. An interdisciplinary team note dated 10/03/24 at 1:50 P.M. indicated Resident #35 was reviewed and had a cardiology appointment pending. On 10/10/24, a weight of 256.2 pounds was recorded. There was no further record of a cardiology appointment being made. Review of a dietary note dated 10/10/24 at 11:33 A.M. revealed Resident #35 was having an annual review completed. The note revealed the dietitian reviewed Resident #35 based on the weight obtained 09/04/24. The monthly weight was pending. No recommendations were made. On 10/22/24 at 1:21 P.M., the Administrator verified staff had not identified the significant weight gain until it was addressed by the survey team. The Administrator stated Resident #35 had been re-weighed to determine the accuracy of the 10/10/24 weight and it was determined to be accurate. The physician was notified on 10/22/24. The weight gain was believed to be related to increased caloric intake. A weight recorded on 10/22/24 was 262.3 pounds. On 10/24/24 at 8:53 A.M., Licensed Practical Nurse (LPN) #583 stated there was nothing on the resident calendar for a cardiologist appointment for Resident #35. On 10/24/24 at 8:54 A.M., Certified Nursing Assistant (CNA) #544. the staff responsible to schedule appointments and provide transportation, stated since Resident #35 had the cardiology referral on 09/30/24 she had made a couple referrals but was waiting on a response. CNA #544 stated she had contacted one of the cardiologist's office again the week of 10/13/24 to 10/19/24 and was was told to re-fax Resident #35's information but she had not received a response. On 10/24/24 at 9:30 A.M., CNA #544 provided the name of two cardiologists she had contacted but had no documentation of when the attempts had been made. CNA #544 indicated she attempted to contact a different cardiologist after the discussion with the surveyor at 8:54 A.M. and was informed if she faxed the paper work for review, Resident #35 could potentially have an appointment the following week. The faxed information was provided. On 10/24/24 at 10:07 A.M., Registered Nurse (RN) #714 reported there should have been documentation to indicate what attempts were made to schedule a cardiology appointment. CNA #544 was new to the position and there was no documentation regarding what attempts were made and when. On 10/24/24 at 10:45 A.M., Registered Dietetic Technician (DTR) #901 reported he completed Resident #35's annual review on 10/10/24 but monthly weights had not been completed. The electronic health record did not send him an alert when the weight of 256.2 pounds was recorded. Without the alert, he was unaware of the significant weight gain. Without the system alerting him, it could have potentially been three months before another review. DTR #901 was unable to state if anybody but him reviewed weights to review for significant changes. On 10/24/24 at 1:45 P.M., CNA #544 revealed a cardiology appointment was made for 10/28/24 at 12:40 P.M. 32801 4. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnosis including cognitive communication deficit, heart failure, and vascular dementia. Review of Resident #15's risk for skin impairment plan related to fragile skin dated 09/24/24 revealed interventions to avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Review of Resident #15's current orders revealed no evidence of orders to monitor or treat skin alteration on the nose or right outer foot. Observation on 10/21/24 at 10:34 A.M. of Resident #15 revealed the resident had several small open and some small scabbed areas on her nose that were actively bleeding and running down the side of her nose. Observation on 10/22/24 at 11:35 P.M. of Resident #15 with CNA #558, confirmed the resident had open and scabbed areas on her nose and a scabbed area the size of a pea on the right lateral foot. The CNA did not now how the resident obtained the skin alterations. The resident reported she didn't know how she acquired the skin alternation on her nose or foot. Observation on 10/23/24 at 8:08 A.M., of Resident #15 with Registered Nurse (RN) #574 and the visiting wound Nurse Practitioner (NP) #716 revealed they had just noted the skin alteration to the resident's nose this morning. RN #574 and NP #716 confirmed they were not aware or monitoring the areas on the right outer foot area or nose. The NP reported she didn't think the area on the right outer foot was pressure, but may be an abrasion. The resident reported she didn't know how she got the area in her foot when staff inquired. The resident's fingernails were noted to be long, and the resident reported staff had just cleaned them this morning. Observed on the resident's nose was dried blood. Review of Resident #15's progress notes dated 10/01/24 to 10/23/24 revealed no evidence of skin alterations on the nose and right outer foot, until the surveyor had confirmed the areas with Registered Nurse (RN) #574 and NP #716. Review of Resident #15's assessments revealed no evidence of a skin assessment for the skin alteration area on the nose, until surveyor verified with staff. Review of Resident #15's progress note dated 10/23/24 and created at 10:24 A.M., revealed the resident was observed scratching at the top of her nose with her nails. Dried blood was noted under the fingernails. Resident stated I just scratched my nose. The area measured 0.5 centimeters (cm) by 0.1 cm by 0.1 cm. The visiting wound Nurse Practitioner (NP) was in and gave orders to cleanse with normal saline, apply A&D ointment twice daily until healed. The resident aware of orders and nail care provided. Review of skin assessment dated [DATE] at 10:25 A.M. revealed the area to the resident's nose measured 0.5 centimeter (cm) by 0.1 cm by 0.1 cm. Review of a progress note dated 10/23/24 at 12:26 P.M. revealed the resident was observed resting her right foot against the wheelchair. The resident has a 0.4 cm x 0.4 cm abrasion to (the) right lateral foot. The visiting wound NP (was) here and gave orders to cleanse with normal saline, apply foam dressing three times weekly, feet being floated while in bed and heel protectors on while in bed as resident tolerates. Resident aware. Review of skin assessment completed on 10/23/24 at 12:27 PM revealed there was an abrasion on the right lateral foot measuring 0.4 cm by 0.4 cm. Interview on 10/23/24 at 12:41 P.M., with RN #714 confirmed there was no documented evidence staff were monitoring the area on Resident #15's nose or the abrasion on the right outer foot prior to this date. The RN confirmed staff would address the areas today and new orders would be implemented. Review of the facility's policy and procedure titled Wound Care dated 10/2021 revealed to review the resident's care plan to assess for any special needs of the resident. The following information may be recorded in the resident medical record: the type of wound care given, any changes in the resident's condition, all assessment data, any problems or complaints made by the resident related to the procedure. Report other information in accordance with facility policy and professional standards of practice.

Based on medical review, review of infection control log, interviews, observations, and policy review the facility failed to ensure appropriate use of antibiotics and/or assessment were completed accurately. This affected five (Resident #12, #41, #48, #52, and #57) of nine reviewed for urinary tract infection and unnecessary medication review. Findings include. 1.Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy, urinary tract infection, Parkinson's, aphasia, cognitive communication deficit, obstructive and reflux uropathy, malignant neoplasm of prostate, sleep terrors, attention and concentration deficit, dementia, major depression, anxiety, spinal stenosis, lower back pain, gastro-esophageal reflux disease, hyperlipidemia, hypertension, pulmonary embolism, constipation, and benign prostatic hyperplasia without lower urinary tract symptoms. a. Review of Resident #52's orders and Medication Administration Records (MAR) dated 07/2024 revealed on 07/17/24 Resident #52 was ordered and received Keflex 500 milligrams (mg) twice daily for two days for preventative due to a new foley catheter replacement. Review of the July 2024 infection control log revealed Resident #52 was ordered and received Keflex for two days. Not applicable was marked for if criteria was met. Interview on 10/29/24 at 7:40 A.M., with Registered Nurse (RN) #714 confirmed the urologist order the Keflex as preventative after replacing the foley, however the resident did not meet criteria for treatment. b. Review of Resident #2's orders dated 10/18/24 revealed the resident was ordered contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) in the wound. The resident also had order for enhanced barrier precautions related to the urinary foley catheter. Review of Resident #52's progress note dated 10/18/2024 revealed the resident returned to facility from hospital stay. The resident had surgery for stimulator removal. There was a surgical incision to lower back. The resident had a peripherally inserted central catheter (PICC) for intravenous (IV)antibiotics in place. Daughter and physician aware and medications reviewed. Resident to be on contact precautions for MRSA of the surgical site. Review of Resident #52's hospital note dated 10/13/24 to 10/18/24 revealed the resident has a PICC line which was put in two days ago. Cefepime two grams intravenous every 12 hours ordered to start tomorrow (counts as the 1st day for your facility) for urinary tract infection (UTI) and wound. Further review of the hospital records revealed the wound had grown MRSA bacteria and Cefepime was not an antibiotic listed on the culture to treat the MRSA. Review of Resident #52's MAR dated 10/2024 revealed the resident had an order for Cefepime two grams intravenous twice daily for a wound infection for 14 days. The IV was started on 10/19/24. Review of general note dated 10/21/2024 revealed received urine culture results from the hospital. The urine showed pseudomonas aeruginosa 50,000-<100,000. The Nurse Practitioner was notified and wanted IV continued for MRSA of the wound. Interview on 10/24/24 at 8:11 A.M. with the Infection Preventionist (IP) #541 revealed the resident did not meet criteria for treatment for the UTI and the antibiotic ordered would not treat the MRSA according to the culture report. The IP reported she had reached out to the facility's physician yesterday (after the surveyor had inquired) and he was going to change the antibiotic to Vancomycin, which was on the culture report as an appropriate antibiotic to treat the MRSA. 2. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including acute kidney disease, cognitive communication deficit, need assistance with personal care, obstructive and reflux uropathy, hydronephrosis, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, intellectual disabilities, and ileus. Review of Resident #57 MDS dated [DATE] revealed the resident had an indwelling catheter. Review of Resident #57's urine culture results dated 06/30/24 revealed the urine culture had three or more bacterial isolated and suggest recollecting urine specimen to conclusively evaluate the resident urine culture results. Review of Resident #57's medical record revealed no evidence the urine was recollected; however, the resident was treated with Macrobid 100 mg twice daily for seven days for a UTI per the Medication Administration records dated 07/2024 from 07/01/24 to 07/08/24. Review of Resident #57 McGeer criteria form dated 06/30/24 revealed the resident did not meet criteria. A handwritten note indicated the resident had a fall and it was discussed with the provider and to continue antibiotic series. Interview on 10/24/24 at 4:31 P.M., with IP #541 confirmed the resident did not meet criteria for treatment on 06/30/24 and the urine was not re-collected to ensure the resident was treated with the correct antibiotic. Review of the facility's policy titled Antibiotic Stewardship dated 12/2023 revealed the Centers for Disease Control (CDC) has reported that antibiotic resistance was one of the major threats to human health, especially because some bacteria have developed resistance to allow classes of antibiotics. The centers would promote appropriate use of antibiotics whole optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. The infection preventionist would collect and review cultures before ordering antibiotics. 28701 3. Review of Resident #41's medical record revealed an admitted [DATE] with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease and dementia. Further review of the medical record revealed physician's orders on 01/11/24 for flagyl (antibiotic) 500 milligrams (mg) twice daily for pneumonia for seven days and cefpodoxime proxetil (antibiotic) 200 mg twice daily for seven days for pneumonia. Review of antibiotic assessments for Resident #41 revealed no evidence of any antibiotic assessment completed to determine appropriate indication for the use of antibiotic. On 10/28/24 at 11:00 A.M. interview with Registered Nurse (RN) #541 verified no antibiotic assessment was completed for the use of flagyl or cefpodoxime proxetil on 01/11/24. 4. Review of Resident #12's medical record revealed an admitted [DATE] with diagnoses that included metabolic encephalopathy, dementia and hypertension. Further review of the medical record revealed on 08/03/24 Resident #12 was prescribed the use of cefdinir (antibiotic) 300 milligrams (mg) twice daily for urinary tract infection (UTI) for seven days. A progress note dated 07/29/24 at 11:11 A.M. indicated Resident #12 had pain and burning upon urination. The certified nurse practitioner (CNP) was informed of the symptoms of Resident #12 and ordered a urinalysis with culture and sensitivity. Review of the culture and sensitivity results dated 08/02/24 revealed 60-70,000 CFU/ml (colony forming unit per milliliter) of Escherichia Coli. Review of the antibiotic assessment for the use of cefdinir on 08/05/24 indicated Resident #12 did not meet criteria for use of an antibiotic for treatment of a UTI. The antibiotic assessment indicated to meet antibiotic use criteria Resident #12 only had pain and did not meet criteria based on culture results. Culture results must be greater than 100,000 CFU/ml of no more than two species of organisms in a voided sample. On 10/28/24 at 1:15 P.M. interview with Registered Nurse (RN) #541 verifies Resident #12 did not meet criteria for use of cefdinir for treatment of a UTI. 28704 5. Medical record review revealed Resident #48 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia and urosepsis. Review of the admission Minimum Data Set 3.0 assessment (dated 09/24/24) revealed Resident #48 was moderately impaired for daily decision-making and was receiving antibiotics. Review of the electronic Physician Orders (dated 09/17/24) revealed to administer cipro (antibiotic) 500 milligrams (mg) twice a day and metronidazole (antibiotic) 500 mg twice a day for urosepsis. Review of the Medication Administration Record (dated September 2024) revealed Resident #48 received four doses of cipro and metronidazole between 09/17/24 and 09/19/24. Review of the Infection Control Log (dated August/September 2024) revealed Resident #48 received cipro and metronidazole for community acquired septic colitis. There was no evidence the facility completed antibiotic surveillance regarding the appropriateness of the antibiotics upon admission. On 10/29/24 at 10:36 A.M., interview with ADON #541 verified there was no infection control antibiotic surveillance completed for Resident #48 for ciprofloxacin or metronidazole due to the resident had been receiving the antibiotics prior to admission and there was no culture information to review.

Based on medical record review, policy review and interview, the facility failed to provide care and services to restore bladder function and treat urinary tract infections (UTI) timely. This affected four (#3, #11, #44 and #52) of four residents reviewed for UTI's, and one (#57) resident reviewed for an indwelling urinary catheter. The census was 75. Findings include: 1. Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including cerebral infarction and a history of urinary tract infections. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was moderately impaired for daily decision-making and had no urinary infections within the last 30 days. Review of the progress note (dated 03/02/24 at 1:03 P.M.) revealed Resident #3 complained of burning with urination and a foul smelling odor (with urination). Nurse Practitioner (NP) #901 ordered a urinalysis and culture to be obtained on 03/04/24. No progress notes were documented on 03/03/24. On 03/04/24, NP #901 documented the resident had also developed suprapubic tenderness and the plan was to obtain a urinalysis/culture and encourage clear fluids. No progress notes were documented on 03/05/24. On 03/06/24, NP #901 documented Resident #3 was incontinent, had dysuria (painful urination), urinary frequency, and suprapubic tenderness. The urine culture result was received indicating an infection with Escherichia Coli (e-coli) and Resident #3 was started on Macrobid (antibiotic). Review of the Urinalysis/Culture Urine Report revealed Resident #3's urine was collected on 03/04/24 at 12:00 A.M., and the urine specimen was received at the laboratory on 03/04/24 at 12:24 P.M. The urine culture result was reported on 03/06/24 at 2:54 P.M On 10/28/24 at 10:37 A.M., interview with Assistant Director of Nursing (ADON) #541 verified Resident #3 developed urinary symptoms on 03/02/24 (Saturday) and the urinalysis/culture was ordered not to be obtained until 03/04/24. ADON #541 stated labs can be sent out for analysis any day of the week and resident concerns over the weekend are addressed with NP #901 on Monday mornings. ADON #541 stated NP #901 saw the resident on 03/04/24 and treatment was initiated once the urine culture result was received. The ADON was unable to provide any additional information to support why the urinalysis was ordered to be obtained on a Monday and not the weekend resulting in delay in treatment for a symptomatic UTI. 2. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including non-traumatic brain dysfunction and pneumonia. Review of the care plan: Bladder incontinence related to impaired mobility and overactive bladder (dated 05/06/24) revealed interventions including to monitor/document signs and symptoms of UTI , altered mental status, changes in behavior, and notify physician if foul odor or cloudy urine was observed. Review of the Infection Surveillance Checklist (dated 08/30/24) revealed Resident #11 met criteria for a urinary tract infection (UTI) as of 09/03/24. Review of the Laboratory Report (dated 09/03/24) revealed Resident #11's urine culture revealed greater than 100,000 colony forming units (cfu) per milliliter of urine with the bacteria, Klebsiella Pneumoniae. (clean catch samples that are properly collected, cultures with greater than 100,000 cfu per ml of one type of bacteria usually indicates infection). Review of the progress notes (dated 09/05/24 and 09/06/24) indicated Resident #11 was tolerating treatment with intravenous (IV) antibiotics for a UTI. Review of the Medication Administration Record (MAR) (dated September 2024) revealed Resident #11 was ordered to receive meropenem (antibiotic) one gram IV twice a day for urinary tract infection between 09/04/24 and 09/17/24. Further review of the record revealed no evidence IV meropenem was administered as ordered on 09/05/24 (one dose), 09/06/24 (two doses) or 09/08/24 (one dose). Review of the MAR (dated October 2024) revealed Resident #11 was ordered to receive meropenem one gram IV three times a day for a UTI between 10/10/24 and 10/20/24. Further review of the record revealed no evidence IV meropenem was administered as ordered on 10/17/24 (one dose) or 10/19/24 (two doses). On 10/23/24 at 7:58 AM interview with ADON #541 verified Resident #11's medical record did not indicate all IV antibiotics were administered to treat his UTI. ADON #541 stated she believed the nursing staff did administer the IV but they did not document it on the MAR. ADON #541 verified medications were to be documented at the time of administration and this was not done. ADON #541 also stated there was a progress note in the electronic record indicating the administration of IV antibiotics; however, this note did not indicate the actual administration of the medication but how the resident was tolerating the antibiotic use. 3. Medical record review revealed Resident #44 was admitted on [DATE] with diagnoses including dementia, diabetes mellitus, impaired balance and history of fractures. Review of the significant change in status Minimum Data Set (MDS) 3.0 assessment (dated 07/18/24) revealed Resident #44 was occasionally incontinent of urine and frequently incontinent of bowel with no toileting programs. Review of the care plan: Bladder and Bowel Incontinent related to impaired mobility (revised 07/26/24) revealed interventions including to assist with being clean, dry and comfortable with briefs, assist with toileting as needed, monitor for signs of an UTI, and apply skin protectant to periarea and buttocks. There was no evidence of a toileting program or type of bladder incontinence identified in the care plan. Review of the quarterly MDS 3.0 assessment (dated 09/04/24) revealed Resident #44 was cognitively intact for daily decision-making and was always continent of bowel and bladder with no toileting program. Review of the Bowel & Bladder Assessment -V 3 (dated 10/07/24) revealed Resident #44 was always continent of bowel and bladder with no toileting program. Review of the Task: Bowel and Bladder Continence/Frequency (dated 09/29/24 to 10/27/24) revealed Resident #44 was incontinent of bowel on 10/07/24 and 10/21/24, and was incontinent of bladder on 10/21/24 and 10/24/24. Review of the record revealed no evidence interventions were implemented to restore bladder and bowel function after incontinence episodes on 10/07/24, 10/21/24 and 10/24/24. On 10/22/24 at 8:18 A.M., interview with Licensed Practical Nurse (LPN) #536 revealed Resident #44 did have episodes of incontinence, she did not know what type of incontinence the resident had and was unaware of any interventions currently in place to restore bladder function. LPN #536 stated the aides check everyone for incontinence and she would have to ask her supervisor who was responsible for completing those types of assessments, as she primarily administers medications. Observations of Resident #44 on 10/22/24 at 10:52 A.M., on 10/24/24 at 7:52 A.M., and on 10/28/24 at 7:30 A.M. revealed no signs of incontinence. On 10/28/24 at 8:50 A.M., interview with Assistant Director of Nursing #541 verified there was no assessment to identify the type of bladder incontinence or interventions implemented to restore continence for Resident #44. On 10/28/24 at 10:15 A.M., interview with Registered Nurse #900 stated currently there were no toileting programs in the facility. When a decline was noted, an assessment would be completed and staff were expected to prompt the resident frequently; however, there was nothing documented regarding this. RN #900 stated she had not been informed about Resident #44's incontinence and she works primarily offsite which makes it difficult at times to be aware of everything going on. RN #900 verified a new bowel and bladder (B&B) assessment should have been completed since there was a change in continence status to try to determine why the resident was incontinent and what interventions could be implemented to restore function. On 10/29/24 at 9:32 A.M., interview with Certified Nursing Assistant (CNA) #565 and CNA #650 revealed the facility does not have restorative programs for toileting, all residents are checked every two hours for incontinence and incontinence care provided. CNA #565 and #650 stated there were a lot of dependent residents on the South Hall and it sometimes gets very busy but everyone does get checked. Review of the policy: Bowel and Bladder (B&B) Management (dated 2018) revealed the intent was to help the resident maintain or improve B&B incontinence for their quality of life. Actions included to complete a B&B assessment upon admission, readmission, significant change and on a quarterly basis. Appropriate interventions shall be put in place when appropriate and may include: assistive devices will be utilized as appropriate, encourage to utilize or assist the resident to the bathroom at strategic periods of the day for that resident i.e. of need if resident is frequently incontinent of B&B and does not have the cognitive ability to follow directions, nursing will anticipate the need to void and assist the resident to bathroom more frequently. Therapy screen for bladder exercises and e-stimulation and incontinence care will be provided during repositioning. 32801 4. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnosis including indwelling urinary catheter, metabolic encephalopathy, urinary tract infection, Parkinson's, cognitive communication deficit, obstructive and reflux uropathy, malignant neoplasm of prostate, dementia, major depression, anxiety, constipation, and benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #52's MDS dated [DATE] revealed the resident had an indwelling urinary catheter. Review of Resident #52's current plan of care revealed the resident had an indwelling (urinary) catheter related to outlet obstruction. Intervention included to monitor/record/report to physician for signs and symptoms of urinary tract infections (UTI): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. a. Review of Resident #52's urine culture results dated 05/29/24 and reported on 05/31/24 revealed the resident's urine culture grew greater than 100,000 cfu/ml of pseudomonas aeruginosa (bacteria). The antibiotic imipehem-cilastatin was sensitive (the bacteria identified in the sample are likely to be effectively killed or inhibited by that specific antibiotic). There was a handwritten note dated 06/03/24 (three days after the results were reported) to start imipehem-cilastatin 500 mg IV every six hours for five days. Review of Resident #52's orders and Medication Administration Record (MAR) dated 06/2024 revealed on 06/04/24 the resident was started on imipehem-cilastatin (antibiotic) 500 milligrams (mg) intravenously every six hour for five days for a urinary tract infection (UTI). There was no evidence the last dose was administered on 06/09/24 at 6:00 A.M. The note indicated the medication was not available. Review of Resident #52's medical record revealed no evidence the provider was notified the last dose of imipehem-cilastatin was not administered. Further review revealed the resident was hospitalized from 06/13/24 to 06/21/24 for sepsis, not secondary to UTI, encephalopathy, anemia, depression, gastric reflux disease, hyperlipidemia, hypertension, and Parkinson's disease. Interview on 10/29/24 at 7:40 A.M., with Registered Nurse (RN) #714 confirmed Resident #52 did not receive the last dose of imipehem-cilastatin on 06/09/24 due to it was not available to be administered and there was no evidence the provider was notified the last dose was not administered. b. Review of Resident #52's orders and Medication Administration Record (MAR) dated 06/2024 revealed on 06/21/24 (date resident returned from hospital) the resident was ordered Zosyn (antibiotic) 4.5 grams intravenously every six hour for 12 days for UTI. There was no documented evidence the medication was administered at 6:00 P.M. on 06/21/24, 06/24/24, and 06/26/24 and midnight on 06/22/24 nor was there evidence the medication was extended to cover the missed doses to ensure the resident received 12 days of the antibiotics. Review of Resident #52's medical record revealed no evidence the provider was notified of the missing doses. Interview on 10/29/24 at 7:40 A.M., with RN #714 confirmed the resident did not receive Zosyn on 06/21/24, 06/24/24, and 06/26/24 at 6:00 P.M. and midnight on 06/22/24. The RN reported on the 06/21/24 the resident would have not received it because he didn't arrive to the facility until 3:46 P.M. and the facility would have not had the medication at that time. On 06/22/24 staff had documented the medication was not available and 06/24/24 and 06/26/24 there were no notes indicating why the medication was not administered. RN #714 confirmed there was no documented evidence the provider was notified of the missed doses nor was the medication extended to account for the missing doses. c. Review of Resident #52's orders and Medication Administration Record (MAR) dated 06/2024 revealed on 06/22/24 the resident was ordered Macrobid 100 mg twice daily for five days for UTI. There was no evidence the Macrobid was administered on 06/22/24 at 8:00 P.M., nor was the order extended to ensure the resident received five full days of Macrobid. Review of Resident #52's medical record revealed no evidence the resident's provider was notified the resident didn't receive Macrobid on 06/22/24. Interview on 10/29/24 at 7:40 A.M., with RN #714 confirmed the resident did not receive Macrobid on 06/22/24 due to the medication was not available. The RN also confirmed there was no documented evidence the provider was notified nor was the order extended to cover the missing dose. d. Review of Resident #52's urine culture dated 08/30/24 and resulted on 09/02/24 revealed the resident urine culture grew greater than 100,000 cfu/ml pseudomonas aeruginosa (bacteria). There as documentation on the culture report dated 09/02/24 at 5:06 P.M. from lab to call the nursing home due to the resident had a UTI and may need intravenous antibiotics. An additional note dated 09/03/24 at 11:25 A.M., revealed the lab called the nursing facility to ensure the facility could administer intravenous therapy and notify the facility of the results. Review of Resident #52's orders and MAR dated 09/2024 reveled the resident was ordered cefdinir 300 mg twice daily by mouth (not intravenous per labs recommendation) on 09/03/24, however not administered until 8:00 P.M., 09/04/24 then it was discontinued and switched to meropenem one gram intravenously every eight hours for 21 doses on 09/05/24 at 4:00 P.M. Interview on 10/29/24 at 7:40 A.M., with RN #714 confirmed there was a delay in treatment due to the laboratory never called report to the facility until 09/03/24. The RN confirmed the provider prescribed cefdinir which was not an appropriate antibiotic, however the following day another provider reviewed the results and changed the antibiotics to intravenous and an appropriate medication per the culture results recommendation. Review of the facility's policy titled Administration and documentation of medication undated revealed the facility policy was to ensure every resident received medication by a licensed nurse as prescribed by a licensed physician or other healthcare provider legally permitted to prescribe medication, safely, properly, and in a timely manner, and that medication shall be accurately and completely documented. 5. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including acute kidney disease, cognitive communication deficit, need assistance with personal care, obstructive and reflux uropathy, hydronephrosis, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, intellectual disabilities, and ileus. Review of Resident #57 MDS dated [DATE] revealed the resident had an indwelling urinary catheter. a. Observation on 10/21/24 at 2:02 P.M. and 2:20 P.M., and 10/23/24 at 12:52 P.M., of Resident #57 revealed the resident was sitting in a recliner and his urinary catheter was hanging from a trash can (which was shared with the roommate) that was filled with trash. The urinary catheter was also noted to be touching the floor. Review of the Resident #57's current plan of care for enhanced barrier precautions revealed the resident preferred to have catheter bag hung from the trash can for comfort. Interview and observation on 10/23/24 at 12:53 P.M. with Licensed Practical Nurse (LPN) #583 confirmed the resident's urinary catheter bag was hanging from a dirty trash can and it was touching the floor. Interview on 10/23/24 at 2:30 P.M., with the Infection Preventionist (IP) #541 revealed the resident's care plan did indicate the resident requested to have the catheter bag hung from the trash can, however the trash can should not have trash in it, and it should not be touching the floor. Staff should place a barrier between the catheter bag and the floor. The IP reported she didn't know if the facility had attempted to hang the catheter bag from anything else other than the trash can for the resident's comfort. Interview on 10/23/24 at 3:00 P.M., with Certified Nursing Assistant (CNA) #597 and #528 confirmed Resident #57 catheter bag should not be placed in the dirty trash can be due to there was only one trash can in the room for both residents to use. The CNAs reported they should have got a basin and placed the catheter bag in the basin. Interview on 10/24/24 at 11:25 A.M., with Registered Nurse (RN) #714 revealed the facility purchased a separate trash can and labeled it not for use for trash so the resident could hang his catheter bag from that trash can to prevent contamination. b. Review of Resident #57's urine culture results dated 06/30/24 revealed the urine culture had three or more bacterial isolated and suggest recollecting urine specimen to conclusively evaluate the resident's urine culture results. Review of Resident #57's medical record revealed no evidence the urine was recollected; however, the resident was treated with Macrobid 100 mg twice daily for seven days for a UTI per the Medication Administration records from 07/01/24 to 07/08/24. Review of Resident #57 McGeer criteria form dated 06/30/24 revealed the resident did not meet criteria for treatment using an antibiotic. A handwritten note indicated the resident had a fall and it was discussed with the provider and to continue antibiotic series. Interview on 10/24/24 at 4:31 P.M., with IP #541 confirmed the resident did not meet criteria for treatment on 06/30/24 and the urine was not re-collected to ensure the resident was treated with the correct antibiotic.

Based on record review, observation, and interview the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected four (Resident #11, #30, #52, and #53) of 27 records reviewed. Findings included: 1. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including encephalopathy, sequelae of cerebral infarction, hemiplegia and hemiparesis, aphasia, and depression. There was no evidence the resident diagnoses list included contractures. Review of Resident #30's Physical Therapy (PT) notes dated 01/22/24 revealed the resident had function limitation of the knee, hip, and ankle on the right lower extremity due to contractures. Review of Resident #30's range of motion (ROM) assessment dated [DATE] revealed the resident had had full loss of voluntary movement of the legs including hip and knee, foot including ankle and toes on one side of the body. Review of Resident #30's current plan of care revealed the resident was at risk for decline in current status for range of motion and contracture development, however, did not indicate the resident had range of motion impairment or contractures or location of impairments. Review of Resident #30's MDS dated [DATE] revealed the resident had limited range of motion one side of the upper extremity and impairment on both sides of the lower extremity. Observation on 10/22/24 at 11:11 A.M. and 10/24/24 at 8:15 A.M. of Resident #30 revealed no evidence of limited range of motion to the lower extremities. Interview on 10/24/24 at 11:24 A.M. and 12:07 P.M., with Registered Nurse (RN) #714 revealed the nurse re-assessed Resident #30's lower extremity range of motion (ROM) and there was only impairment on the right lower extremity. The resident has contractures in the right knee and foot, and limited range of motion in the right hip. The left lower extremity had no limited range of motion. RN #714 reported she will have MDS correct the MDS dated [DATE] to reflect limited range of motion to one side of the lower extremity not both sides. 2. Record review revealed Resident #52 was admitted to the facility on [DATE] discharged home on 07/28/23 and readmitted [DATE] with diagnosis including metabolic encephalopathy, urinary tract infection, Parkinson's, aphasia, cognitive communication deficit, obstructive and reflux uropathy, malignant neoplasm of prostate, sleep terrors, attention and concentration deficit, dementia, major depression, anxiety, spinal stenosis, lower back pain, gastro-esophageal reflux disease, hyperlipidemia, hypertension, pulmonary embolism, constipation, and benign prostatic hyperplasia without lower urinary tract symptoms. There was no evidence hip fracture was listed on the diagnoses list. Review of Resident #52's progress note dated 10/25/23 revealed the resident had complaints of hip pain and an x-ray confirmed a hip fracture. The resident was transported to the emergency room for treatment. Review of Resident #52's hospital note dated 10/26/23 revealed the resident had a left hip fracture. Review of Resident #52's MDS dated [DATE] revealed no evidence of a fall with a major injury. Interview on 10/22/24 at 3:46 P.M., with RN #714 confirmed Resident #52 had a fall with fracture on 10/22/23. Interview on 10/28/24 at 2:25 P.M., with RN #900 confirmed the MDS dated [DATE] was inaccurate and didn't reflect the fall with major injury that occurred on 10/22/23 and she would modify the MDS to capture the fall with major injury. 3. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including low back pain, cervical disc disorder, falls, dementia, weakness, and impaired mobility. Review of Resident #53's orders and medication records dated 07/11/24 to 10/24/24 revealed the Resident had been receiving a Lidoderm patch 5% to back topically every day for pain since admission (07/11/24). Review of Resident #53's current plan of care revealed the resident was at risk for pain related to low back pain and generalized discomfort. Review of Resident #53's MDS dated [DATE] revealed the Resident was not on a scheduled pain medication regimen. Interview on 10/28/24 at 8:34 A.M., with RN #517 confirmed the resident receives a pain patch every morning for back pain. Interview on 10/28/24 at 10:44 A.M, with RN (MDS nurse) #900 confirmed the MDS was marked inaccurate due to the resident was on pain management (Lidoderm Patch) daily for pain control since admission. RN #900 reported she would modify the MDS to reflect the resident was on a scheduled pain regimen. 28704 4. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including non-traumatic brain dysfunction and pneumonia. a. Review of the Infection Surveillance Checklist (dated 08/30/24) revealed Resident #11 met criteria for a urinary tract infection (UTI) as of 09/03/24. Review of the Laboratory Report (dated 09/03/24) revealed Resident #11 urine culture revealed greater than 100,000 Klebsiella Pneumoniae (bacteria). Review of the Progress Notes (dated 09/05/24 and 09/06/24) indicated Resident #11 was tolerating treatment with intravenous (IV) antibiotics for a UTI. Review of the Medication Administration Record dated September 2024 revealed Resident #11 received Meropenem (antibiotic) one gram IV twice a day for urinary tract infection between 09/04/24 and 09/17/24. Review of the quarterly MDS 3.0 assessment (dated 09/16/24) revealed Resident #11 did not have a UTI in the last 30 days. Review of the quarterly MDS 3.0 assessment (dated 10/08/24) revealed Resident #11 did not have a UTI in the last 30 days. On 10/28/24 at 3:44 P.M., interview with RN #900 verified the MDS 3.0 assessments (09/16/24 and 10/08/24) were inaccurate as described above for Resident #11.

Based on medical record review, review of shower schedules, and interview, the facility failed to ensure bathing preferences were honored. This affected one (Resident #178) of 14 residents interviewed related to choices. Findings include: Review of Resident #178's medical record revealed diagnoses including left hip fracture, depression, and type two diabetes mellitus. An assessment for Preference for Everyday Living (PELI) dated 10/07/24 revealed it was somewhat important for Resident #178 to choose between a tub bath, shower, bed bath or sponge bath. Resident #178 preferred a tub bath with no preference for bathing time. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #178 was able to make herself understood and was able to understand others. Resident #178 was assessed as cognitively intact. Review of an Interdisciplinary team (IDT) note dated 10/18/24 revealed Resident #178 required substantial/maximal assistance with bathing. Review of shower schedules revealed Resident #178 was scheduled to receive showers on day shift on Mondays, Wednesdays and Fridays. Review of bathing records revealed Resident #178 received a shower on 10/14/24. There was no evidence of bathing being offered 10/21/24 or 10/25/24. Documentation only revealed bathing activities were offered one day between 10/20/24 and 10/26/24. On 10/21/24 at 3:14 P.M., Resident #178 indicated she preferred to receive bed baths but staff had provided showers instead. Resident #178 stated she was not bathed with the frequency requested and she had been bathed about twice a week. On 10/28/24 at 11:45 A.M., the Director of Nursing (DON) verified she was unable to locate evidence of bathing being offered to Resident #178 on 10/21/25 or 10/25/25 and that documentation revealed Resident #178 did receive one shower. On 10/28/24 at 7:37 A.M., the DON verified residents had the right to choose the type of bath they received. The DON verified Resident #178 preferred bed baths.

Based on medical record review, policy review and interview, the facility failed to ensure advanced directives were accurate. This affected one (#59) of 24 residents reviewed for advanced directives. The census was 75. Findings include: Medical record review revealed Resident #59 was admitted on [DATE] with diagnoses including cerebral infarction. Review of the medical record revealed no Advanced Directive form for review. Review of the Baseline Care Plan (dated [DATE]) revealed Resident #59 was a Full Code (a medical directive that indicates that a resident should receive all possible medical care to save their life in the event of a medical emergency). Review of Nurse Practitioner #901's History and Physical (dated [DATE]) revealed Resident #59 was a Full Code. Review of the electronic medical record, including the Physician Orders as of [DATE], indicated Resident #59 was a DNR-CCA (Do-Not-Resuscitate Comfort Care Arrest which is a medical abbreviation that allows residents to receive aggressive interventions to extend their life until they experience cardiac or respiratory arrest. After the cardiac or respiratory arrest, the resident will only receive comfort care). On [DATE] at 12:39 P.M., interview with Assistant Director of Nursing (ADON) #541 stated Resident #59 was a full code and had been out to the hospital many times. ADON #541 stated there should be a signed code status in the chart and staff were to go to the hard chart to verify code status prior to initiation of cardiopulmonary resuscitation (CPR), but the code status was also in the electronic physician orders. ADON #541 verified Resident #59's physician orders indicated Resident #59 was a DNR-CCA but the medical record did not contain an advanced directive form indicating the resident was a DNR-CCA status. On [DATE] at 3:23 P.M., interview with ADON #541 stated Resident #59's family did request to change the resident's code status on [DATE] to a DNR-CCA; however, the Ohio Advanced Directive paperwork had not yet been signed by the physician or family. ADON #541 verified until the physician signed DNR paperwork was in the resident's chart, the resident's code status would be a Full Code. Review of the PT (Physical Therapy) Evaluation and Plan of Treatment (dated [DATE]) revealed Resident #59 code status was a Full Code. As of [DATE], review of the medical record revealed no documented evidence of a signed Ohio Advanced Directive. Review of the policy: Advanced Directive Guidance (revised [DATE]) revealed all residents without advanced directives will be treated as Full Codes. If the resident wants to decide their advanced directives after speaking to the nurse, physician, or advanced nurse practitioner, a nurse or social service will initiate an Ohio Advanced Directive form with the resident signature. If the resident is unable to sign, the appointed resident representative may sign. The Ohio Advanced Directive form will need to be fully executed by the resident's physician, then a nurse will obtain a physician order following the advanced directive wishes of the resident. The advanced directive order will be entered into the resident's electronic health record. The advanced directive physician's order in the electronic health record will be the primary source the nurses will follow during a code blue situation. This can be found immediately when accessing the resident's electronic record. The Director of Nursing or designee will be responsible for reporting on auditing and managing each Ohio Advanced Directive fully executed form with each resident's advanced directive physician's order.

Based on record review and interview the facility failed to ensure comprehensive information was conveyed to the receiving health care provider and documented as such in the medical record. This affected one (Resident #52) of two residents reviewed for hospitalization . Findings included: Record review revealed Resident #52 was initially admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy, urinary tract infection, Parkinson's disease, cognitive communication deficit, attention and concentration deficit, dementia, major depression, anxiety, and benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #52's census tab from 06/01/24 to 10/18/24 revealed the resident was transferred and admitted to the hospital on 06/13/24, 08/11/24, 09/26/24, and 10/13/24. The resident was transferred to the hospital on 09/06/24, however was not admitted to the hospital and returned to the facility. Further review of Resident #52's medical record revealed no documented evidence all the required information (including but not limited to physician contact information, resident representative contact information. advanced directives (code status), all special instructions and/or precautions for ongoing care, as appropriate; and all other information necessary to meet the resident's needs) was documented and conveyed to the receiving provider for the hospital transfers that occurred on 06/13/24, 08/11/24, 09/06/24, 09/26/24, and 10/13/24. Interview on 10/29/24 at 7:48 A.M., with Registered Nurse (RN) #714 confirmed there was no documented evidence all the required information was conveyed to the hospital on 06/13/24, 08/11/24, 09/06/24, 09/26/24, and 10/13/24. The RN reported the facility has an assessment tool/form that staff were to complete with each transfer with all the required information, however the staff did not complete the assessment form for 06/13/24, 08/11/24, 09/06/24, 09/26/24, or 10/13/24 transfers. Interview on 10/29/24 at 9:42 A.M. with RN #714 confirmed the facility did not have a policy or procedure for transfer, however the facility would follow the regulation.

Based on medical record review and staff interview, the facility failed to ensure a discharge summary of a resident stay was completed following discharge from the facility. This affected one (Resident #75) of one residents reviewed for discharge. The facility census was 75. Findings include: Review of Resident #75's medical record revealed an admitted [DATE] with diagnoses that included congestive heart failure, atherosclerotic heart disease, hypertension and hyperlipidemia. Further review of the medical record revealed on 08/16/24 Resident #75 was discharged to the assisted living facility connected to the facility. Review of the discharge summary revealed no evidence of completion by the nursing or dietary departments. On 10/28/24 at 10:41 A.M. interview with the Director of Nursing verified Resident #75's discharge summary was not completed thoroughly.

Based on observations, medical record review, review of shower schedules and interview, the facility failed to provide hygiene and/or grooming for three (Residents #29, #54, and #73) of 24 residents screened for hygiene/grooming. Findings include: 1. Review of Resident #73's medical record revealed diagnoses including metabolic encephalopathy (a condition in which brain function is disturbed by diseases or toxins in the body), Parkinson's disease, fracture of the fourth metacarpal of the left hand, and neurocognitive disorder. A baseline care plan dated 09/18/24 indicated Resident #73 was to be assisted with bathing as needed. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 was usually understood and usually understood others. Resident #73 was assessed as moderately cognitively impaired. No rejection of care was documented. Resident #73 required substantial/maximal assistance with bathing and partial/moderate assistance with personal hygiene. a. The medical record revealed no evidence the resident refused to be shaved in October 2024. Observations on 10/21/24 at 10:40 A.M., on 10/22/24 at 10:54 A.M. and 1:04 P.M., and on 10/23/24 at 8:41 A.M., 12:24 P.M., and 5:25 P.M. revealed Resident #73 was unshaven. On 10/23/24 at 9:14 A.M., Certified Nursing Assistant (CNA) #514 verified Resident #73 was unshaven. CNA #514 reported residents were generally shaved during showers and Resident #73 needed staff to assist with shaving. CNA #514 reported Resident #73 was compliant with care but was unable to state when he last had a shower. b. An assessment for Preference for Everyday Living (PELI) dated 10/22/24 revealed it was very important for Resident #73 to choose between a tub bath, shower, bed bath or sponge bath. Resident #73 preferred a tub bath in the mornings. Review of the shower schedule revealed Resident #73 was on a list for showers/baths every day. Review of shower records since 10/01/24 revealed no evidence showers/baths were offered on 10/05/24, 10/10/24 or 10/21/24. On 10/23/24 at 1:55 P.M., the Director of Nursing (DON) verified there was no documented evidence of baths/shower being offered on 10/05/24, 10/10/24, or 10/21/24. 2. Review of Resident #29's medical record revealed diagnoses including anxiety disorder, asthma, chronic obstructive pulmonary disease, osteoarthritis, and type two diabetes mellitus. A baseline care plan dated 10/04/23 indicated Resident #29 needed assistance with bathing and transfers as needed and indicated the use of a mechanical lift for transfers. A physician order dated 09/03/24 revealed Resident #29 had an order for hoyer lifts for all transfers. Review of shower schedules revealed Resident #29 was scheduled to get a shower on dayshift on Mondays and Thursdays. Review of bathing records since 09/01/24 revealed no evidence of showers being offered on 09/23/24, 09/26/24, and 09/30/24. Documentation revealed Resident #29 refused bathing and documented no hoyer batteries on 10/17/24. During an interview on 10/21/24 at 11:56 A.M., Resident #29 reported she was scheduled to receive showers on Mondays and Thursdays. Resident #29 reported she did not receive a shower since 10/14/24 because staff were unable to find a working battery for the mechanical lift. Resident #29's hair had an oily appearance . On 10/23/24 at 8:50 A.M., CNA #597 verified she was assigned to care for Resident #29 on 10/17/24. Resident #29 was willing to take a shower but there was no batteries charged to transfer her. CNA #597 reported a bed bath was offered and refused. On 10/23/24 at 12:00 P.M., the lack of evidence of showers being offered on 09/23/24, 09/26/24 and 09/30/24 was discussed with the DON. No additional information was provided to prove Resident #29 received showers as scheduled/per plan of care. 28704 3. Medical record review revealed Resident #54 was admitted on [DATE] with diagnoses including Creutzfeldt-[NAME] disease (rare brain disease), diabetes mellitus type-2, anxiety disorder and dementia. Review of the quarterly MDS 3.0 assessment (dated 09/04/24) revealed Resident #54 was severely impaired for daily decision-making. Review of the South Shower list revealed Resident #54 was to receive his showers on Tuesday, Thursday and Sunday on dayshift. Review of the Task: Self-Care Shower/bathe self (assessment reference date 09/13/24) revealed Resident #54 required substantial/maximal assistance on 09/07/24 to complete the task and was dependent on staff completing the task on 09/08/24, 09/09/24, 09/11/24 and 09/12/24. Review of Resident #54's Shower Sheets and Bathing Task (dated August 2024 through October 2024) revealed no documented evidence a bath/shower/hygiene was completed as scheduled on 08/13/24, 09/10/24, 09/15/24, 09/26/24, 09/29/24, 10/01/24 or 10/15/24. On 10/21/24 at 2:28 P.M., observation revealed Resident #54's hair was disheveled and oily. [NAME] hair and dirty fingernails were also observed. On 10/23/24 at 9:01 A.M., interview with CNA #565 verified Resident #54 required assistance and cues with all activities of daily living. On 10/23/24 at 9:35 A.M., interview with Licensed Practical Nurse (LPN) #572 verified bath/shower/hygiene should be done as scheduled and were not completed as scheduled. On 10/23/24 at 9:44 A.M., Resident #54 was observed with facial hair. On 10/24/24 at 7:40 A.M., observation revealed Resident #54 had heavy facial hair stubble. On 10/24/24 at 10:20 A.M., interview with regional Regional Nurse #714 verified there was no evidence Resident #54's showers were completed as required and there was no additional information to provide. Review of the policy: Personal Care (revised August 2023) revealed a shower was typically scheduled twice a week unless the resident request additional showers. A bed bath should be offered or encouraged on days a resident does not get a shower and assist as needed to shave, comb/brush hair etc. If a resident refuses after repeated attempts to shower or bathe, notify the charge nurse.

Based on observation, staff interview, and medical record review the facility failed to develop a pain management program to address pain during dressing changes and pain associated with finger contractures. Harm occurred to Resident #4 when facility staff moved the resident's hand extending his fingers and removed a dressing from the resident's right ear causing the resident extreme pain as evidenced by facial grimacing, groaning, wincing, clenching his fists, and crying. This affected one of one resident (Resident #4) reviewed for pain. The facility census was 58. Findings include: Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #4's speech was clear, he sometimes made himself understood, he sometimes understands others, his short-term and long-term memory was impaired, he recalled staff name and faces, that he was in a nursing home, and decision making was moderately impaired. Resident #4 had mild depression, no indicators of [CONDITION(S)], had no behaviors, and did not reject care. Resident #4 required extensive assistance of two staff for bed mobility and was dependent on two staff to transfer, required extensive assistance of one staff for personal hygiene, and no range of motion (ROM) impairment and he had no pain. Review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review revealed on 02/12/21 Resident #4 was diagnosed with cancer of the right ear. Resident #4 did not have a pain management program. Observation of Resident #4 on 06/09/21 at 7:20 A.M. with Licensed Practical Nurse (LPN) #169 revealed the last three fingers of his right hand were contracted. When LPN #169 attempted to touch Resident #4's right hand he pulled it back and guarded his hand. Resident #4 let LPN #169 touch his hand, when she tried to extend his last three fingers Resident #4 pulled his hand away, was groaning and facially expressed pain. LPN #169 was unable to passively stretch Resident #4's last three fingers. LPN #169 confirmed she was not able to passive fully extend his last three fingers. When the LPN #160 removed the dressing to his right ear he clinched his eyes closed, turned his head away, his face was reddened, he groaned continually, and he clenched his fists. As LPN #169 cleansed his right ear he was wincing, clinched his fist, and had tears slowly running down the right side of his face. LPN #169 stated during the procedure that Resident #4 was very confused and could not tell you he was in pain. She stated if Resident #4 was in pain he says no, straightens his arms and makes a fist. LPN #169 stated she just had to talk him through the treatment. LPN #169 did not think grimacing and guarding was evidence Resident #4 was in pain, but rather it was a behavior. Interview with the Director of Nursing (DON) on 06/09/21 at 10:30 A.M. confirmed Resident #4 did not have a pain management program. She stated if the resident had pain then his physician would be notified and could order medication to treat the pain. The DON confirmed grimacing and guarding were examples of non-verbal expressions of pain. The DON confirmed Resident #4 was confused.

Based on observation, staff interview, and medical record review the facility failed to ensure one resident (Resident #4) did not develop contractures to the fingers. Actual Harm occurred to Resident #4 when the resident did not receive the needed range of motion to prevent the development of avoidable finger contractures. This affected one of three sampled residents reviewed for limited range of motion. Findings include: Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's annual Minimum Data Set (MDS) 3.0 dated 06/09/2020 revealed the following: Resident #4's speech was clear, he sometimes made himself understood, he sometimes understands others, his short-term and long-term memory was impaired, he recalled staff name and faces, that he was in a nursing home, and decision making was moderately impaired. Resident #4 had mild depression, no indicators of [CONDITION(S)], had no behaviors, and did not reject care. Resident #4 required extensive assistance of two staff for bed mobility and was dependent on two staff to transfer, required extensive assistance of one staff for personal hygiene, and had no range of motion (ROM) impairment. Observation of Resident #4 on 06/09/21 at 7:20 A.M. with Licensed Practical Nurse (LPN) #169 revealed the last three fingers of his right hand were contracted. LPN #169 was unable to passively stretch Resident #4's last three fingers. LPN #169 confirmed she was not able to passive fully extend his last three fingers. Interview with State tested Nursing Assistant (STNA) #193 on 06/09/21 at 11:17 A.M. revealed Resident #4 was unable to extend the last three fingers on his right hand. STNA #193 stated the contractured fingers had developed over time. STNA #193 stated Resident #4 did not resist care, and staff just have to take time with him as he did not hear well and it takes time for him to understand. Observation and interview with the DON on 06/09/21 at 2:12 P.M. revealed Resident #4 was unable to extend his last 3 fingers on his right hand, The DON was unable to passively extend the last three fingers of Resident #4's right hand. The DON revealed restorative programs were placed on hold due to COVID-19. Interview with Registered Nurse (RN) #176 on 06/09/21 at 2:38 P.M. revealed when she last assessed Resident #4 on 03/12/21 she could passively extend all of his fingers. Interview with STNA #208 on 06/10/21 at 8:56 A.M. revealed she provided range of motion for Resident #4 if she had time. STNA #208 stated if put lotion on Resident #4's arms and legs then she would get him to lift his legs or lift his arms, however she did not always have time to do this.

Based on observation, record review, interview and policy review the facility failed to ensure ongoing accurate weight monitoring was completed, failed to ensure meal intakes were documented and failed to address abnormal [MEDICATION NAME] results for Resident #33 who was assessed to have significant weight loss and multiple skin alterations. The facility also failed to monitor fluid intake and ensure Resident #73 was provided sufficient fluid to prevent dehydration. This affected two residents (#33 and #73) of three residents reviewed for weight loss and hydration. Actual harm occurred when Resident #33 sustained a 27.7 pound (15.4%) severe weight loss in three months, from 06/16/20 to 09/10/20 without evidence of an individualized and comprehensive nutritional plan of care to prevent the loss or promote weight gain. In addition, the facility was not obtaining weights accurately, did not document 144 meal intakes for the resident, was not monitoring weekly weights per policy and did not timely follow up on an abnormal laboratory result (low pre-[MEDICATION NAME] level) per the nurse practitioner's recommendation. The resident continued to lose weight, losing an additional 3.5 pounds from 09/10/20 to 10/01/20 without any evidence of new interventions being implemented at that time. Findings include: 1. Review of Resident #33's medical record revealed the resident was originally admitted to the facility on [DATE] with a latest readmission date of [DATE]. [DIAGNOSES REDACTED]. The resident had unhealing open wounds to the bilateral heels, right lower leg, distal chest, and proximal chest. Review of Resident #33's current plan of care revealed the resident had the potential for alteration in nutrition and hydration related to diabetes, diuretic use, being overweight, use of a therapeutic diet, and medical [DIAGNOSES REDACTED]. Interventions included weights per order, provide diet per order and dietitian referral as needed. Record review revealed the resident was documented to weigh 180 pounds on admission (06/16/20). The next documented weight was obtained on 06/30/20 which reflected the resident weighed 166 pounds, a 14 pound weight loss in two weeks. There was no evidence a reweight was obtained following the identified weight loss to ensure the weight was accurate. Review of a dietary assessment, dated 06/18/20 revealed the resident required supervision with eating. The assessment revealed the resident's weight was 180 pounds on admission and his hospital weight was 182 pounds. No nutritional interventions were noted at that time. The resident had been seen by speech therapy with no trouble swallowing noted. Record review revealed no new dietary progress note or dietary interventions were initiated on 06/30/20 after the identification of the 14 pound weight loss. The resident was hospitalized from [DATE] to 07/13/20. His re-admission weight on 07/13/20 was 164 pounds. Review of a dietary progress note, dated 07/16/20 revealed dietary recommended house liquid protein 30 milliliters (ml) daily to promote wound healing (the resident was being treated for [REDACTED]. This note also reflected the resident had a significant weight loss of 16 pounds in the last thirty days. His weight was 166 pounds on 06/30/20 and 164 pounds on 07/13/20. The note revealed the weight could have been possibly fluid related but did not provide any other information related to the resident's nutritional status, nutritional needs or recommendations for interventions to prevent additional weight loss/promote weight gain. A dietary note, dated 07/20/20 revealed the liquid protein was discontinued because the resident disliked it. The note also revealed the resident reported the [MEDICATION NAME] (appetite supplement) that was ordered was not helping and indicated the resident needed increased protein for (wound) healing. The resident agreed to a nutritional supplement (Boost) chocolate twice a day at lunch and dinner which would provide 480 calories, 20 grams of protein . There was no evidence the resident's weight loss or nutritional status was re-assessed at that time. A dietary note, dated 07/27/20 revealed the resident requested a visit because he could not taste most foods and he did not think the appetite stimulant was working. He consumed very little for lunch. Food preferences were updated at that time. A [MEDICATION NAME] and yogurt at breakfast were ordered due to the resident being on antibiotics with complaints of diarrhea. There was no evidence the resident's weight was re-assessed at that time. A dietary note, dated 08/05/20 revealed the resident's food preferences were again updated. On 08/06/20 the resident's meal intakes were noted to vary between 25-100%. The resident estimated needs were calculated to be 2205-3080 calories and 110-132 grams of protein per day. This note indicated the residents house supplement provided 1080 calories and 42 grams of protein, however, review of the 07/20/20 note revealed this supplement only provided 480 calories and 20 grams of protein. No new recommendations were made at that time. There was no evidence the resident's weight was re-assessed. The resident was hospitalized again from 08/07/20 to 08/13/20 and weighed 151.8 on readmission. On 08/17/20 a dietary assessment revealed the resident was re-assessed following his re-admission. The note indicated the resident had been hospitalized for [REDACTED]. He was readmitted with one ounce of liquid protein for 30 days and a house supplement three times a day. The three house supplement provided 1082 calories and 42 grams of protein a day. (However, the dietician indicated on 08/06/20 two eight-ounce house supplements provided 1080 calories and 42 grams of protein and on 07/16/20 two eight-ounce house supplements provided 480 calories and 20 grams of protein). The note revealed the resident complained of poor appetite. His weight on 08/13/20 was 151.8 pounds. The dietary assessment revealed the resident was at risk for malnutrition due to poor appetite, unplanned significant weight loss and increased nutritional needs due to alternation in skin integrity and with loss. The note recommended to add arignaide (protein powder) one packet daily for wound healing. Review of the facility weight policy and weight documentation for Resident #33 revealed weekly weights should have been obtained but were not from 06/21/20 to 06/27/20, 07/19/20 to 07/25/20, 07/26/20 to 08/01/20, 08/02/20 to 08/07/20, 08/16/20 to 08/22/20, 08/30/20 to 09/05/20, 09/13/20 to 09/19/20 or 09/20/20 to 09/24/20. In addition, the resident had only been weighed two additional times since his last admission on 08/13/20. He weighed 150 pounds on 08/26/20 and 152.3 pounds on 09/10/20. The resident's weight on 09/10/20 reflected a 27.7 pound severe weight loss from the resident's admission weight of 180 pounds. Review of Resident #33's meal intake records, from 06/24/20 to 09/22/20 revealed 144 meal intakes were not documented for the resident during this time period. Review of Resident #33's laboratory results, dated 08/19/20 revealed the resident's [MEDICATION NAME] level was 10.8 low (normal range 17.6-36). A handwritten note from the nurse practitioner revealed dietician to see and address. Review of Resident #33's medical record revealed no evidence the dietician had reviewed or addressed the low [MEDICATION NAME] level. The Minimum Data Set (MDS) 3.0 assessment, dated 08/20/20, the resident required set up assistance from one staff member for meals. The dietary notes reviewed from 08/25/20 and 09/15/20 revealed no changes from the 08/17/20 note with no additional nutritional recommendations noted to address the resident's weight loss. A wound note dated 09/17/20 revealed the resident had two areas on his sternum that required extensive debridement. There was an open area on the resident's right lower leg and the right and left heels had Stage III Wagner ulcers (deeper tissue is involved, with abscess, osteo[DIAGNOSES REDACTED], or tendonitis). Review of the nutritional evaluation, dated 09/24/20 revealed the resident was on regular diet and liquids. He was prescribed a house supplement three eight ounces severing daily and arignaide daily. His intakes were 51%-75%. His last weight on 09/10/20 was 152.3 pounds with no evidence of a current weight. The note revealed the resident had a significant weight loss of 27.7 pounds (15.4%) in the last three months. The resident's nutritional needs were calculated to be 1725-2070 calories per day and 69-86 grams of protein daily. He was currently ordered a house supplement (570 calories/48 grams of protein). No new orders or recommendations were made at this time. On 09/22/20 at 2:13 P.M. and 09/23/20 at 9:29 A.M. interview with Resident #33 revealed he tries to drink the Boost (nutritional supplement) and his family has also brought Boost drinks in for him to drink. He reported he doesn't have much of a taste and stated his usual body weight was 194 pounds. On 09/24/20 at 9:39 A.M. interview with Registered Dietary Technician (RDT) #100 and Registered Dietician (RD) #102 verified the [MEDICATION NAME] results dated 08/19/20 were not reviewed by the RDT or RD. They reported they were working remotely from home and only had access to what was in the electronic medical record and the laboratory results were not part of the electronic medical records at this time. During the interview RDT #100 and RD #102 confirmed weights would be important to accurately assess a resident's nutritional status, but they only had what was available to them in the electronic medical record because they were working remotely from home. Obtaining weights was nursing staffs responsibility, however they should have been obtained weekly following admission and re-admission and a re-weight should have been obtained if a significant change in weight was noted. RDT #100 and RD #102 also confirmed meal intakes would be important to accurately assess a resident's nutritional status, but again stated they only had what was available to them in the electronic medical record because they were working remotely from home. The RD reported she was new to the position since August 2020 On 09/24/20 at 10:37 A.M. interview with the Director of Nursing (DON) confirmed nursing staff did not provide the RDT or RD with a copy of the [MEDICATION NAME] results for the resident. The DON also verified the resident was not weighed per facility policy. The DON stated the resident should have been weighed weekly for four weeks on admission, re-admission, and if a significant weight loss was noted. The DON confirmed there was no evidence weights were obtained for the dates listed above. The DON reported she was new to the position and was not aware tracking weights was part of her job duty. During the interview, the DON also confirmed the lack of documented meal intakes for the resident to accurately determine how much the resident was consuming. On 10/01/20 at 9:35 A.M. and 10:07 A.M. Registered Nurse (RN) #58 and State tested Nursing Assistant (STNA) #16 were observed to weigh Resident #33. The resident was in a wheelchair and dressed in a hospital gown with a bath blanket over his shoulders. The resident asked the staff if they wanted him to remove the bath blanket. The staff reported no. They wheeled the resident onto the scale and indicated the wheelchair weighed 35.6 pounds and then indicated the resident weighed 150 pounds. The surveyor intervened and asked RN #58 to weigh the bath blanket. RN #58 and surveyor weighed the bath blanket and it weighed 1.2 pounds. The RN confirmed after subtracting the bath blanket from the resident's weight (150) his actual weight should have been 148.8. RN #58 indicated she didn't think the bath blanket would weigh that much. On 10/01/20 at 10:07 A.M. interview with the Director of Nursing (DON) verified the resident should not be weighed with bath blankets on to obtain an accurate weight. On 10/01/20 at 10:11 A.M. interview with STNA #48 revealed she weighed Resident #33 yesterday in his wheelchair. She confirmed she had a bath blanket on his lap and one on his shoulders when she weighed him. He weighed 155.2 at that time per the STNA. STNA #48 revealed she thought he had weighed 142 or 144 pounds recently at the doctor's office. On 10/01/20 at 10:40 P.M. interview with RD #102 revealed she had completed an evaluation on Resident #33 on 09/24/20. The RD reported she reviewed what intakes were recorded in the resident's chart, supplement intakes, and spoke with nursing and the resident. She stated she was not aware staff were not accurately performing weight measurements and only had the information that was provided to her. RD #102 indicated it was her opinion the resident was getting adequate calorie intake even though she did not have a current weight to reflect if the resident had sustained any additional weight loss. The resident's last weight prior to her assessment on 09/24/20 was on 09/10/20. The resident's weight today (10/01/20) was 148.8 pounds which indicated the resident continued to lose weight. Review of the facility undated weight policy revealed weight was an important factor in accurately assessing the nutritional status of every resident. All weights would be documented in the electronic medical record. All newly admitted and readmitted resident shall be weighed weekly for four weeks to establish a base-line weight. Weekly weights should be done on the same day of each week. Residents who have experienced unplanned, significant weight loss or insidious weight loss shall be weighed weekly for four weeks or until stable unless deemed clinically inappropriate. Re-weights would be completed on any weight change of five or more pounds and would be done immediately (within 72 hours). Review of the facility undated Nutrition and Hydration intervention guidelines revealed nutrition interventions were intended to enhance the resident's dietary intake in order to provide adequate nutrition and hydration for the resident's clinical condition. Interventions shall be individualized to meet the resident's specific needs, personal goals, and preferences. Nutrition risk factors that indicate the need for a nutrition interventions may include, but are not limited to significant change in appetite, unfavorable decrease in oral intake and or history of reduced appetite, gradual weight loss, significant weight loss, abnormal laboratory values and signs and symptoms of dysphagia. Interventions included super nutrient/fortified foods, snacks, altered portion sizes, supplement's, increase weight monitoring, consider artificial nutrition for hydration (IV fluids and enteral feedings), hospice consult, or provide liquids in different form (gelatin, popsicle, or soups). 2. Review of Resident #73's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #73's physician's orders [REDACTED]. There was no evidence of any additional hydration interventions during this time period. The dietary assessment, dated 07/09/20 (admission) was blank. A dietary assessment, dated 07/16/20 revealed the resident's estimated fluid needs were 1636-1950 milliliters (ml) per day. Record review revealed no further dietary assessments were completed after 07/16/20 to address the resident's hydration needs or interventions. A five day MDS 3.0 assessment, dated 07/15/20 revealed the resident required extensive assistance from one staff for eating and had no swallowing issues. The resident received the anti-anxiety medication, [MEDICATION NAME], diuretic medication, [MEDICATION NAME] and supplement, Magnesium Oxide. Record review revealed Resident #73 had a potential for alteration in nutrition and hydration plan of care which indicated the resident was a risk related to overweight status, mechanically altered diet, right [MEDICAL CONDITION], dysphagia, dementia, diuretic use and requiring assistance with meals. Interventions included to offer alternative fluid options. Review of Resident #73's fluid intake documentation, dated 07/09/20 to 08/09/20 revealed no evidence of the amount of fluid consumed by the resident on 07/09/20, 07/10/20, 07/11/20, 07/15/20, 07/16/20, 07/17/20, 07/19/20, 07/20/20, 07/22/20, 07/23/20, 07/24/20, 07/25/20, 07/26/20, 07/27/20, 08/03/20, 08/04/20, 08/06/20 or 08/07/20. In addition, on 07/12/20 the resident was documented to have consumed 840 ml of fluid, on 07/13/20 240 ml, on 07/14/20 120 ml, on 07/18/20 840 ml, on 07/21/20 720 ml, on 07/28/20 120 ml, on 07/29/20 240 ml, on 07/30/20 600 ml, on 08/01/20 360 ml, on 08/02/20 240 ml, on 08/05/20 440 ml and on 08/08/20 20 ml. There was no evidence the resident received the estimated fluids per the dietary assessment completed on 07/16/20 of 1636-1950 ml per day. Record review revealed Resident #73 was transferred to the hospital on [DATE] due to a change in condition. Review of the hospital record documentation, dated 08/09/20 revealed the resident had a Foley (urinary) catheter in place with no output. She was unresponsive and exhibiting some agonal breathing. The hospital record identified the resident [MEDICAL CONDITION]ly secondary to suspected urinary tract infections. However, the hospital was not able to collect a urine specimen. The resident had severe dehydration and [MEDICAL CONDITION] secondary to dehydration. The emergency room physician had an extensive discussion with the family and decided to implement comfort measures for the resident to allow her pass away in peace. On 10/01/20 at 10:40 P.M. interview with RDT #100 revealed she had completed an assessment for the resident on 07/09/20 but later identified it had not saved in the computer so she completed a new assessment on 07/16/20. RDT #100 confirmed the resident's estimated fluid needs were calculated to be 1636-1950 ml daily. RDT #100 revealed she had not seen the resident in person following her admission because she had been working remotely from home. Following the assessment on 07/16/20, RDT #100 revealed she had not re-assessed or updated any type of hydration recommendation for Resident #73 prior to her discharge on 08/09/20. On 10/01/20 at 11:01 A.M. interview with the DON confirmed the above fluid intake records for Resident #73. The DON was unable to provide any additional evidence of fluid intake to ensure the resident was provided the fluid to meet her estimated needs of 1636-1950 ml daily. The resident was subsequently admitted to the hospital on [DATE] with severe dehydration. Review of the facility undated Nutrition and Hydration intervention guidelines revealed nutrition interventions were intended to enhance the resident's dietary intake in order to provide adequate nutrition and hydration for the resident's clinical condition. Interventions shall be individualized to meet the resident's specific needs, personal goals, and preferences. Nutrition risk factors that indicate the need for a nutrition interventions may include, but are not limited to significant change in appetite, unfavorable decrease in oral intake and or history of reduced appetite, gradual weight loss, significant weight loss, abnormal laboratory values and signs and symptoms of dysphagia. Interventions included super nutrient/fortified foods, snacks, altered portion sizes, supplement's, increase weight monitoring, consider artificial nutrition for hydration (IV fluids and enteral feedings), hospice consult, or provide liquids in different form (gelatin, popsicle, or soups). This deficiency substantiates Complaint Number OH 909.

Based on closed record review and staff interview the facility failed to prevent a significant medication error when Resident #71 was administered four doses of the antibiotic, [MEDICATION NAME] 500 milligrams (mg) a medication she was allergic to. This affected one resident (#71) of three residents reviewed for medication allergies [REDACTED].>Actual harm occurred on 02/20/20 when Resident #71 was administered [MEDICATION NAME]. On 02/22/20 the resident began to complain of itching and burning to her legs and neck with multiple red areas on her face, arms, legs and trunk with her skin peeled off in these areas after receiving four doses of the antibiotic, [MEDICATION NAME], a medication she was allergic to. On 02/26/20 the resident was admitted to the hospital and diagnosed with [REDACTED]. The syndrome is caused by certain medications including antibiotics. Complications include dehydration,[MEDICAL CONDITION], pneumonia, and multiple organ failure. Treatment is typically hospitalization ) related to the allergic reaction to the [MEDICATION NAME]. The resident subsequently passed away. Findings include: Review of Resident #71's closed medical record revealed the resident was admitted to the facility assisted living on 09/19/12 and was transferred to the skilled nursing center on 12/20/19 with [DIAGNOSES REDACTED]. Review of Resident #71's physician's orders [REDACTED]. Review of Resident #71's progress notes dated 12/20/19 to 02/26/20 revealed the resident was admitted to the nursing home on 12/20/19 from the attached assisting living due to a decline in mobility. On 02/20/20 the resident was assessed to have a hip wound that had foul smelling exudate noted. The physician was notified, and new orders were received for the antibiotic, [MEDICATION NAME]. Review of Resident #71's Medication Administration Record, [REDACTED]. She received one dose on 02/20/20, two doses on 02/21/20, and one dose on 02/22/20. On 02/22/20 the resident complained of itching and burning to her legs and neck. The nurse noted a red rash to those areas. The physician was notified, and the [MEDICATION NAME] was discontinued and [MEDICATION NAME] (antibiotic) was ordered. On 02/23/20 the resident's skin started to peel due to an allergic reaction to the [MEDICATION NAME]. On 02/25/20 there were multiple red areas on the resident's face, arms, legs, and trunk where the skin had peeled off. On 02/26/20 the resident was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. Review of Resident #71's hospital admission records, dated 02/26/20 revealed the resident was admitted with(NAME)Johnso[DIAGNOSES REDACTED] most likely related to [MEDICATION NAME] use at the nursing home. The resident had large blisters all over and would be evaluated by dermatology and wound care. She was admitted to the medical surgical floor for pain management and intravenous fluids. Speech was consulted for moderate oropharyngeal phase dysphagia, which could be acutely related to(NAME)Johnso[DIAGNOSES REDACTED], especially if there was [MEDICAL CONDITION]/blistering within the pharynx. On 09/28/20 at 11:51 A.M. interview with the Director of Nursing (DON) revealed at the time of the incident she was not the DON, however, she was the nurse that helped with Resident #71's admission on 12/20/19. The DON reported during the admission see had seen a hospital discharge sheet dated 05/02/19 (seven months old) that indicated the resident had allergies [REDACTED]. The DON verified she only entered the allergies [REDACTED]. On 09/28/20 at 1:22 P.M., interview with Resident #71's durable power of attorney (DPOA) revealed she could not recall if the facility called with the new order of [MEDICATION NAME] from 02/20/20, however when the resident resided in the attached assisting living she had to go to the hospital due an allergic reaction to [MEDICATION NAME]. She stated the resident had broken out in big blisters all over her body from the [MEDICATION NAME]. The blisters were so bad her clothes would get wet when she walked from her legs rubbing. It took the resident months to get back to normal from the reaction. The DPOA was upset with the facility because it was on her records at the assisted living that she had an allergy to [MEDICATION NAME] and it should have been transferred onto her records when she moved to the skilled side (nursing home) since they were in the same building. The DPOA indicated she felt the physician should have known of this allergy as well. The DPOA shared that following the administration of the [MEDICATION NAME] in 02/2020 and subsequent hospitalization , the hospital had to basically wrap the resident like a mummy because her skin was just peeling off. The DPOA reported the resident had a miserable death. She only lived three or four more days after being discharged from the hospital with Hospice services for pain management and she believed the facility administering the [MEDICATION NAME], that she was allergic to contributed to her death. The DPOA indicated she had maintained pictures of the resident's skin to show the severe reaction the resident sustained [REDACTED]. This deficiency substantiates Complaint Number OH 756.

Based on observation, review of the medical record, staff statements, facility policy and procedures for abuse, behavior management and restraints and interview, the facility failed to ensure one resident (Resident #177) was not manually physically restrained by two State tested nurse assistants (STNA) while a licensed practical nurse (LPN) attempted to apply a wander guard (a system that tracks a person using a wrist or ankle band that automatically locks doors or alarms if the person moves outside the defined perimeter) device to the resident's left ankle in the day room/dining room area during the lunch meal on 07/10/18. This resulted in Immediate Jeopardy when the staff provoked and heightened behaviors of yelling out, crying, swearing and resisting application of the device by Resident #177. The facility failed to honor the resident's request to not have the wander guard applied by manually restraining the resident to attempt to apply the device. Actual Harm occurred as a result of the incident when the resident's behaviors escalated, she became visibly upset during the incident, combative, tearful and crying. This affected one of two residents reviewed for abuse. The facility census was 82. On 07/11/18 at 10:13 A.M., Administrator #200, the Director of Nursing (DON), and Corporate Registered Nurse (RN) #104 were notified Immediate Jeopardy began on 07/10/18 at 12:34 P.M. when three staff, STNA #90, STNA #96, and LPN #91 were witnessed attempting to apply a wander guard device to Resident #177 against her will (all agency staff members). STNA #90 and STNA #96 were observed manually restraining Resident #177 by holding her hands and blocking her leg movements as LPN #91 attempted to apply a wander guard device to Resident #177's left ankle. The resident was observed attempting to swing her arms loose, kick her legs, screaming and crying, as staff continued to attempt to apply the wander guard. The Immediate Jeopardy was removed on 07/12/18 when the facility implemented the following corrective actions: · On 07/10/18 between 12:35 P.M. and 1:00 P.M. LPN #91, STNA #90 and STNA #96 were removed from the facility and suspended pending a facility investigation. · On 07/10/18 at 3:42 P.M. the Administrator submitted an initial self-reported incident (SRI), tracking number 8 for an allegation of physical abuse involving Resident #177. · On 07/10/18 at approximately 1:00 P.M. LPN #51, who functioned as the facility social service designee interviewed Resident #177. A plan for the resident to be interviewed every day for five days by licensed nursing staff focusing on any distress (defined by the facility as crying, tearful, and wringing of hands, fearful, anxiety) with follow up as needed was implemented. · On 07/10/18 at 4:10 P.M. RN #61 assessed Resident #177. The assessment revealed the resident was anxious, calmed after much re-direction and re-orienting to situation. A plan was developed for the resident to be assessed every day for five days completed by the licensed nurse with follow up as needed. · Beginning on 07/11/18 and continuing through 07/12/18 the Director of Staff Development (RN) #106 initiated all facility staff training related to challenging behaviors in dementia care and abuse, neglect and misappropriation. The training was also provided to all agency staff working in the facility on 07/11/18 and 07/12/18. Training was completed either in person or via telephone either one on one or in small groups with staff and included education related to restricting resident movements, resident's rights and honoring a resident's right to refuse care/treatment. As of 07/12/18 at 3:00 P.M. the facility identified 97 of 100 staff were educated which included 13 agency nursing staff, permanent staff, staff who were employed by a sister facility but were working at the facility and corporate staff. A plan to ensure the three remaining staff were educated prior to their next working shift was implemented. · On 07/11/18 at approximately 1:30 P.M. Resident #177 was assessed by Medical Director (MD) #102 who was also the physician assigned to care for Resident #177. · On 07/11/18 at 2:00 P.M. a special Quality Assurance (QA) meeting with the interdisciplinary team meeting, which included the Administrator, Medical Director #102, the DON, RN #104 and all department heads was held to discuss admissions, incidents and abuse investigations. The facility plan related to staff education, follow up for Resident #177 and observations and interviews with current facility residents was discussed. · On 07/11/18 beginning at approximately 2:15 P.M. LPN #51, RN #24 and RN #107 screened all alert and oriented residents by interview asking the following questions: How are you today? Any problems with staff or your treatment? Anyone mistreating you? Anything you would like to share? Has your movement been restricted by staff in anyway? For residents who were not able to interviewed, LPN #51, RN #24 and RN #107 observed for any signs/symptoms of distress (crying, tearful and wringing of hands, fearful, anxiety) and if the resident had any restricted movement. Follow up was completed for any negative responses. · On 07/11/18 a plan was implemented for the DON and/or designee to audit 25% of the resident population two times per week for four weeks either via interview or observation using the resident interview and observation questions noted above. · On 07/12/18 the facility implemented a plan that all new Agency staff scheduled to work in the facility beginning 07/12/18 would be required to complete online training, including post testing that included challenging behaviors in dementia care, preventing and recognizing and reporting abuse prior to providing any resident care. The DON was identified to be responsible for ensuring the training was completed. · On 07/12/18 at 3:15 P.M. the Administrator educated RN #24 and LPN #51 regarding a new process beginning 07/12/18 during the admission process/when completing admission paperwork, any statements made from any residents or resident family members that would be associated with not wanting to reside in the facility would require an in-depth conversation about why with LPN #51. The resident's family would be contacted to come into the facility to assist with a plan and the initial care conference would consist of follow up. Although the Immediate Jeopardy was removed on 07/12/18 the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of ensuring all staff education was complete and monitoring and verifying the corrective action was effective. Findings include: Medical record review revealed Resident #177 was admitted to the facility on [DATE] at 10:25 A.M. with [DIAGNOSES REDACTED]. Resident #177 was transferred from the facility residential care unit located on the same campus. Review of a report- new admissions form, dated 07/10/18 at 10:30 A.M. revealed the resident was alert/oriented and confused. The form revealed the resident was ambulatory with a walker and one staff assistance with a history of falls. There was no evidence of behaviors identified on the report-new admissions form. On 07/10/18 at 11:12 A.M. RN #61 developed an admission plan of care. The care plan included adjustment to facility, is a new admission to facility. The goal developed was for the resident to become familiar with the facility routines and be able to make choices about care and be familiar with meal times, choices and prescribed diet. Interventions included to orient to surroundings and daily routines, encourage resident to make choices about routine to lessen the amount and significance of changes in routine, allow resident time to become familiar with places and people in the new environment, answer questions and provide re-assurance as needed, allow resident time to vent feelings about placement, support resident goals whenever possible and monitor for signs/symptoms of being withdrawn. An electronic nursing progress note, dated 07/10/18 at 1:14 P.M. completed by RN #61 revealed at approximately 10:45 A.M. the resident was walking down the hall with her walker, visibly upset and crying. RN #61 asked her why she was crying and she stated because she did not want to be here so she asked her if she would like to sit down at the table in the day room and she said yes. RN #61 walked with her over to the chair and helped her sit down. RN #61 offered to call the resident's niece and the resident declined. The resident kept repeating she did not understand why she was here (at the nursing home) instead of at the residential care facility. RN #61 explained she was at the nursing home because she had so many falls recently and they wanted to keep her safe and explained to her the nursing home was a lot like the residential care facility with activities and the dining room for meals. The resident continued to state she didn't care that she didn't want to be here. RN #61 informed the resident she would check on her in a little while and she said okay. The note indicated the resident sat quietly in the North hall day room at the table. Record review revealed on 07/10/18 at 12:25 P.M. a physician telephone order was obtained by LPN #91 for a wander guard to the resident's left ankle for exit seeking behaviors. There was no corresponding nursing progress note related to this telephone order, evidence the resident was exhibiting exit seeking behaviors or assessed at the time the order was received. On 07/10/18 at 12:34 P.M. observation revealed an unidentified female resident could be heard yelling out and cursing. Upon further investigation, the resident (identified as Resident #177) was observed in the day room/dining room area sitting in a chair yelling and cursing at staff. Additional residents were observed seated in the day room/dining room at that time. Three staff members, LPN #91, STNA #96 and STNA #90 were observed with Resident #177. LPN #91 was observed on her hands and knees on the floor in front of the resident attempting to hold the resident's ankle. STNA #96 was observed holding the resident's hands down on her lap by her wrist, and the third staff member, STNA #90 was observed blocking the resident's legs as she tried to kick at staff. After observing the incident for a couple minutes, while the resident continued to scream, curse and attempt to hit and kick the staff members the surveyor approached the nurse's station where the unit manager, RN #61 was observed on the phone and Pharmacist #100 was observed standing (at the nurse station). The surveyor requested assistance to both RN #61 and Pharmacist #100 as based on the observation above it was determined that someone needed to intervene and protect Resident #177. Pharmacist #100 looked over at the resident and staff members and stated she would go get the DON immediately. An ongoing observation revealed Resident #177 continued to resist the three agency staff members until the DON arrived and instructed all staff to step away from the resident. Resident #177 was heard stating, I hope you don't treat all your residents like this and stated they would be sorry they brought her here. An interview with STNA #21 at the time of the above incident revealed the STNA was walking near the day room and reported the resident was upset and it would be intimidating for anyone to have three staff huddling around them. STNA #21 verified the agency staff members were holding the resident's wrist and legs and indicated they were trying to apply a wander guard to her ankle. STNA #21 revealed Resident #47, who was present in the day room and had witnessed the incident was upset and crying because of it and had to be removed from the day room to be calmed down. STNA #21 revealed there were other residents in the day room who were either waiting on staff to deliver their lunch trays or eating their lunch at the time of the incident. An interview with LPN #91 following the incident revealed the LPN did not know what a catastrophic event was and reported it was necessary to put the wander guard on Resident #177 at that time because the resident voiced she wanted to leave the facility. LPN #91 confirmed the resident was upset, crying, and was combative as she tried to apply the wander guard, however she did not stop or try other alternative methods to prevent the resident from trying to leave the facility. An interview with STNA #96 following the incident revealed she did not know what a catastrophic event was. STNA #96 revealed they had been trying to apply a wander guard to the resident's ankle for the past hour and a half. An interview with STNA #90 following the incident revealed Resident #177 was very upset and they should have just walked away from the situation to let the resident calm down. STNA #90 revealed it was inappropriate to upset the resident during meal time and in front of other residents. STNA #90 was also unaware what a catastrophic event was. On 07/10/18 at 12:52 P.M. Resident #177 was observed seated in the day room. The resident was crying and her eyes were red and swollen. The resident appeared to be upset and was yelling, I don't know why I'm here. An unidentified staff member was observed taking the resident from the day room at that time. On 07/10/18 at 12:52 P.M., interview with Resident #11's wife revealed she was present in the day room/dining area when staff were observed with Resident #177. Resident #11's wife indicated staff were attempting to place an ankle bracelet on the resident during lunch and the resident was trying to hit and kick the staff. The resident was cursing. She stated she could not see if staff were holding the resident down because the resident's back was towards her, however they were bent over to her. The resident's wife stated she heard the resident tell staff, I can't believe you would treat patients like this. On 07/10/18 at 1:20 P.M., interview with Pharmacist #100 revealed while standing at the nurse's station she heard Resident #177 being vocal and indicated she had heard the resident for about 10 to 15 minutes prior to the surveyor arriving. Pharmacist #100 further explained the resident was cursing and yelling, stating she wanted out of here. During the interview, Pharmacist #100 revealed she observed nursing staff, one staff member at the resident's feet and another staff member standing next to the resident. She stated the resident was combative, one staff member was bent over the resident preventing the resident from rising and hitting them. The pharmacist indicated she was now confused and so upset that she could not recall how the STNA's hand placement was on the resident hands for sure. She confirmed she reported the incident to the DON. Review of Pharmacist #100's written statement provided to the facility as part of the facility investigation, dated 07/10/18 revealed on 07/10/18 Resident #177 was being very loud and vocal about not wanting to stay here. This went on for several minutes, then the State surveyor came over stating they were holding the resident down and it was inappropriate. She said someone needed to stop it. The pharmacist statement indicated she ran down the hall to get the DON, brought the DON back and she went over to the resident. The statement indicated Pharmacist #100 saw two staff around the resident. One was kneeling at her feet and the other was standing over her. The pharmacist reported she did not remember if she saw staff actually holding her down, but the resident was very upset and cussing. The DON had everyone step back from the resident to help calm her down. On 07/10/18 at 1:39 P.M., interview with STNA #90 revealed she had heard screaming as she left a resident room. When she reached the day room she saw STNA #96 trying to talk to Resident #177. At first Resident #177 had ahold of STNA #96's arms. The resident was cursing and screaming she wanted out of there. STNA #90 revealed STNA #96 restrained Resident #177's arms down to prevent the resident from hitting, however she could not recall exactly how the STNA had her hands placed on the resident. STNA #90 stated she then placed her hands across the resident's leg touching her arm against the resident legs to prevent the resident from kicking the nurse. She stated she thought she was doing what she was supposed to do, however now looking back she should have told STNA #96 and LPN #91 to back off. STNA #90 revealed the resident had been observed crying earlier in the day. She stated she was sorry the incident had occurred and sorry it upset the other residents, especially Resident #47. She reported Resident #47 was crying and upset following the incident. Review of STNA #90's written statement, dated 07/10/18 revealed she was walking down the hall when she heard someone yelling and screaming. When she walked up to Resident #177 she tried to re-direct her. The resident was holding and flinging around STNA#96's arms and trying to hit LPN #91. She stated she then bent down and put her arm in front of the resident's legs and between her and the nurse. The DON walked up to us and told all of us to back up and walk away. The statement indicated the STNA did was she was told. On 07/10/18 at 1:52 P.M. and during a subsequent interview at 3:18 P.M., with the DON revealed Pharmacist #100 had come to her office (on this date) and said the surveyor or resident needs you. The DON reported Pharmacist #100 sounded like it was urgent so she ran down to the day room/dining area. She observed Resident #177 at the table with three staff members around her. One staff member, STNA #96 had both hands straight above the resident's lap in the air, the resident had ahold of one of the STNA's wrist and she stated she could not recall where the other hand was. STNA #90 was bent down and had one arm straight in the air out to prevent the resident from kicking the nurse. LPN #91 was on the floor trying to apply a wander guard to the resident's left ankle. As she approached the resident was yelling out, however she couldn't recall what the resident was saying. She instructed the staff to step back as well as the unit manager and to clear the area. She knelt beside the resident and put her hand out. The resident was tearful, and she was screaming off and on. The resident was removed from the area, taken to the front patio by social service staff (LPN #51) to try to calm her down. Resident #47, who was present in the day area was also upset and removed from the area and taken to his room. She stated she asked visitors, residents, and family in the day room if they were okay. She stated after the incident STNA #96 and LPN #91 left the facility and STNA #90 went to her office. STNA #96 then returned to the facility to provide a written statement. During the interview the DON revealed when Resident #177 started yelling out the staff should have stepped back. She indicated standing around any resident that was yelling could have potentially made the situation worse. On 07/10/18 at 2:43 P.M., Resident #177 was observed seated in a wheelchair outside with LPN #51 who functioned as the facility social service designee. An attempt to interview the resident revealed she did not want to be in the facility and the resident continued to appear upset. Further attempts to interview or obtain additional information from the resident were unsuccessful at that time. The resident would answer yes or no general questions about the weather/flowers but would not engage in conversation or discuss the incident that had occurred earlier in the day. On 07/10/18 at 2:47 P.M., interview with STNA #96 revealed she had passed lunch trays and was starting to assist a resident with her lunch when LPN #91 was attempting to place a wander guard on Resident #177's ankle in the day room/dining room area as the residents were eating. The resident became very combative and almost kicked the nurse in the face. STNA #96 stated she approached the nurse and resident and attempted to calm the resident down. She placed her hands around the residents and had her hands resting in her palms with her index and thumb slightly around the resident's wrist and then the resident grabbed her hands. She stated STNA #90 then arrived and placed herself between the nurse and resident. The resident was hitting, kicking, and screaming for 10-15 minutes as the nurse tried to apply the wander guard to the resident's ankle. STNA #96 stated she asked LPN #91 if it was okay to be doing this because she had never seen a resident be so combative and agitated and stated she was afraid they were going to get in trouble. She stated the nurse never responded. At that time the DON arrived and told them to back up and she left to assist another resident with her lunch. STNA #96 reported she honestly didn't know what she would do if she witnessed an incident like this one again. She confirmed it was inappropriate to upset the resident, and the other residents and family members in the dining room. However, she felt she was following LPN #91's directive. She confirmed the resident had been upset earlier that day because she had to move to the nursing home side of facility. STNA #96 voiced she had been in-serviced on abuse. The DON was present during interview. Review of STNA #96's written statement, dated 07/10/18 revealed the nurse was trying to place a wander guard bracelet on Resident #177. The resident became very combative and kicked the nurse, that's when I stopped in and tried to calm her down. The statement indicated Resident #177 grabbed her hand and arm and she had ahold of her hand just enough to guard the nurse so the resident wouldn't hit her. The statement indicated she tried the whole time to calm the resident down and ease her mind. The statement indicated STNA #96 asked while the incident was occurring if they were allowed to do this and wrote she didn't want to get in trouble. On 07/10/18 at 3:58 P.M. interview with LPN #51 revealed she functioned as the facility social service designee. She stated she had gone to the day room because someone had called her to come down. She stated following the incident with LPN #91 and STNAs #90 and #96 she took Resident #177 outside per her wishes. She stated the resident was upset and crying and her eyes were red and swollen. She stated the resident told her she wanted to go back to the assistive living side of the building. She stated she really didn't know anything about the actual incident that had occurred and the resident did not mention anything specifically to her. She stated if a resident became combative during the provision of care, staff should keep them safe and not keep badgering them, give them a minute to calm down and try to approach later. She reported after she took the resident outside, it took a while for her to calm down and she talked very little. During the interview, she also shared, that she had never seen Resident #47, who was nonverbal get that upset before. She stated the resident had a little tear coming down his cheek as they removed him from the day room. Review of Resident #177's electronic nursing progress notes revealed on 07/10/18 at 4:10 P.M. RN #61 assessed the resident. The resident was assessed to be anxious, calmed after much redirection and reorienting to the situation. On 07/10/18 at 9:11 P.M. an electronic nursing progress note revealed family was onsite with the resident and the resident was sitting in the hall. On 07/10/18 at 4:24 P.M., interview with Resident Care Assistant (RCA) #105 revealed she had provided care to Resident #177 while she resided in the residential care facility. RCA #105 revealed the resident could have a temper and be nasty at times, however if you walked away and left her be she would calm down. She reported the resident had never been physical with staff or residents while residing on the residential care facility side of the facility. Review of the LPN #91's written statement obtained as part of the facility investigation, dated 07/11/18 revealed at approximately 12:15 P.M. on 07/10/18 Resident #177 was at the nurse's station yelling at to her that she wanted to talk to her doctor right now. She stated she explained the doctor had been contacted and was aware that she was in the nursing home and wanted to speak with him. LPN #91 stated Resident #177 then stated, I'm not staying here. At that point she obtained an order from the doctor for a wander guard to be placed on the resident's left ankle due to exit seeking behavior and concern that the resident would attempt to leave the facility and she didn't want her to have a heat stroke or get lost or hit by traffic. The statement revealed after obtaining the order and wander guard device she found the resident sitting in a chair at the dining room table. She explained to the resident what the wander guard was, where it goes and kneeled to put it on her left ankle when Resident#177 began hitting her. STNA #96 came over and began holding hands with the resident and talking to her to divert her attention from hitting and kicking at her. At some point another STNA came over and placed herself in front of the resident to keep her from kicking her. The statement indicated the resident had been yelling out since she had arrived at approximately 8:00 A.M. or 9:00 A.M. At this point more staff members had arrived and she heard someone yell stop. The statement indicated LPN #91 said, I'm trying to put a wonder guard on her, because she said she was not staying here and I don't want her to go out in the heat and get lost or smothered by the humidity. The statement indicated LPN #91 thought she had the wander guard secured and got up and walked back to nurse's station. Interview on 07/11/18 at 10:20 A.M., with LPN #91 in the presence of the DON revealed the resident had not physically attempted to leave the facility at any time since her admission, however she had verbalized she was not staying there. LPN #91 verified she obtained an order for [REDACTED].#91 stated she was not trying to hurt the resident and felt the incident took place over two to three minutes. LPN #91 verified the resident was combative, cussing, screaming, and crying as a result of the incident but was unable to recall exactly what the resident was saying. LPN #91 revealed she told the resident that everyone was very busy and explained that the wander guard was to warn staff if she attempted to leave. She stated she believed the resident thought they were trying to restrict her and monitor her. On 07/11/18 at 2:45 P.M., interview with facility Medical Director (MD) #101 revealed he had assessed Resident #177 and noted some new and old bruising on the resident's body. No additional information was provided as to whether he believed the bruising was a result of the incident with LPN #91, STNA #90 and STNA #96. He stated the resident appeared to be comfortable at that time and had slight cognitive impairment. During the interview, MD #101 revealed the proper way to have handled the situation with Resident #177, when she refused to allow staff to apply the wander guard, should have included redirection, an attempt to calm and then redirect the resident. MD #101 indicated he believed the incident was handled inappropriately by the staff members. On 07/12/18 at 1:22 P.M. during an interview with Administrator #200, DON, RN #104 and RN #106 the administrative staff verified there was no nursing progress note contained in the resident's medical record from LPN #91 regarding the incident that occurred related to the attempted application of the wander guard. There was no written evidence the resident was exhibiting wandering or safety related behaviors prior to LPN #91 obtaining the physician order [REDACTED]. or attempting to place the wander guard device on the resident. During the interview, the DON also verified when she arrived to the day room after being summoned for assistance, all three agency staff were still with the resident and she verbally instructed staff to move away from her. The administrative staff indicated as a result of the incident, statements were obtained from LPN #91, STNA #90 and STNA #96 and then the staff were removed from the facility. When asked if the agencies who employed the staff were notified of the incident, the DON indicated she had called the two different agencies but had only notified one of the two of the actual incident as of this time. She revealed she had not notified the agency who employed LPN #91 and STNA #96 of the incident that had occurred. On 07/12/18 at 3:35 P.M. an observation of Resident #177 revealed she was in her room with the television on and curtain pulled around her bed. Upon knocking and receiving permission to enter the resident's room, the resident was observed on the floor. The resident voiced she needed to use the bathroom and the surveyor obtained staff to assist the resident. On 07/12/18 at 4:16 P.M. telephone interview with Administrator #108, the administrator of the staffing agency who employed STNA #90 revealed she had heard something in passing for the first time on this date regarding an aide witnessing something at the facility but did not have any specific details or knowledge of the facility reporting any concerns, issues or allegations of abuse or improper care by one of the agency staff members or that the facility had removed an employee from providing resident care. Administrator #108 stated it was the expectation that if there was a problem or concern, the facility would notify either the agency staffing scheduler or herself as the administrator. Administrator #108 denied any evidence the staffing scheduler had been notified of any problems or issues regarding the care of a nursing home resident by one of the agency staff. On 07/12/18 at 5:07 P.M. telephone interview with Staffing Scheduler #109 from the agency staffing company revealed on 07/10/18 STNA #90 arrived to the staffing agency building after her shift at the facility at about 3:10 P.M. Scheduler #109 indicated STNA #90 had asked to speak to the supervisor and was directed to that employee. Scheduler #109 revealed she didn't have any details about what was discussed between the two. Upon prompting from the facility DON, Scheduler #109 revealed she had been contacted by the DON that same evening but could not recall the specifics of what had been reported to her by the DON other than it was the same thing that STNA #90 had reported even though she denied knowledge of what had been reported to the supervisor by STNA #90. On 07/12/18 at 3:56 P.M. attempts to reach staff from the second agency staffing company who employed LPN #91 and STNA #96 were unsuccessful. On 07/13/18 at 11:35 A.M. Resident #177 was observed seated in a wheelchair in the hallway outside her room. At the time of the observation, the resident was heard talking with Activity Aide #19. During the conversation, Resident #177 voiced concerns to Activity Aide #19 that she had been brought to the nursing home on Tuesday morning with no explanation and it was now Friday and she didn't want to be in the nursing home. The resident told the Activity Aide that she was very upset and bitter with her placement, the fact that no one was telling her what was going on and she was not receiving any care. The resident indicated she wanted to go back to the residential care facility. During the conversation, the resident became tearful and expressed frustration with the care provided to her from facility staff and the lack of perceived follow up to her concerns with placement. Activity Aide #19 attempted to reassure the resident and informed her she would relay her conc (TRUNCATED)

Based on observation, review of the medical record, staff statements, and facility policy and procedure for abuse the facility failed to effectively implement their abuse policy and procedure to ensure all staff were knowledgeable of and appropriately responded to a catastrophic event involving Resident #177. This resulted in Immediate Jeopardy when staff provoked and heightened the behaviors of Resident #177 resulting in the resident yelling out, crying, swearing and resisting the application of a wander guard (a system that tracks a person using a wrist or ankle band that automatically locks doors or alarms if the person moves outside the defined perimeter) device when staff attempted to apply the device in the day room during the lunch meal on 07/10/18. The facility failed to honor the resident's request to not have the wander guard applied by manually restraining the resident to attempt to apply the device. Actual Harm occurred as a result of the incident when the resident's behaviors escalated, she became visibly upset during the incident, combative, tearful and crying and staff did not stop the attempt at applying the device. This affected one of two residents reviewed for abuse. The facility census was 82. On 07/11/18 at 10:13 A.M., Administrator #200, the Director of Nursing (DON), and Corporate Registered Nurse (RN) #104 were notified Immediate Jeopardy began on 07/10/18 at 12:34 P.M. when three staff, State tested Nursing Assistant (STNA) #90, STNA #96, and Licensed Practical Nurse (LPN) #91 were witnessed attempting to apply a wander guard device to Resident #177 against her will (all agency staff members). STNA #90 and STNA #96 were observed manually restraining Resident #177 by holding her hands and blocking her leg movements as LPN #91 attempted to apply a wander guard device to Resident #177's left ankle. The resident was observed attempting to swing her arms loose, kick her legs, screaming and crying, as staff continued to attempt to apply the wander guard. The Immediate Jeopardy was removed on 07/12/18 when the facility implemented the following corrective actions: · On 07/10/18 between 12:35 P.M. and 1:00 P.M., LPN #91, STNA #90 and STNA #96 were removed from the facility and suspended pending a facility investigation. · On 07/10/18 at 3:42 P.M., the Administrator submitted an initial self-reported incident (SRI), tracking number 8 for an allegation of physical abuse involving Resident #177. · On 07/10/18 at approximately 1:00 P.M., LPN #51, who functioned as the facility social service designee interviewed Resident #177. A plan for the resident to be interviewed every day for five days by licensed nursing staff focusing on any distress (defined by the facility as crying, tearful, and wringing of hands, fearful, anxiety) with follow up as needed was implemented. · On 07/10/18 at 4:10 P.M., RN #61 assessed Resident #177. The assessment revealed the resident was anxious, calmed after much re-direction and re-orienting to situation. A plan was developed for the resident to be assessed every day for five days completed by the licensed nurse with follow up as needed. · Beginning on 07/11/18 and continuing through 07/12/18 the Director of Staff Development, RN #106, initiated all facility staff training related to challenging behaviors in dementia care and abuse, neglect and misappropriation. The training was also provided to all agency staff working in the facility on 07/11/18 and 07/12/18. Training was completed either in person or via telephone either one on one or in small groups with staff and included education related to restricting resident movements, resident's rights and honoring a resident's right to refuse care/treatment. As of 07/12/18 at 3:00 P.M. the facility identified 97 of 100 staff were educated which included 13 agency nursing staff, permanent staff, staff who were employed by a sister facility but were working at the facility and corporate staff. A plan to ensure the three remaining staff were educated prior to their next working shift was implemented. · On 07/11/18 at approximately 1:30 P.M., Resident #177 was assessed by Medical Director (MD) #101 who was also the physician assigned to care for Resident #177. · On 07/11/18 at 2:00 P.M., a special Quality Assurance (QA) meeting with the interdisciplinary team meeting, which included the Administrator, MD #101, the DON, RN #104 and all department heads was held to discuss admissions, incidents and abuse investigations. The facility plan related to staff education, follow up for Resident #177 and observations and interviews with current facility residents was discussed. · On 07/11/18 beginning at approximately 2:15 P.M., LPN #51, RN #24 and RN #107 screened all alert and oriented residents by interview and asking the following questions: How are you today? Any problems with staff or your treatment? Anyone mistreating you? Anything you would like to share? Has your movement been restricted by staff in anyway? For residents who were not able to interviewed, LPN #51, RN #24 and RN #107 observed them for any signs/symptoms of distress (crying, tearful and wringing of hands, fearful, anxiety) and if the resident had any restricted movement. Follow up was completed for any negative responses. · On 07/11/18 a plan was implemented for the DON and/or designee to audit 25% of the resident population two times per week for four weeks either via interview or observation using the resident interview and observation questions noted above. · On 07/12/18 the facility implemented a plan that all new Agency staff scheduled to work in the facility beginning 07/12/18 would be required to complete online training, including post testing that included challenging behaviors in dementia care, preventing and recognizing and reporting abuse prior to providing any resident care. The DON was identified to be responsible for ensuring the training was completed. · On 07/12/18 at 3:15 P.M., the Administrator educated RN #24 and LPN #51 regarding a new process beginning 07/12/18 during the admission process when completing admission paperwork, any statements made from any residents or resident family members that would be associated with not wanting to reside in the facility would require an in-depth conversation about why with LPN #51. The resident's family would be contacted to come into the facility to assist with a plan and the initial care conference would consist of follow up. Although the Immediate Jeopardy was removed on 07/12/18 the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of ensuring all staff education was complete and monitoring and verifying the corrective action was effective. Findings include: Medical record review revealed Resident #177 was admitted to the facility on [DATE] at 10:25 A.M. with [DIAGNOSES REDACTED]. Resident #177 was transferred from the facility residential care unit located on the same campus. Review of a report- new admissions form, dated 07/10/18 at 10:30 A.M. revealed the resident was alert/oriented and confused. The form revealed the resident was ambulatory with a walker and one staff assistance with a history of falls. There was no evidence of behaviors identified on the report-new admissions form. On 07/10/18 at 11:12 A.M., RN #61 developed an admission plan of care. The care plan included adjustment to facility, is a new admission to facility. The goal developed was for the resident to become familiar with the facility routines and be able to make choices about care and be familiar with meal times, choices and prescribed diet. Interventions included to orient to surroundings and daily routines, encourage resident to make choices about routine to lessen the amount and significance of changes in routine, allow resident time to become familiar with places and people in the new environment, answer questions and provide re-assurance as needed, allow resident time to vent feelings about placement, support resident goals whenever possible and monitor for signs/symptoms of being withdrawn. Record review revealed on 07/10/18 at 12:25 P.M. a physician telephone order was obtained by LPN #91 for a wander guard to the resident's left ankle for exit seeking behaviors. There was no corresponding nursing progress note related to this telephone order, evidence the resident was exhibiting exit seeking behaviors or assessed at the time the order was received. On 07/10/18 at 12:34 P.M. observation revealed an unidentified female resident could be heard yelling out and cursing. Upon further investigation, the resident, identified as Resident #177, was observed in the day room/dining room area sitting in a chair yelling and cursing at staff. Additional residents were observed seated in the day room/dining room at that time. Three staff members, LPN #91, STNA #96 and STNA #90 were observed with Resident #177. LPN #91 was observed on her hands and knees on the floor in front of the resident attempting to hold the resident's ankle. STNA #96 was observed holding the resident's hands down on her lap by her wrist, and the third staff member, STNA #90 was observed blocking the resident's legs as she tried to kick at staff. After observing the incident for a couple minutes, while the resident continued to scream, curse and attempt to hit and kick the staff members the surveyor approached the nurse's station where the unit manager, RN #61 was observed on the phone and Pharmacist #100 was observed standing (at the nurse's station). The surveyor requested assistance to both RN #61 and Pharmacist #100 as based on the observation above it was determined that someone needed to intervene and protect Resident #177. Pharmacist #100 looked over at the resident and staff members and stated she would go get the DON immediately. An ongoing observation revealed Resident #177 continued to resist the three agency staff members until the DON arrived and instructed all staff to step away from the resident. Resident #177 was heard stating, I hope you don't treat all your residents like this and stated they would be sorry they brought her here. An interview with STNA #21 at the time of the above incident revealed the STNA was walking near the day room and reported the resident was upset and it would be intimidating for anyone to have three staff huddling around them. STNA #21 verified the agency staff members were holding the resident's wrist and legs and indicated they were trying to apply a wander guard to her ankle. STNA #21 revealed Resident #47, who was present in the day room and had witnessed the incident was upset and crying because of it and had to be removed from the day room to be calmed down. STNA #21 revealed there were other residents in the day room who were either waiting on staff to deliver their lunch trays or eating their lunch at the time of the incident. An interview with LPN #91 following the incident revealed the LPN did not know what a catastrophic event was and reported it was necessary to put the wander guard on Resident #177 at that time because the resident voiced she wanted to leave the facility. LPN #91 confirmed the resident was upset, crying, and was combative as she tried to apply the wander guard, however she did not stop or try other alternative methods to prevent the resident from trying to leave the facility. An interview with STNA #96 following the incident revealed she did not know what a catastrophic event was. STNA #96 revealed they had been trying to apply a wander guard to the resident's ankle for the past hour and a half. An interview with STNA #90 following the incident revealed Resident #177 was very upset and they should have just walked away from the situation to let the resident calm down. STNA #90 revealed it was inappropriate to upset the resident during meal time and in front of other residents. STNA #90 was also unaware what a catastrophic event was. On 07/10/18 at 12:52 P.M. Resident #177 was observed seated in the day room. The resident was crying and her eyes were red and swollen. The resident appeared to be upset and was yelling, I don't know why I'm here. An unidentified staff member was observed taking the resident from the day room at that time. On 07/10/18 at 1:20 P.M., interview with Pharmacist #100 revealed while standing at the nurse's station she heard Resident #177 being vocal and indicated she had heard the resident for about 10 to 15 minutes prior to the surveyor arriving. Pharmacist #100 further explained the resident was cursing and yelling, stating she wanted out of here. During the interview, Pharmacist #100 revealed she observed nursing staff, one staff member at the resident's feet and another staff member standing next to the resident. She stated the resident was combative, one staff member was bent over the resident preventing the resident from rising and hitting them. The pharmacist indicated she was now confused and so upset that she could not recall how the STNA's hand placement was on the resident hands for sure. She confirmed she reported the incident to the DON. Review of Pharmacist #100's written statement provided to the facility as part of the facility investigation, dated 07/10/18 revealed on 07/10/18 Resident #177 was being very loud and vocal about not wanting to stay here. This went on for several minutes, then the State surveyor came over stating they were holding the resident down and it was inappropriate. She said someone needed to stop it. The pharmacist statement indicated she ran down the hall to get the DON, brought the DON back and she went over to the resident. The statement indicated Pharmacist #100 saw two staff around the resident. One was kneeling at her feet and the other was standing over her. The pharmacist reported she did not remember if she saw staff actually holding her down, but the resident was very upset and cussing. The DON had everyone step back from the resident to help calm her down. On 07/10/18 at 1:39 P.M., interview with STNA #90 revealed she had heard screaming as she left a resident room. When she reached the day room she saw STNA #96 trying to talk to Resident #177. At first Resident #177 had ahold of STNA #96's arms. The resident was cursing and screaming she wanted out of there. STNA #90 revealed STNA #96 restrained Resident #177's arms down to prevent the resident from hitting, however she could not recall exactly how the STNA had her hands placed on the resident. STNA #90 stated she then placed her hands across the resident's leg touching her arm against the resident legs to prevent the resident from kicking the nurse. She stated she thought she was doing what she was supposed to do, however now looking back she should have told STNA #96 and LPN #91 to back off. STNA #90 revealed the resident had been observed crying earlier in the day. She stated she was sorry the incident had occurred and sorry it upset the other residents, especially Resident #47. She reported Resident #47 was crying and upset following the incident. Review of STNA #90's written statement, dated 07/10/18 revealed she was walking down the hall when she heard someone yelling and screaming. When she walked up to Resident #177 she tried to re-direct her. The resident was holding and flinging around STNA #96's arms and trying to hit LPN #91. She stated she then bent down and put her arm in front of the resident's legs and between her and the nurse. The DON walked up to us and told all of us to back up and walk away. The statement indicated the STNA did was she was told. On 07/10/18 at 1:52 P.M. and during a subsequent interview at 3:18 P.M., with the DON revealed Pharmacist #100 had come to her office (on this date) and said the surveyor or resident needs you. The DON reported Pharmacist #100 sounded like it was urgent so she ran down to the day room/dining area. She observed Resident #177 at the table with three staff members around her. One staff member, STNA #96 had both hands straight above the resident's lap in the air, the resident had ahold of one of the STNA's wrist and she stated she could not recall where the other hand was. STNA #90 was bent down and had one arm straight in the air out to prevent the resident from kicking the nurse. LPN #91 was on the floor trying to apply a wander guard to the resident's left ankle. As she approached the resident was yelling out, however she couldn't recall what the resident was saying. She instructed the staff to step back as well as the unit manager and to clear the area. She knelt beside the resident and put her hand out. The resident was tearful, and she was screaming off and on. The resident was removed from the area, taken to the front patio by social service staff (LPN #51) to try to calm her down. Resident #47, who was present in the day area was also upset and removed from the area and taken to his room. She stated she asked visitors, residents, and family in the day room if they were okay. She stated after the incident STNA #96 and LPN #91 left the facility and STNA #90 went to her office. STNA #96 then returned to the facility to provide a written statement. During the interview the DON revealed when Resident #177 started yelling out the staff should have stepped back. She indicated staff standing around any resident that was yelling could have potentially made the situation worse. On 07/10/18 at 2:43 P.M., Resident #177 was observed seated in a wheelchair outside with LPN #51 who functioned as the facility social service designee. An attempt to interview the resident revealed she did not want to be in the facility and the resident continued to appear upset. Further attempts to interview or obtain additional information from the resident were unsuccessful at that time. The resident would answer yes or no general questions about the weather/flowers but would not engage in conversation or discuss the incident that had occurred earlier in the day. On 07/10/18 at 2:47 P.M., interview with STNA #96 revealed she had passed lunch trays and was starting to assist a resident with her lunch when LPN #91 was attempting to place a wander guard on Resident #177's ankle in the day room/dining room area as the residents were eating. The resident became very combative and almost kicked the nurse in the face. STNA #96 stated she approached the nurse and resident and attempted to calm the resident down. She placed her hands around the residents and had her hands resting in her palms with her index and thumb slightly around the resident's wrist and then the resident grabbed her hands. She stated STNA #90 then arrived and placed herself between the nurse and resident. The resident was hitting, kicking, and screaming for 10-15 minutes as the nurse tried to apply the wander guard to the resident's ankle. STNA #96 stated she asked LPN #91 if it was okay to be doing this because she had never seen a resident be so combative and agitated and stated she was afraid they were going to get in trouble. She stated the nurse never responded. At that time the DON arrived and told them to back up and she left to assist another resident with her lunch. STNA #96 reported she honestly didn't know what she would do if she witnessed an incident like this one again. She confirmed it was inappropriate to upset the resident, and the other residents and family members in the dining room. However, she felt she was following LPN #91's directive. She confirmed the resident had been upset earlier that day because she had to move to the nursing home side of facility. STNA #96 voiced she had been in-serviced on abuse. The DON was present during interview. Review of STNA #96's written statement, dated 07/10/18 revealed the nurse was trying to place a wander guard bracelet on Resident #177. The resident became very combative and kicked the nurse, that's when I stopped in and tried to calm her down. The statement indicated Resident #177 grabbed her hand and arm and she had ahold of her hand just enough to guard the nurse so the resident wouldn't hit her. The statement indicated she tried the whole time to calm the resident down and ease her mind. The statement indicated STNA #96 asked while the incident was occurring if they were allowed to do this and wrote she didn't want to get in trouble. On 07/10/18 at 3:58 P.M. interview with LPN #51 revealed she functioned as the facility social service designee. She stated she had gone to the day room because someone had called her to come down. She stated following the incident with LPN #91 and STNAs #90 and #96 she took Resident #177 outside per her wishes. She stated the resident was upset and crying and her eyes were red and swollen. She stated the resident told her she wanted to go back to the assistive living side of the building. She stated she really didn't know anything about the actual incident that had occurred and the resident did not mention anything specifically to her. She stated if a resident became combative during the provision of care, staff should keep them safe and not keep badgering them, give them a minute to calm down and try to approach later. She reported after she took the resident outside, it took a while for her to calm down and she talked very little. During the interview, she also shared, that she had never seen Resident #47, who was nonverbal get that upset before. She stated the resident had a little tear coming down his cheek as they removed him from the day room. Review of Resident #177's electronic nursing progress notes revealed on 07/10/18 at 4:10 P.M. RN #61 assessed the resident. The resident was assessed to be anxious, calmed after much redirection and reorienting to the situation. On 07/10/18 at 9:11 P.M. an electronic nursing progress note revealed family was onsite with the resident and the resident was sitting in the hall. On 07/10/18 at 4:24 P.M., interview with Resident Care Assistant (RCA) #105 revealed she had provided care to Resident #177 while she resided in the residential care facility. RCA #105 revealed the resident could have a temper and be nasty at times, however if you walked away and left her be she would calm down. She reported the resident had never been physical with staff or residents while residing on the residential care facility side of the facility. Review of the LPN #91's written statement obtained as part of the facility investigation, dated 07/11/18 revealed at approximately 12:15 P.M. on 07/10/18 Resident #177 was at the nurse's station yelling at to her that she wanted to talk to her doctor right now. She stated she explained the doctor had been contacted and was aware that she was in the nursing home and wanted to speak with him. LPN #91 stated Resident #177 then stated, I'm not staying here. At that point she obtained an order from the doctor for a wander guard to be placed on the resident's left ankle due to exit seeking behavior and concern that the resident would attempt to leave the facility and she didn't want her to have a heat stroke or get lost or hit by traffic. The statement revealed after obtaining the order and wander guard device she found the resident sitting in a chair at the dining room table. She explained to the resident what the wander guard was, where it goes and kneeled to put it on her left ankle when Resident#177 began hitting her. STNA #96 came over and began holding hands with the resident and talking to her to divert her attention from hitting and kicking at her. At some point another STNA came over and placed herself in front of the resident to keep her from kicking her. The statement indicated the resident had been yelling out since she had arrived at approximately 8:00 A.M. or 9:00 A.M. At this point more staff members had arrived and she heard someone yell stop. The statement indicated LPN #91 said, I'm trying to put a wonder guard on her, because she said she was not staying here and I don't want her to go out in the heat and get lost or smothered by the humidity. The statement indicated LPN #91 thought she had the wander guard secured and got up and walked back to nurse's station. Interview on 07/11/18 at 10:20 A.M., with LPN #91 in the presence of the DON revealed the resident had not physically attempted to leave the facility at any time since her admission, however she had verbalized she was not staying there. LPN #91 verified she obtained an order for [REDACTED].#91 stated she was not trying to hurt the resident and felt the incident took place over two to three minutes. LPN #91 verified the resident was combative, cussing, screaming, and crying as a result of the incident but was unable to recall exactly what the resident was saying. LPN #91 revealed she told the resident that everyone was very busy and explained that the wander guard was to warn staff if she attempted to leave. She stated she believed the resident thought they were trying to restrict her and monitor her. On 07/11/18 at 2:45 P.M., interview with facility Medical Director (MD) #101 revealed he had assessed Resident #177 and noted some new and old bruising on the resident's body. No additional information was provided as to whether he believed the bruising was a result of the incident with LPN #91, STNA #90 and STNA #96. He stated the resident appeared to be comfortable at that time and had slight cognitive impairment. During the interview, MD #101 revealed the proper way to have handled the situation with Resident #177, when she refused to allow staff to apply the wander guard, should have included redirection, an attempt to calm and then redirect the resident. MD #101 indicated he believed the incident was handled inappropriately by the staff members. On 07/12/18 at 1:22 P.M. during an interview with Administrator #200, DON, RN #104 and RN #106, these administrative staff verified there was no nursing progress note contained in the resident's medical record from LPN #91 regarding the incident that occurred related to the attempted application of the wander guard. There was no written evidence the resident was exhibiting wandering or safety related behaviors prior to LPN #91 obtaining the physician order [REDACTED]. or attempting to place the wander guard device on the resident. During the interview, the DON also verified when she arrived to the day room after being summoned for assistance, all three agency staff were still with the resident and she verbally instructed staff to move away from her. The administrative staff indicated as a result of the incident, statements were obtained from LPN #91, STNA #90 and STNA #96 and then the staff were removed from the facility. When asked if the agencies who employed the staff were notified of the incident, the DON indicated she had called the two different agencies but had only notified one of the two of the actual incident as of this time. She revealed she had not notified the agency who employed LPN #91 and STNA #96 of the incident that had occurred. On 07/12/18 at 3:35 P.M. an observation of Resident #177 revealed she was in her room with the television on and curtain pulled around her bed. Upon knocking and receiving permission to enter the resident's room, the resident was observed on the floor. The resident voiced she needed to use the bathroom and the surveyor obtained staff to assist the resident. On 07/12/18 at 4:16 P.M. telephone interview with Administrator #108, the administrator of the staffing agency who employed STNA #90, revealed she had heard something in passing for the first time on this date regarding an aide witnessing something at the facility but did not have any specific details or knowledge of the facility reporting any concerns, issues or allegations of abuse or improper care by one of the agency staff members or that the facility had removed an employee from providing resident care. Administrator #108 stated it was the expectation that if there was a problem or concern, the facility would notify either the agency staffing scheduler or herself as the administrator. Administrator #108 denied any evidence the staffing scheduler had been notified of any problems or issues regarding the care of a nursing home resident by one of the agency staff. On 07/12/18 at 5:07 P.M. telephone interview with Staffing Scheduler #109 from the agency staffing company revealed on 07/10/18 STNA #90 arrived to the staffing agency building after her shift at the facility at about 3:10 P.M. Scheduler #109 indicated STNA #90 had asked to speak to the supervisor and was directed to that employee. Scheduler #109 revealed she didn't have any details about what was discussed between the two. Upon prompting from the facility DON, Scheduler #109 revealed she had been contacted by the DON that same evening but could not recall the specifics of what had been reported to her by the DON other than it was the same thing that STNA #90 had reported even though she denied knowledge of what had been reported to the supervisor by STNA #90. On 07/12/18 at 3:56 P.M. attempts to reach staff from the second agency staffing company who employed LPN #91 and STNA #96 were unsuccessful. On 07/13/18 at 11:35 A.M. Resident #177 was observed seated in a wheelchair in the hallway outside her room. At the time of the observation, the resident was heard talking with Activity Aide #19. During the conversation, Resident #177 voiced concerns to Activity Aide #19 that she had been brought to the nursing home on Tuesday morning with no explanation and it was now Friday and she didn't want to be in the nursing home. The resident told the Activity Aide that she was very upset and bitter with her placement, the fact that no one was telling her what was going on and she was not receiving any care. The resident indicated she wanted to go back to the residential care facility. During the conversation, the resident became tearful and expressed frustration with the care provided to her from facility staff and the lack of perceived follow up to her concerns with placement. Activity Aide #19 attempted to reassure the resident and informed her she would relay her concerns to nursing staff. Review of the facility's Abuse, Mistreatment, Neglect, Injuries of Unknown Source and Misappropriation of Resident Property policy, dated 03/07/18, revealed staff would be educated upon orientation and periodically thereafter regarding the facility's policy and dealing with aggressive and/or catastrophic reaction of residents. Catastrophic reactions were defined as extraordinary reactions of residents to ordinary stimuli, such as the attempt to provide care. The policy indicated the facility would not tolerate abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This is a recite to the survey completed on 06/20/18.

Based on observation, record review and staff interview the facility failed to ensure pressure relieving interventions were implemented and in place to prevent the development of an avoidable pressure ulcer for one resident (Resident #44). Actual harm occurred when a red area to Resident #44's heel declined to an unstageable pressure ulcer (tissue necrosis or death that typically develops when soft tissue is compressed between a bony prominence and an external surface for a long period of time and may be covered with yellowish/gray slough tissue or dark black/brown eschar tissue and prevents visualization of the wound bed for accurate staging) as a result of a lack of interventions and assessments. In addition the facility failed to ensure Resident #68 was provided appropriate treatment for [REDACTED]. This affected two of three residents reviewed for pressure ulcers. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/06/17 Resident #44 was assessed to be at high risk for developing a pressure ulcer. On 02/10/17 and 02/19/17, Resident #44 was identified as a moderate risk for pressure ulcer development and on 04/20/17 Resident #44 remained at risk. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 had severe cognitive impairment and had one unstageable pressure ulcer. Further review of the MDS revealed Resident #44 required extensive assistance of one to two staff for turning and repositioning. Review of the current care plan revealed soft boots (pressure relieving boots) were to be worn when in bed and an aqua-gel cushion was to be used as ordered in the chair. Review of Resident #44's care directives for the state tested nursing assistants (STNA's) revealed soft blue heel boots where to be on Resident #44 when she was in bed and the aqua-gel cushion was to be at the foot of bed or in the geriatric chair with Resident #44. Review of a progress report dated 02/15/17, written by the surgeon, revealed physician orders [REDACTED].#44's heels off of the bed surface and for heel protectors to be applied to her feet. Review of a nurse progress note dated 03/03/17 at 5:51 P.M. revealed Resident #44 complained of her left heel burning. The nurse's assessment of Resident #44's left heel revealed it was red and soft. On this date, a physician order [REDACTED].#44 to wear soft boots while in bed and for staff to apply skin prep (a protective barrier to toughen skin) to her heels for seven days. On 03/06/17 at 9:59 A.M. a progress note by Registered Nurse (RN) #46 revealed a dark purplish area to Resident #44's left heel was identified. The area measured 1.6 centimeters (cm) long and 0.5 cm wide. Resident #44 complained of pain to the the area. On 03/08/17 at 8:02 A.M., a progress note by Licensed Practical Nurse (LPN) #100, the wound nurse, revealed Resident #44's heels were red and soft. There was no mention of the heel being purple as noted two days before. Review of the treatment administration record (TAR) revealed skin prep was applied to Resident #44's heels from 03/03/17 to 03/09/17. No treatments were in place from 03/09/17 to 03/28/17 for her left heel. On 03/28/17 at 12:09 P.M. a progress note by LPN #100 revealed Resident #44 had a Stage II pressure ulcer that was an open, peeling blister, to her left heel. The wound bed was described as pink and measured 2.0 cm long, 3.0 cm wide, and 0.1 cm deep. The physician was contacted and treatment orders for the application of Alleyvn, an absorbent foam dressing, were obtained on 03/28/17. On 04/03/17, the skin alteration record or skin assessment, revealed the pressure ulcer to Resident #44's left heel was a Stage II pressure ulcer which was open and moist. The pressure ulcer was larger in size and measured 4.5 cm long, 2.5 cm wide, and 0.1 cm deep. The physician was notified and the treatment was changed to cleanse with normal saline, apply [MEDICATION NAME] soaked dressing and wrap with a Kerlix, a gauze wrap. On 04/10/17 the skin alteration record revealed the area to Resident #44's left heel had declined further and was now an unstageable pressure ulcer. There was no evidence in the medical record the physician was notified until 04/13/17, three days later, when a new order for the aqua-gel cushion was ordered to be used for Resident #44 in bed and chair. The wound treatment itself was not changed. This was verified in a nursing progress note on 04/14/17 at 6:10 A.M. The progress note by LPN #100 revealed Physician #500 (the podiatrist) was aware Resident #44's left heel was covered entirely with eschar (black/brown leathery, dead tissue) and a new order was given for an aqua-gel cushion to be placed at the foot of the bed or in Resident #44's geriatric chair (a large, specialized chair that can recline) with her. On 05/23/17 at 4:24 P.M., an interview with STNA #18 confirmed she was not aware an aqua-gel cushion was to be placed at the foot of Resident #44's bed or in her geriatric chair. An observation at that time revealed Resident #44 did not have the aqua-gel cushion in place as ordered by the physician. This concern was verified with STNA #18. On 05/24/17 at 10:45 A.M., an observation was made of Resident #44 lying in bed. An interview with LPN #100 at that time confirmed the aqua-gel cushion was in the seat of Resident #44's geriatric chair and was not in bed for Resident #44 as ordered by the physician. On 05/24/17 at 10:47 A.M., an observation was made of the dressing change to Resident #44's left heel. Resident #44 stated her heel had hurt really bad before. The pressure ulcer had black eschar and had a visible open area measuring 3.0 cm by 1.9 cm. When LPN #100 completed the dressing change, a regular pillow was placed under Resident #44's feet and the aqua-gel cushion was not placed at the foot of the bed as ordered. This was verified with LPN #100 after the treatment was completed. On 05/24/17 at 2:11 P.M., STNA #26 verified a regular pillow, not the aqua-gel cushion, was used for Resident #44 while in bed. On 05/24/17 at 4:36 P.M. an interview with LPN #100 revealed the physician progress report dated 02/15/17 was written by Resident #44's surgeon. LPN #100 verified a clarification order was written on 03/03/17 for Resident #44 to wear pressure relieving boots while in bed since they had not been implemented as ordered previously on 02/15/17. The pressure relieving boots were not implemented until after Resident #44 complained of pain and was found with a reddened, soft left heel, the beginning of the pressure ulcer. On 05/24/17 at 5:34 P.M. an interview with LPN #100 revealed she looked at Resident #44's foot two days after RN #46 identified a purplish area. LPN #100 stated Resident #44's heels were red and soft. and she did not know why RN #46 would document there was a purple area. LPN #100 further stated the broken blister was discovered on 03/28/17 and she was not aware when the blister developed before it was found as a broken blister. On 05/25/17 at 9:22 A.M. an interview with RN #46 revealed Resident #44 did have a purple area to her heel and she had two other nurses look at the area to verify the area to the heel was purple. RN #46 stated she completed a skin sheet to notify the wound nurse, LPN #100, of this area to Resident #44's left heel. On 05/25/17 at 12:49 P.M. an interview with LPN #100 confirmed there was no documentation or assessment of the pressure ulcer to Resident #44's left heel from 03/08/17 to 03/28/17, when a Stage II pressure ulcer was identified. LPN #100 said she had not received skin assessments from RN #46 and was not sure who received the skin assessments. The skin care management policy and procedure (no date) revealed appropriate preventive measures would be implemented for all residents identified at risk for pressure ulcers. The policy and procedure also revealed that treatment, interventions, care planning, and the appropriate skin documentation records were to be initiated in a timely manner. 2. Review of Resident #68's medical record revealed a readmission date of [DATE] with [DIAGNOSES REDACTED].#68's skin alteration record revealed Resident #68 had a Stage II pressure ulcer with the date of onset listed as 05/22/17. The pressure ulcer was documented as being 4.0 cm wide, 0.5 cm long and with a depth of 0.2 cm. Review of the physician orders [REDACTED]. Review of the Dr. Smith's adult barrier spray product information revealed the product was effective for treating incontinence (involuntary loss of urine and/or stool) associated [MEDICAL CONDITION] (skin irritation/rashes). There were no indications the product should be used for the treatment of [REDACTED]. An observation was completed on 05/24/17 at 9:36 A.M. with LPN #100 who prepared and completed Resident #68's dressing change. After cleansing Resident #68's coccyx pressure ulcer with normal saline, LPN #100 was observed to spray Dr. Smith's adult barrier spray onto the beefy red, open area on Resident #68's coccyx. Immediately following this observation LPN #100 confirmed the wound currently appeared as a open area with a red beefy wound bed with edges intact. LPN #100 confirmed the area was a Stage II pressure ulcer. LPN #100 indicated the facility did not have any guidance related to what products or treatments were to be used for the different stages of pressure ulcers. An interview was completed on 05/24/17 at 1:59 P.M. with Resident #68's primary physician, Physician #116, who had ordered the Dr.(NAME)adult barrier treatment. Physician #116 said he was unfamiliar with the Dr. Smith's adult barrier product. He said he depended on the wound care nurse, LPN #100, to suggest the treatment. Physician #116 indicated he was unaware if what LPN #100 had used, Dr Smith's barrier spray, treatment was appropriate for Resident #68's Stage II pressure ulcer. Interview on 05/24/17 at 2:17 P.M. with LPN #100 confirmed the Dr. Smith's adult barrier product was for helping to treat and prevent rashes caused by adult incontinence and protection of chafed skin. LPN #100 confirmed there was no evidence the product was appropriate for treating a Stage II pressure ulcer.

Based on observation, staff interview, and medical record review, the facility failed to provide interventions to prevent the development of and promote the healing of pressure ulcers for one of two residents reviewed during Stage 2 for pressure ulcers (Resident #90) in a total sample of 15. Harm occurred when the facility failed to implement interventions for identified risk factors for pressure to Resident #90's ears due to the use of oxygen tubing and she sustained a pressure ulcer to the left ear. The pressure ulcer caused the resident pain as evidenced by moaning during the dressing change. Findings include: Review of Resident #90's medical record revealed [DIAGNOSES REDACTED]. Resident #90 had a Stage II (a partial thickness loss of skin layers) pressure ulcer on her left outer foot near her fifth toe (present on admission on 07/16/10). Resident #90 had resolved pressure ulcers on her back and both of her feet. A care plan with an onset date of 07/19/10 identified risks for skin problems and delayed healing due to recent hospitalization . The care plan indicated Resident #90 had a past medical history of [REDACTED]. The care plan indicated Resident #90 had severe Alzheimer's dementia and was on [MEDICATION NAME] (an anti-psychotic) as necessary. The care plan indicated both caused impairment to cognition, decreased functional ability and decreased mobility. Resident #90 was also considered at risk due to history of a fractured humerus and from prolonged immobility, increasing the risk of contractures causing skin friction and sheer. Other risk factors identified included resistance to care, use of oxygen and tube feed via peg tube. The care plan indicated tubing from all of those could irritate skin and cause pressure to skin surfaces. Other risk factors identified included inability to respond meaningfully to pressure related discomfort, incontinence, chairfast, and elevation of the head of the bed due to the use of the tube feed. The care plan did not reveal interventions to prevent pressure on the ears. Interventions included keeping heels elevated off of surfaces, using caution during transfers, using lifting devices as needed, and using draw sheet as needed for positioning. A quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/24/10 revealed Resident #90 was rarely/never able to make herself understood, sometimes understood others, was totally dependent of one assist for bed mobility, did not walk, was totally dependent on one for dressing, toilet use, personal hygiene, and bathing, and was totally incontinent of bowel and bladder. Resident #90 had a physician order [REDACTED]. Documentation on a skin alteration record revealed Resident #90 was first assessed with [REDACTED]. The physician ordered to cleanse the pressure area behind the left ear due to oxygen tubing with normal saline and apply triple antibiotic ointment topically and leave open to air daily until healed (3:00 P.M.-11:00 P.M. shift) and oxy-ear to oxygen tubing. On 12/08/10 at 9:40 A.M., Licensed Practical Nurse (LPN) #24 was interviewed and stated Resident #90 did not have padding for oxygen tubing when the open area behind her ear was discovered. On 12/08/10 at 10:28 A.M., LPN #24 was observed administering treatments to Resident #90's ulcers on her left ear and left foot near her fifth digit. After washing her hands, LPN #24 obtained supplies from the treatment cart, washed her hands, then obtained more guaze from the cart. LPN #24 obtained a paper towel from the bathroom and applied gloves. The paper towel was placed on the bedside table and the supplies were placed on top of the paper towel. After cleansing the ulcer behind the left ear, LPN #24 removed the glove from her left hand and discarded the glove and the guaze used to clean the left ear onto the paper towel that had clean guaze and a plastic cup with [MEDICATION NAME] cream. LPN #24 then applied a clean glove to her left hand and opened antibiotic ointment then changed the left glove again. The antibiotic ointment was then applied. LPN #24 then threw the glove from her left hand onto the table with the edge of the glove resting on the towel. LPN #24 replaced the padding onto the oxygen tubing and reapplied it. LPN #24 then removed the glove from her right hand and washed her hands. A new set of gloves was applied. Resident #90 had prevalon boots on both feet with a blanket between her legs. Her boots were resting on the surface of the bed. LPN #24 used the sheet under Resident #90 and pulled her across the surface of the bed toward her. LPN #24 changed her gloves and cleansed the ulcer to the lateral aspect of the left foot near the base of the fifth digit. LPN #24 changed her gloves, and applied [MEDICATION NAME]. It was noted during the dressing change to the resident's left ear, Resident #90 moaned out in pain. On 12/08/10 at 10:43 A.M., LPN #24 was interviewed and stated Resident #90 usually had a pillow under her legs to elevate feet off the bed but verified none was present. LPN #24 also verified she had used the sheet and scooted Resident #90 across the surface of the bed instead of lifting her. On 12/08/10 at 4:32 P.M., Registered Nurse (RN) #19 verified there were no interventions other than the monitoring of the skin to address the relief of pressure from the use of the oxygen tubing. RN #19 stated Resident #90 started using the oxygen continuously on 11/01/10.