Every finding on record at Continuing Healthcare of Gahanna

Based on observation, staff and resident interview, and facility policy review, the facility failed to serve food that was palatable and maintained at an appetizing temperature. This had the potential to affect all 93 residents who received food from the kitchen. The census was 93. Findings include: Observation and interview on 08/03/26 from 11:30 A.M. to 1:07 P.M. was made as dietary staff prepared the lunch meal that consisted of beef stroganoff and a steamed vegetable medley. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the second floor food cart. Observation was made as the test tray was prepared, placed on the cart at 12:53 P.M., and transported by Dietary Aide (DA) #200 to the 200 hallway where it arrived at 12:58 P.M. The test tray remained on the cart in view of the surveyor, until all other trays were distributed to residents. The test tray was removed from the cart at 1:09 P.M. by DA #200 who used a facility thermometer that confirmed the temperature of the beef stroganoff was 85 degrees Fahrenheit (F) and the vegetable medley temperature was 96 degrees F. Immediately following confirmation of the test tray temperatures, the surveyor taste-tested the beef stroganoff revealing the noodles were overcooked and soggy. DA #200 confirmed the food temperatures at the time they were obtained and agreed that towards the end of the batch the noodles become overcooked.Interviews on 08/04/26 between 10:30 A.M. and 3:30 P.M. with Resident #5 and Resident #30 revealed they were not satisfied with the taste or the temperature of the lunch consisting of beef stroganoff and vegetable medley.Review of the facility's policy titled, Nutrition Services Policies and Procedures, revised 02/2022, revealed all foods are stored, prepared, and served at temperatures that prevent bacterial growth. At point of delivery, hot foods should be between 120 and 140 degrees F.This deficiency represents non-compliance investigated under Complaint Number 3124981.

Based on medical record review, staff and resident interview, and review of a facility policy, the facility failed to timely and consistently follow a physician order to ensure a resident was provided a wearable device to monitor blood sugar levels. This affected one (#5) of three residents reviewed for physician orders. The facility census was 93. Findings include:Record review for Resident #5 revealed the resident was admitted to the facility on [DATE] with diagnoses including sepsis, type II diabetes mellitus, muscle wasting and atrophy, non-pressure chronic ulcer of the left ankle, dysphagia, diabetic neuropathy, depression, and acquired absence of the right leg above the knee. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition and was assessed to require mobility and self-care assistance.Review of the care plan for Resident #5 dated [DATE] revealed the resident was at risk for hypo/hyperglycemia due to his diabetes mellitus. An intervention included monitoring his blood glucose levels.Review of the physician orders for Resident #5 revealed an order dated [DATE] for a FreeStyle Lite sensor to be applied and worn everyday to monitor the resident's blood glucose levels.Review of the medication administration record of Resident #5 revealed the device was not received and applied to the resident until [DATE].Review of Resident #5's nursing progress notes revealed on [DATE] the sensor had expired and a new one was to be applied. Review of the nursing progress notes revealed a new sensor had not been received as of [DATE].During an interview with Resident #5 on [DATE] at 1:06 P.M. he expressed frustration with the facility not having procured the sensor he needed. Resident #5 stated without being able to check his blood sugar using the sensor and reader, his blood glucose was to be taken using a finger prick, which he was not agreeable to due to discomfort.During an interview with the interim Director of Nursing (DON) at 2:35 P.M. on [DATE], she confirmed Resident #5's blood sugar monitoring device had not been available to him per the physician's order. The interim DON confirmed education had been provided to staff about ensuring the resident's orders are fulfilled in a timely manner.Review of the facility's policy titled, Physician Orders, revised 12/2025, revealed the facility staff was responsible for carrying out orders promptly.This deficiency represents non-compliance investigated under Complaint Number 3124981.

Based on record review, interview, and facility policy review, the facility failed to ensure the resident's legal guardian/representative was notified of a significant change in condition and refusal of emergency room/hospital transfer for one resident (#93) of three residents reviewed for change in condition and notification. The facility census was 86. Findings include:Review of Resident #93's clinical record revealed the resident had diagnoses that included chronic respiratory failure, pulmonary hypertension, heart failure, chronic atrial fibrillation, atherosclerotic heart disease, dysphagia, bipolar disorder, major depressive disorder, generalized anxiety disorder, and insomnia.Review of Resident #93's Social Services assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.Review of Resident #93's contact information revealed the resident had a guardian listed as the first emergency contact, and also had another individual listed as the second emergency contact. Review of the SItuation, Background, Assessment and Recommendation (SBAR)/change-in-condition documentation dated [DATE] at 10:52 P.M. revealed Resident #93 had a change in condition related to a significant loss of appetite. The SBAR documented the nurse received report that Resident #93 refused breakfast, lunch, and supper due to significant loss of appetite. The SBAR documented the resident reported minor stomach discomfort and loss of appetite. The SBAR further documented the nurse provided the resident with cereal and milk, and the resident ate and took nighttime medication. the SBAR documented Resident #93 refused to go to the emergency room when suggested by the nurse. The SBAR documented the Director of Nursing was notified and directed the nurse to complete a SAR-Cov-2 (COVID-19) test and notify the physician to reassess the resident's situation in the morning. The nurse documneted on the SBAR that the second emergency contact was notified on [DATE] at 10:42 P.M. The SBAR did not identify documentation that Resident #93's listed legal guardian, Emergency Contact 1, was notified of the resident's change in condition or refusal of emergency room transfer.Review of a nursing progress note dated [DATE] at 11:23 A.M. revealed the physician assistant gave new orders for an antibiotic and chest X-ray due to suspected pneumonia.Review of a nursing progress note dated [DATE] at 4:14 P.M. revealed the chest X-ray was completed and results were pending.Review of a nursing progress note dated [DATE] at 5:20 A.M. revealed Resident #93 was encouraged to transfer to the emergency room multiple times the previous day but refused each time. The note documented during morning rounds on [DATE], Resident #93 was found unresponsive. Cardiopulmonary resuscitation was initiated while a second staff member provided oxygenation with an Ambu bag. Emergency medical services were notified and arrived at approximately 5:00 A.M. The note documented emergency medical services declared the resident expired.Review of the clinical record did not identify documentation that Resident #93's legal guardian was notified on [DATE] or [DATE] of the resident's change in condition, poor intake, suspected infection/pneumonia, refusal of emergency room transfer, or refusal of hospital transfer prior to the resident being found unresponsive on [DATE].During interview on [DATE] at 1:18 P.M., Resident #93's legal guardian verified she stated the guardianship program received a call from the facility on [DATE] at approximately 5:51 A.M. after Resident #93 was found unresponsive/passed away. The guardian stated the facility did not notify the guardian prior to that time regarding the resident's decline, poor intake, suspected infection, or refusal of emergency room/hospital transfer. The guardian stated Resident #93 could not make her own medical decisions and the guardian would have expected to be contacted for significant medical concerns, refusals, changes in condition, or hospital transfer decisions. The guardian stated the facility could not physically force Resident #93 to go to the hospital nor as the guardian could they make her go to the hospital and stated she believed notification would not have changed the outcome. The guardian confirmed the facility did not notify the guardian of the resident's decline or refusal of hospital transfer prior to the resident being found unresponsive.During interview on [DATE] at 3:58 P.M., the Director of Nursing stated it was her understanding the legal guardian was notified, but acknowledged she was not sure if she could provide documentation to support the legal guardian was notified. The Director of Nursing stated she would look for documentation showing guardian notification.During follow-up interview on [DATE] at 4:48 P.M., the Director of Nursing confirmed she was unable to locate documentation showing Resident #93's legal guardian was notified of the resident's health decline and refusal of hospital transfer prior to the resident being found unresponsive. The Director of Nursing acknowledged she could not provide documentation showing the guardian was notified of the change in condition, poor intake, suspected infection/need for further evaluation, or refusal of emergency room/hospital transfer before the resident's decline progressed.Review of the facility policy titled Change of Condition, revised 08/2025, revealed it was the policy of the facility to ensure changes in a resident's condition were recognized, assessed, communicated, and addressed in a timely and appropriate manner. The policy defined a change in condition as a significant deviation from a resident's baseline status that may indicate actual or potential instability, decline, or need for medical evaluation or intervention. The policy documented changes may include alterations in mental status or level of consciousness, acute pain, distress or new symptoms, changes in respiratory, cardiac, or neurological status, and staff concerns regarding resident safety or stability. The policy further documented nursing staff were to assess the resident, obtain vital signs as clinically indicated, and notify the attending physician or on-call provider promptly of significant changes in condition based on clinical findings and resident status.This deficiency represents non-compliance investigated under Complaint Number 3067299.

Based on record review, interview, and facility policy review, the facility failed to ensure a resident was free from verbal abuse by staff. This affected one resident (#51) of one reviewed for an allegation of staff-to-resident abuse. The facility census was 86. Findings include:Review of Resident #51's clinical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, essential hypertension, major depressive disorder, oropharyngeal dysphagia, anxiety disorder, muscle weakness, personal history of venous thrombosis and embolism, malignant neoplasm of base of tongue, and other intervertebral disc degeneration of the lumbar region with discogenic back pain only.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a quarterly assessment completed. The MDS identified the resident as being cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15.Review of a progress note dated 07/07/26 at 8:00 A.M. revealed Resident #51 was seen for follow-up related to pain. The progress note documented the resident was a [AGE] year-old male with a past medical history of hypertension, diabetes mellitus, and hyperlipidemia. The note documented the resident appeared stable on examination, and the plan was to monitor and continue the current treatment regimen.Review of Resident #51's care plan dated 12/10/25 revealed the resident had a behavior of verbal aggression with an intervention for observe for early warning signs of behaviors, to approach in a calm manner, call by name and to remove unwanted stimuli.Review of Self-Reported Incident (SRI) tracking number 276635, dated 07/07/26, revealed the facility reported an allegation of emotional/verbal abuse involving Resident #51 and Housekeeping Supervisor #238. The SRI documented the date of discovery was 07/07/26. The alleged/suspected perpetrator was identified as facility staff or other care provider. The SRI revealed the incident began after Housekeeper (HK) #548 reported an issue involving Resident #51 allegedly placing $20 in her pocket. HK # 548 stated she attempted to return the money, but Resident #51 became upset. HK # 548 reported the matter to management and was instructed to give the $20 to Housekeeping Supervisor #238 so it could be returned to Resident #51. The money was placed in an envelope, and staff witnesses were present when the money was handed to Resident #51 by Housekeeping Supervisor #238. When Housekeeping Supervisor #238 handed the envelope to Resident #51, the resident asked what it was. Housekeeping Supervisor #238 explained the envelope contained the $20 which was given to Housekeeper (HK) #548 and it was being returned to the resident. Resident #51 stated Housekeeping Supervisor #238 was misinformed and stated HK # 548 had asked him to hold the money for her. Housekeeping Supervisor #238 acknowledged the resident's explanation and informed Resident #51 the cash had to be returned to him. Resident #51 became visibly angry, began yelling, used profanity, and made verbal threats toward Housekeeping Supervisor #238. The SRI documented Resident #51 repeatedly stated he was going to beat my ass and fuck me up because, according to the resident, Housekeeping Supervisor #238 was misinformed. The SRI documented Resident #51 ran across the front of the nurses' station toward Housekeeping Supervisor #238, got in his face, and continued yelling and making threats. Housekeeping Supervisor #238 told Resident #51 he was not going to put his hands on him. The SRI revealed it was also alleged that during the incident, Housekeeping Supervisor #238 picked up a vase in a threatening manner toward a resident. The SRI documented that due to Housekeeping Supervisor #238's threatening behavior and the allegations involving a resident, Housekeeping Supervisor #238 was immediately suspended pending the outcome of the investigation.Review of the facility investigation summary dated 07/07/26 revealed the facility determined, based on the investigation findings, witness statements, and the severity of Housekeeping Supervisor #238's conduct, Housekeeping Supervisor #238 violated facility standards related to workplace violence, threatening behavior, and professional conduct. The investigation summary documented the facility determined there was credible evidence of verbal threats and aggressive actions toward a resident. The facility terminated Housekeeping Supervisor #238's employment effective 07/07/26.Review of resident interview documentation dated 07/07/26 revealed Resident #51 denied being hit, pushed, grabbed, handled in a way that hurt him, touched in an unwanted way, threatened, injured, or caused pain by someone else. Resident #51 reported he felt safe around staff and other residents.During interview on 07/08/26 at 10:15 A.M., the Administrator confirmed the SRI details regarding the interaction between Resident #51 and Housekeeping Supervisor #238, confirming the altercation involved verbal threats, threatening behavior and aggressive action taken by the faciity staff toward Resident #51. The Administrator confirmed the incident involved the return of Resident #51's, $20 and that Resident #51 became upset during the interaction. The Administrator verified Housekeeping Supervisor #238 held a vase behind him during the incident but did not lift the vase toward Resident #51. The Administrator stated staff interviews also confirmed Housekeeping Supervisor #238 held the vase behind him and did not lift the vase toward the resident. The Administrator stated Housekeeping Supervisor #238 was suspended immediately and later terminated due to the facility's investigation findings related to threatening behavior, verbal threats, aggressive actions, and professional conduct.Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The policy documented the facility would investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation, mistreatment, and injuries of unknown source. The policy further documented facility staff should immediately report allegations to the Administrator and the Ohio Department of Health in accordance with facility procedures. This deficiency represents an incidental findings discovered during the course of this complaint investigation.

Based on policy review, observation, resident and staff interviews, and record review ,the facility failed to ensure staff provided adequate supervision to prevent a resident, with altered mental status and was an elopement risk, from leaving the facility unsupervised. This affected one (Resident #33) of two residents reviewed for elopement risk. The facility census was 87. Findings include:Review of hospital documentation dated from 05/31/26 to 06/09/26 revealed Resident #33 was hospitalized with a primary diagnosis of dementia and was alert and oriented to self at baseline.Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included non traumatic subdural hemorrhage, cerebral infarction, dementia, and hearing loss.Review of the care plan dated 06/10/26 revealed Resident #33 was identified as an elopement risk. Interventions included to monitor location frequently throughout the shift, maintain safety during wandering, initiate elopement procedures if the resident became missing, provide engaging activities, offer fluids and snacks during wandering, encourage rest breaks, and provide comfort measures such as familiar objects, music, or sensory activities.Review of the physician visit note dated 06/11/26 revealed Resident #33 had significant dementia, a history of stroke with right sided weakness, chronic kidney disease, a recent spinal fracture after a mechanical fall, and incidental findings of extensive right pulmonary embolic disease and acute partial deep vein thrombosis (DVT).Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had severe cognitive impairment, was dependent on staff for transfers, had no evaluation for walking, and did not utilize a mobility device.Review of the physical therapy encounter dated 06/24/26 revealed Resident #33 ambulated three hundred feet on uneven surface with setup or cleanup assistance using a four wheeled walker.Review of the Medication Administration Record dated 06/28/26 at 9:00 P.M. revealed missed doses of atorvastatin (treats high cholesterol) and mirtazapine (treats depression).Review of the vital signs summary dated 06/28/26 at 9:38 P.M. by Licensed Practical Nurse (LPN) #228 revealed the resident's vital signs were taken at 9:31 P.M.Review of the progress note dated 06/28/26 at 11:15 P.M. revealed Certified Nursing assistant (CNA) #240 reported she was unable to locate Resident #33. Documentation indicated the Director of Nursing (DON) arrived at 11:20 P.M. and was informed Resident #33 had been located in a nearby parking lot and returned to the facility. Resident #33 was found outside the facility between 11:10 P.M. and 11:15 P.M., approximately 0.2 miles away.Review of the elopement risk assessment dated [DATE] at 12:08 A.M. revealed Resident #33 was not confined to bed or chair, had a cognitive deficit with intent to elope, had Alzheimer's dementia, received multiple medications, and had a history of elopement.Review of the skin assessment dated [DATE] at 1:00 A.M. revealed no new skin impairments.Review of the physician orders dated 06/29/26 at 7:00 A.M. revealed an order for a wander management device application with function checks every shift.Review of the smoking break schedule dated 04/23/26 revealed scheduled breaks were at 6:00 A.M., 10:00 A.M., 2:00 P.M., 6:00 P.M., and 10:00 P.M.Interview on 06/29/26 at 11:50 A.M. with the DON revealed she believed Resident #33 exited through the smoking area during a scheduled smoke break for the residents and the back gate lacked a lock, allowing Resident #33 to exit the property without any notification to staff. The DON stated Resident #33 was later found in a plaza near a restaurant, and police were not contacted. The DON confirmed Resident #33 had severe cognitive impairment and was care planned for elopement risk. She stated an elopement investigation was underway.Interview on 06/29/26 at 12:03 P.M. with CNA #240 revealed she last saw the resident at approximately 7:30 P.M. when she provided a sandwich. CNA #240 returned at approximately 10:15 P.M., observed Resident #33 was not in bed or the restroom, and initiated a search. CNA #240 stated she had not received report that Resident #33 was an elopement risk or that he was able to ambulate. Resident #33 was found in the plaza behind the facility and he was dressed street clothes, had on grippy socks for footwear, and had been out of the facility for approximately one and a half hours.Interview on 06/29/26 at 1:10 P.M. with Resident #33 revealed he stated went outside last night because he was going to the movie theater. Interview on 06/29/26 at 1:15 P.M. with LPN #129 and CNA #139 revealed neither staff member had knowledge of the resident's elopement risk and reported the resident had not previously demonstrated exit seeking behavior.Observation on 06/29/26 at 2:13 P.M. of the patio revealed the patio exit door required input of a code, the patio area opened into a courtyard leading to a large gate labeled Exit, which opened easily and allowed direct access off the property.Interview 06/29/26 at 4:04 P.M. with Physician #333 revealed he was notified late in the evening and stated the resident was ambulatory in some capacity but unsafe to be outside alone. Physician #333 confirmed a wander management device was ordered after Resident #33 returned to the facility.Interview on 06/30/26 at 8:04 A.M. with CNA #152 revealed she worked the night of the incident and stated she did not know the resident could ambulate without assistance. She stated she completed a whole house head count and believed the resident was out of the facility for thirty to forty five minutes. She denied knowing who opened the patio door.Interview on 06/30/26 at 2:35 P.M. with the DON revealed the elopement occurred because a staff member opened the secured patio door during smoke time, allowing Resident #33 who was at risk for elopement to exit unattended. The DON stated that once outside, the resident accessed an unsecured gate marked Exit and left facility property. The DON confirmed Resident #33 was last seen at 9:38 P.M. and located at approximately 11:10 to 11:15 P.M.Attempts to interview LPN #228 during the survey was unsuccessful.Review of the elopement policy dated 05/2024 revealed requirements for routine risk assessments, supervision based on risk, alarm checks, missing resident profiles, pdated assessments, complete progress notes, physician notification, responsible party notification, and updated care plans.

Based on medical record review, review of the self-reported incidents, review of facility witness statements, staff and resident interview, and facility policy review, the facility failed to report an allegation of abuse. This affected one (Resident #26) out of three residents reviewed for abuse. The facility census was 90. Findings include: Review of the medical record for Resident #26 revealed an admission date of 03/01/24. Diagnoses included bipolar disorder, generalized anxiety disorder, major depressive disorder, and type two diabetes. Review of the annual Minimum Data Set (MDS) 3.0 dated 03/02/26 revealed a Brief Interview of Mental Status (BIMS) score of 12, revealed Resident #26 had mild cognitive impairment. Further review of the medical record revealed the resident had a Guardian of Person since 2021. Interview on 06/10/26 at 10:01 A.M., with the Director of Nursing (DON) revealed Resident #26 reported abuse to their caseworker, referring to the residents Guardian, but what the resident reported was different to what she told Social Services. The DON reported a head-to-toe assessment was completed and no bruising was identified. The DON reported a soft file was made regarding the incident. During a follow-up interview at 11:15 A.M., the DON verified a Self-Reported Incident (SRI) was not completed for Resident #26's allegations of abuse and stated one was not done because the resident later denied the allegation and had no bruising. Interview on 06/10/26 at 10:10 A.M., Resident #26 initially reported no issues with staff but then stated she had an issue with a Certified Nursing Assistant (CNA) and identified CNA #159. Resident #26 reported CNA #159 was rough with her during care and left bruises on her legs. Resident #26 said she reported this to a nurse, Licensed Vocational Nurse (LVN) #165, and afterwards staff came into her room to do a head-to-toe assessment and found no bruising. Resident #26 reported that since the incident CNA #159 has not been assigned to her care. Interview on 06/10/26 at 1:37 P.M. with the Administrator verified they had not submitted an SRI after Resident #26's Guardian reported the allegation of abuse. The Administrator reported they did not complete an SRI due to Resident #26 denying the abuse claims when staff asked her about the allegation, the resident did not have any bruising during the skin assessment, and the resident's history of hallucinations and false allegations. Review of the witness statement dated 05/27/26 from the Social Service Director #114 documented the guardian of Resident #26 sent an email on 05/27/26 about an allegation that an aide had caused bruising to Resident #26's legs. Review of the self-reported incidents revealed there was no reported incident on 05/27/26 and an SRI with a discovery date of 06/12/26 and a created on 06/15/26 for Resident #26 was opened. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, undated revealed facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health. In addition, the policy documented the Administrator, or their designee, will notify the Ohio Department of Health immediately, but no later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Complaint Number 3030707.

Based on medical record review, staff and resident interviews, review of the facility soft file, and facility policy review, the facility failed to thoroughly investigate an allegation of staff to resident abuse. This affected one (Resident #26) out of three residents reviewed for abuse. The facility census was 90.Findings include:Review of the medical record for Resident #26 revealed an admission date of 03/01/24. Diagnoses included bipolar disorder, generalized anxiety disorder, major depressive disorder, and type two diabetes.Review of the annual Minimum Data Set (MDS) 3.0 dated 03/02/26 revealed a Brief Interview of Mental Status (BIMS) score of 12, revealed Resident #26 had mild cognitive impairment. Further review of the medical record revealed the resident had a Guardian of Person since 2021.Review of the medical record for Resident #26 revealed no documentation of the abuse allegation or investigation details.Interview on 06/10/26 at 10:01 A.M., with the Director of Nursing (DON) revealed Resident #26 reported abuse to their caseworker, referring to the residents Guardian, but what the resident reported was different to what she told Social Services. The DON reported a head-to-toe assessment was completed and no bruising was identified. The DON reported a soft file was made regarding the incident but additional investigation was completed.Interview on 06/10/26 at 10:10 A.M., Resident #26 had initially reported no issues with staff but then stated she had an issue with a Certified Nurses Aide (CNA) and identified CNA #159. Resident #26 reported CNA #159 was rough with her during care and left bruises on her legs. Resident #26 said she reported this to a nurse, Licensed Vocational Nurse (LVN) #165, and afterwards staff came into her room to do a head-to-toe assessment and found no bruising. Resident #26 reported that since the incident CNA #159 has not been assigned to her care.Interview on 06/10/26 at 12:35 P.M. with Unit Manager #359 verified a skin assessment was completed following Resident #26's report of abuse to their Guardian. The Unit Manager #359 revealed Resident #26 was the only skin assessment they completed related to this allegation.Interview on 06/10/26 at 12:51 P.M. with LVN #165 verified they completed a skin assessment on Resident #26 after an allegation of abuse was made and reported the resident did not have bruising. LVN #165 reported Resident #26 was the only skin assessment they completed following the allegation of abuse.Interview on 06/10/26 at 1:37 P.M., with the Administrator verified a full investigation was not completed following Resident #26's report of abuse. The administrator reported a full investigation was not completed due to the resident denying the claims, not having bruising during a skin evaluation, and a history of hallucinations and false allegations.Review of the soft file provided by the DON revealed a letter from the administrator detailing his conversation with Resident #26's Guardian, a statement by CNA #159, a skin assessment dated [DATE] with two out of seven questions answered, a statement from the Director of Social Services #114, and a witness statement from Unit Manager #359. There were no additional documents provided regarding an investigation for the abuse allegation made by Resident #26.Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, undated revealed it is the facility policy to investigate all alleged violations involving abuse. Additionally, the policy revealed the investigation must be completed within five working days and include an interview with the resident, the accused, all witnesses, employees who worked that day, and interviews with other residents.This deficiency represents non-compliance investigated under Complaint Number 3030707.

Based on medical record review, staff interview and review of the facility policy and procedure, the facility failed to maintain a resident's dignity in regard to urinary catheters. This affected one resident (#92) of one resident reviewed for catheters. The census was 88. Findings include:Review of Resident #92's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included encephalopathy, diabetes, cerebral infarction, and high blood pressure.On 05/20/26 at 9:11 A.M. observation revealed Resident #92's urinary catheter bag was observed hanging on the bed uncovered facing the door. Yellow urine was noted in the drainage bag. The urinary catheter bag was in view of staff, residents, and visitors in the hallway.On 05/20/26 at 9:30 A.M. observation revealed Resident #92's urinary catheter bag was hanging on the resident's bed uncovered facing the door. Yellow urine was noted in the drainage bag. The urinary catheter bag was in view of staff, residents, and visitors in the hallway. At the time of the observation, this was verified during interview with Registered Nurse (RN) #101. RN #101 verified it was not dignified for the resident to have his urinary catheter uncovered and in view of others.Review of the facility Catheter Care policy dated 02/2024 revealed urinary catheter bags were to be stored in a privacy bag to maintain dignity.This deficiency represents non-compliance investigated under Complaint Number3007833.

Based on medical record review, observation, staff interview and facility policy review, the facility failed to provide resident privacy during treatment of a pressure wound. This affected one resident (#16 ) of two residents observed for wound care. The census was 88. Findings include:Review of Resident #16's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included cirrhosis of the liver, depression, HTN, anxiety, urinary retention, adult failure to thrive, and alcohol dependence. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. She required set up or clean up assistance with eating, oral hygiene, and was dependent on staff for toileting, shower/bathing, dressing lower body, turning and repositioning and partial/moderate assistance for personal hygiene. The resident was always incontinent of bowel. On 05/21/26 at 9:14 A.M. observation of a dressing change to Resident #16's sacrum revealed Registered Nurse (RN) #101 left the blinds open to the window facing the parking lot while completing the dressing change. Resident #16's partially naked body would have been visible to any person in the facility parking lot. On 05/21/26 at 9:43 A.M. interview with RN #101 verified she had left the blinds open to the parking lot while she completed the dressing change to Resident #16's sacrum. On 05/21/26 at 12:13 P.M. interview with Resident #16 revealed she wanted the blinds closed during her treatment. She would be very upset if someone had seen her from the window while she was exposed. Review of the facility Resident Rights, Dignity, and Privacy Handout not dated revealed staff were to use a closed door, a drawn curtain, or both to shield the resident during all personal care and treatment procedures. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 3013153.

Based on record review, observation, staff interview and review of facility policy and procedure, the facility failed to ensure a resident with impaired skin integrity received the necessary care and treatment to promote healing of wounds on her foot. This affected one resident (#7) of three residents reviewed for wounds. The census was 88. Findings include:Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included aphasia, high blood pressure, hemiplegia and hemiparesis, and idiopathic peripheral neuropathy. Review of physician orders revealed an order dated 05/12/26 to conduct weekly skin evaluations. Staff were to document under assessments - Skin Observations. Staff were to notify the physician of new skin conditions one time a day every Tuesday for skin assessment.Review of Resident #7's admission skin assessment dated [DATE] revealed two areas were noted on the bottom of the right foot. The areas were noted as hard calloused areas that were not open. There was no additional information provided including size or color of the areas. There was no evidence the resident's physician was aware of the areas.Review of Resident #7's medical record revealed no additional skin assessments were completed of the hard calloused areas of the resident's right foot. There was no evidence of any skin treatments being provided,On 05/21/26 at 9:43 A.M. observation revealed Resident #7 stopped Registered Nurse (RN) #101 and pointed at her right foot. The resident implied it was painful. RN #101 put on gloves and removed the resident's nonskid sock; two areas were noted on the bottom of the resident's right foot. The areas appeared as two white calloused areas that were approximately 1.5 cm in diameter. The areas appeared closed with no drainage. At the time of the observation, RN #101 stated the resident came in with those last week (Note- per the medical record, the resident was admitted to the facility with the areas on 05/12/26, nine days earlier). RN #101 stated that she was padding them to protect them but was waiting for the doctor to see the resident. At the time of the observation, there was no padding in place and nothing to protect the areas.On 05/26/26 at 9:59 A.M. interview with RN #101 verified Resident #7 had no treatment started, no physician notification of the areas, and no weekly measurements of the area since 05/12/26 upon the resident's admission. Review of the facility policy and procedure, Wound Documentation dated 06/2019, revealed tracking of all wounds will be completed weekly on the Wound Tracking Worksheet. This deficiency represents non-compliance investigated under Complaint Number 3007833.

Based on medical record review, observation and staff interview, the facility failed to ensure a resident with an urinary catheter received appropriate care and services. This affected one resident (#92) of two residents reviewed for urinary catheters. The census was 88. Findings include:Review of Resident #92's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included encephalopathy, diabetes, cerebral infarction, and high blood pressure. The resident had an indwelling urinary catheter. Review of the resident's medical record revealed no evidence of any physician orders for the resident's urinary catheter and no evidence of any orders for catheter care. In addition, review of the medical record revealed no evidence any care was provided to the resident's indwelling urinary catheter.On 05/20/26 at 9:11 A.M. observation revealed Resident #92's urinary catheter was draining yellow urine.On 05/26/26 at 11:25 A.M. interview with the Director of Nursing verified no evidence of physician orders for the indwelling urinary catheter and no evidence catheter care was provided for Resident #92. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 3007833.

Based on medical record review, observation, staff interview and review of facility policy and procedure, the facility failed to ensure comprehensive weekly assessments of residents with pressure ulcers and failed to ensure pressure relief interventions were in place. This affected two residents (#16, #77) of three residents reviewed for pressure ulcers. The census was 88 Findings include:1.Review of Resident #16's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included cirrhosis of the liver, depression, HTN, anxiety, urinary retention, adult failure to thrive, and alcohol dependence. Review of Resident #16's pressure ulcer risk assessment dated [DATE] revealed the resident was identified to be high risk for pressure ulcer development.Review of Resident #16's plan of care dated 03/20/26 revealed the resident has pressure injuries and is at risk for further skin breakdown, infection, worsening of existing pressure injury, new pressure injury for coccyx. Interventions included pressure injury/injuries will show signs and symptom of improvement through the review period, provide low air loss mattress, assist with turning/re-positioning during rounds and PRN, consult Dietitian, consult Wound MD, keep Resident/RP/MD informed of the wound status, monitor resident's response/tolerance to pain associated with wound status, monitor site for s/s of infection, presence of dressing if indicated, or onset of pain, perform treatments per order, provide ordered diet/feedings/supplements and encourage intake to promote wound healing, and use pillows and/or positioning devices for resident positioning and comfort.Review of the admission minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. She required set up or clean up assistance with eating, oral hygiene, and was dependent on staff for toileting, shower/bathing, dressing lower body, turning and repositioning and partial/moderate assistance for personal hygiene. She was always incontinent of bowel.The resident had a pressure ulcer to the coccyx.Review of the measurements for the coccyx revealed the following:03/24/26- 6.5 centimeters (cm) x 2.5 cm x 0.4 cm03/31/26- 6.5 cm x 2 cm x 0.8 cm04/07/26- 5 cm x 1.5 cm x 0.6 cm04/21/26- 6 cm x 1.5 cm x 1.2 cm05/05/26- 3.5 cm x 1 cm x 1.1 cm05/12/26- 3.9 cm x 1 cm x 0.9 cm05/19/26- 3.5 cm x 1cm x 0.8 cmFurther review revealed comprehensive wound measurements were missing for the week of 04/28/26. On 05/26/26 at 9:59 A.M. interview with Registered Nurse (RN) #101 verified the lack of comprehensive wound measurements for Resident #16.2. Review of Resident #77's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included chronic osteomyelitis of the left foot and ankle, diabetes, atrial fibrillation, high blood pressure, dementia, cellulitis of left foot, non-pressure chronic ulcer of the left foot, congestive heart failure and lymphedema. Resident #77 had a pressure ulcer risk assessment dated [DATE] that identified the resident was at high risk for pressure ulcer development.Resident #77 had a plan of care identifying the resident was at risk for alteration in skin integrity and pressure ulcer formation. Interventions included: assist resident for toileting as indicated, assist resident with incontinent care as indicated, assist with turning/re-positioning during rounds and PRN, perform weekly skin checks, provide pressure reducing device for bed and wheel chair, serve diet as ordered - monitor intake - offer subs if less than 75% of meal is eaten, and use padding between areas of pressure and positioning devices for proper body alignment. Review of the admission MDS assessment dated [DATE] revealed cognition was moderately impaired. She required supervision or touching assistance for eating, substantial/maximal assistance for oral hygiene and turning and repositioning, dependent on toileting, shower bathing, dressing and personal hygiene. The resident was always incontinent of bowel and bladder. Observations revealed on 05/21/26 at 9:49 A.M. Resident #77's heels were not elevated off the bed. On 05/21/26 at 2:15 P.M. observation revealed Resident #77's feet were on the mattress and not elevated. On 05/26/26 at 9:45 A.M. observation revealed the resident's heels were on the bed and were not elevated. On 05/26/26 at 9:59 A.M. interview with Registered Nurse (RN) #101 verified Resident #77's her heels were on the mattress and should be elevated off the mattress to promote healing and prevent future development of pressure ulcers. Review of the facility policy, Wound Documentation dated 06/2019, revealed on admission and or discovery, the nurse initiates the wound documentation process. Wound evaluation and treatments are documented in point click care and on the appropriate form. Tracking of all wounds will be completed weekly and on the wound tracking sheet. This deficiency represents non-compliance investigated under Complaint Number 3007833.

Based on medical record review, staff interview, review of self reported incident (SRI) and the police report revealed the facility failed to prevent staff to resident verbal abuse. This affected one resident (#89) of ten residents reviewed for abuse. The census was 88. Findings include:Review of Resident #89's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included osteomyelitis of the right ankle and foot, ulcers of the foot, diabetes, right BKA, absence of the left leg and disorder of the kidney. Review of the minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required set up or clean-up assistance for eating, oral hygiene, toileting, dressing and personal hygiene, and supervision or touching assistance for shower/bathing. The resident was always continent of bladder and occasionally incontinent of bowel.Review of the Self-Reported Incident (SRI) dated 04/24/26 at 10:00 A.M. revealed the Administrator and Resident #89 were having a conversation regarding the smoking policy. The Administrator stated the resident became aggressive and rolled wheelchair towards his feet while resident was recording incident. The Administrator told Resident #89 he did not have his permission to record him at this time. Resident #89 continued to record and come towards the Administrator. It was at this point the Administrator raised his middle finger towards Resident #89. A staff member intervened to de-escalate the situation and told the Administrator to go outside.The SRI documentation revealed the facility had done the following: Resident #89 requested police notification. Police arrived and interviewed the resident and watched video. Officer reported back to the resident that there was no physical contact viewable on video. The only thing the officer saw was the Administrator raising his middle finger towards the resident. Head to toe assessment completed on resident with no evidence of bruising, swelling or redness noted. All residents interviewed with a BIMS above 12. All residents reported feeling safe with no concerns regarding staff members. Residents with BIMS 11 or below were assessed and no indications of new redness, bruising or swelling was found. The Administrator was an Interim and would not be returning to the facility. Review of Resident #89's statement dated 04/24/26 revealed he was recording the Interim Administrator, on his phone. Resident #89 reported during the interaction the Administrator made an inappropriate gesture by raising his middle finger toward the camera. Resident further stated the Administrator placed their hands on his shoulders and proceeded to take the phone out of the resident's hands. Review of the Police report dated 04/25/26 revealed no charges were issued at the time as the video did not show an assault, and witness statements advised they did not observe an assault. The resident was unable to send the police investigator the video at the time due to difficulties with files. The resident stated he would forward the videos to his lawyer. The police investigator suggested through email that he download them to USB flash drive or have his lawyer upload them to digital media then he or the lawyer could contact the police investigator via email, on emergency line, or in person to submit the video. All parties were advised that a report would be filed and how to obtain a copy.Interview on 05/26/26 at 1:45 P.M. with the facility social services director (SSD) revealed the SSD felt it was verbal abuse. The SSD stated he had seen the video, and did not see the Administrator put his hands on the resident, but did see the Administrator flip the resident off and try to take his phone. The SSD stated he believed the resident.This deficiency represents non-compliance investigated under Master Complaint Number 3013153.

Based on record review, interviews, review of hospital discharge documents, and policy review, the facility failed to ensure a resident's diabetes was managed when going on Leave of Absences (LOAs). This resulted in Actual Harm on 03/06/26 when Resident #14 went on an undisclosed LOA and went to the Emergency Department (ED) with low blood sugar. This affected one (Resident #14) of one resident reviewed for diabetes management and LOAs. The facility census was 92. Findings Include:Review of Resident #14's medical record revealed an admission date of 04/14/25 and medical diagnoses including anxiety, borderline intellectual disability, cholecystitis, cognitive impairment, developmental delay, diabetes mellitus, gastroparesis, gastroesophageal reflux, irritable bowel syndrome, anemia, diabetic retinopathy of both eyes, chronic kidney disease, nonalcoholic steatohepatitis, pulmonary embolism, and need for a guardian for healthcare decisions. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. The resident was independent with transfers and mobility and did not require the assistance of mobility devices. Review of Resident #14's guardianship paperwork revealed Resident #14 was deemed incompetent on 06/16/25 and was appointed a guardian for an indefinite amount of time. Review of Resident #14's care plan, last revised 01/14/26, revealed the resident has impaired thought processes related to being developmentally delayed. Interventions include administering medications as ordered, monitor and document for side effects and effectiveness, communicate with the resident, family, caregiver regarding resident's capabilities and needs, cue reorient, and supervise as needed, monitor and document any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The care plan revealed the resident has diabetes mellitus with interventions to administer diabetic medications as orders and monitor and document for side effects and effectiveness, dietary consult for nutritional regimen and ongoing monitoring, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, monitor/document/report as needed (PRN) signs and symptoms (s/s) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, and coma, and monitor/document/report PRN any s/s of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait. There was no documentation in the care plan of interventions related to the LOA. Review of Resident #14's insulin orders revealed, an order dated 02/16/26 for insulin Glargine Solution, inject 15 units subcutaneously two times per day for diabetes. Further review revealed an order dated 12/27/26 for insulin Lispro Injection Solution, inject per sliding scale: 150-200- 1 unit, 201-250- give 2 units, 251-300- 3 units, 301-350- 4 units, 351-400- 5 units, greater than 400 contact the physician, and give 6 units subcutaneously before meals and at bedtime for diabetes. Review of the social services progress note dated 02/20/26 revealed social services met with Resident #14 to discuss expectations and safety guidelines related to LOAs. Resident #14 was educated about adhering to prescribed medications and treatment recommendations and maintaining appropriate contact with the facility as required. Resident #14 was reminded to return by the agreed-upon time and to notify the facility promptly of any delays. Review of Residents #14's blood glucose monitoring and Medication Administration Record (MAR) for March 03/2026 revealed unstable blood glucose levels with readings as low as 82 on 03/04/26 and a high of 511 on 03/04/26. On 03/06/26, her blood glucose level was 108 in the morning. Review of the MAR revealed 15 units of insulin Glargine was administered in the morning of 03/06/26. Review of Resident #14's meal intakes revealed on 03/06/26 she ate 75 percent of her breakfast. Review of the medical record revealed Resident #14 left on a LOA on 03/06/26 at 7:43 A.M. There was no evidence that the resident was educated on diabetes management while out of the facility. There was no evidence that the resident ate lunch or dinner while out of the facility. Review of the Leave of Absence Form revealed Resident #14 did not sign out on 03/06/26. Review of the progress note dated 03/06/26 at 9:26 P.M. revealed Resident #14 left for a LOA in the morning and did not come back to the facility. It was discovered the resident was taken to the local hospital due to hypoglycemia. Review of Resident #14's hospital record from Hospital #1 dated 03/06/26 at 7:55 P.M. revealed Resident #14 presented to the ED by Emergency Medical Services (EMS) for low blood sugar. Resident #14 stated she has type 1 diabetes, took Lantus this morning, and did not eat breakfast. Resident #14 reported her friend called EMS because she was difficult to arouse. Upon arrival, blood glucose was 38. She was alert and eating crackers. At 10:11 P.M. Resident #14 reported she was feeling better and was eating and drinking. At 10:50 P.M. Resident #14 was eating and drinking, feels much better, very bizarre that she is now hyperglycemic. She was given 10 units of Lantus and 8 units of Lispro. Review of medical record revealed history of the resident presenting to the hospital with hypoglycemia then going hyperglycemic. At 4:25 A.M. the resident was accepted to Hospital #2. Resident #14 was sent to Hospital #2 because her endocrinologist was there and they wanted to manage her diabetes. Review of Resident #14 hospital summary report from Hospital #2 dated 3/07/26 revealed Resident #14 was admitted on [DATE] from an outside hospital (unknown) for symptomatic, refractory hypoglycemia and metabolic acidosis. She was found unresponsive by EMS with undetectable blood glucose levels, requiring Emergency Response Team (ERT) intervention upon arrival. Review of hospital course and interventions revealed Resident #14 was treated with IV dextrose and dextrose-containing IV fluids, which restored her mental status. Further review revealed the resident was managed for extremely labile blood sugars (BS). Initial glucose the outside hospital was 38, peaked at 320, and dropped to 23. At Hospital #2, the resident required an insulin drip and subsequent transition to subcutaneous sliding scale and basal insulin (Lantus/Glargine). Review of discharge needs revealed Resident #14 requires frequent blood glucose checks (up to seven times daily) due to history of undetectable lows and highs into the 400s. Resident #14 was hospitalized from [DATE] to 03/13/26. She returned to the facility after hospitalization. During an interview on 04/02/26 at 10:09 A.M., the Director of Social Services stated the facility did not believe Resident #14 had a guardian and were allowing the resident to make her own decisions. During an interview on 04/02/26 at 11:31 A.M., the Director of Nursing (DON) stated Resident #14 was known to leave the facility without signing out and would not inform staff prior to leaving. Resident #14 does not have a personal glucometer and when leaving the facility and Resident #14 was unable to check her blood glucose. When Resident #14 leaves the building, the resident does not take medications with her and would miss scheduled insulin and other medications. The facility was concerned about the resident's ability to self-administer medications and would be very concerned about the resident self-administering insulin. When the resident went on unannounced LOA, the resident would not answer calls from the facility and would only answer calls from her father and the facility relied on the resident's father to contact the resident. During an interview on 04/02/26 at 12:42 P.M., Resident #14's father stated he had concerns about the facility providing regular updates and would only get calls when the facility was unable to locate the resident. He wanted to allow the resident to continue going on LOA but was concerned regarding the facility plan to manage medications and blood glucose when Resident #14 was out of the building. During an interview on 04/06/26 at 9:07 A.M., the Director of Social Services confirmed the facility located Resident #14's Guardian paperwork and would begin contacting them for all health-related questions. During an interview on 04/06/26 at 9:37 A.M., the DON stated they did not believe the resident was an elopement risk but now knowing the resident has a guardian and are unable to make medical decisions, they should be considered an elopement risk if they continue to leave the facility without signing out and not notifying staff. During an interview on 04/21/26 at 1:24 P.M., Resident #14 stated she was knowledgeable on how to check her blood glucose levels and how to administer insulin. Resident #14 reported she was able to read the sliding scale orders to see how much insulin was needed based on her blood glucose level. Resident #14 verified the facility does not send her with supplies to check her blood glucose level or administer insulin. Resident #14 reported she has had a diabetes diagnosis for 10 years and lived on her own prior. Resident #14 reported on 03/06/26 she remembers going to the hospital, but doesn't remember all the details, other than she was tired. Resident #14 verified she has not received education on how to handle diabetes management when on LOAs. During an interview on 04/21/26 at 1:37 P.M., Medical Director (MD) #700 verified Resident #14 is a very brittle diabetic. MD #700 stated he cannot hold her in the facility against her will. If the guardian told the facility she was not allowed to go on LOAs, he would honor that, but the guardian is OK with her going on LOAs. #700 was unsure if the resident was able to administer insulin on her own. The facility has taken steps to get a Dexcom (continuous glucose monitoring (CGM) system used by people with diabetes to track blood sugar levels in real-time without daily finger pricks) for the resident. During an interview on 04/21/26 at 1:40 P.M., the Assistant Director of Nursing (ADON) verified Resident #14 was deemed incompetent by the court to make medical decisions. The ADON verified Resident #14 was unable to administer insulin. The ADON stated the resident was asked to show how to administer insulin and was unable to do so. The ADON verified the facility is working on a risk agreement with the resident and trying to get the guardian to come in to review. The ADON said the guardian has not been available to come to the facility to review and sign. Review of the facility policy titled Day Outings/Therapeutic Leaves of Absence, last revised June 2019, revealed If facility staff is not notified when the resident leaves or the resident does not return to the facility within a reasonable time as determined by the circumstances surround the patients/resident's leave of absence, the facility will defer the to the Elopement policies and procedures. Review of the facility policy titled Elopement, last revised May 2024, revealed If the search fails to locate the missing resident, the Administrator/Designee will notify the Police Department, Responsible Party, and Regional Support Team.' Review of the facility policy titled Blood Glucose Monitoring, dated 01/26 revealed it was the policy of the facility to provide safe, accurate, and timely blood glucose monitoring and appropriate response to abnormal blood glucose values in accordance with physician orders and resident condition.

Based on employee file reviews and interviews, the facility failed to do annual evaluations for Certified Nursing Assistants (CNAs) and to provide a minimum of 12 hours of in-service for the previous year. This affected three (CNAs #242, #324, and #325) of the three employee files reviewed for CNAs employed for more than one year. This has the potential to affect all residents in the facility. The facility census was 91. Review of employee files for CNAs #242, #324, and #325 revealed no annual evaluations were completed in the last 12 months. There was also no documentation of in-service education.Interview on 04/07/26 at 1:00 P.M. with the Director of Nursing (DON) confirmed there was no record of CNA education (12 hours for the last year) and there was no record of performance evaluations in the past 12 months for the CNAs whose employee files were reviewed.

Based on resident medical record review, review of medication regimen reviews, interview, and review of facility policy, the facility failed to complete medication regimen reviews (MRR). This affected four residents (Resident #02, #03, #93, and #99) out of five reviewed for unnecessary medication. The facility census was 91.Findings include: 1. Review of the medical record for Resident #93 revealed an admission date of 03/01/24 with diagnoses of, but not limited to, bipolar disorder, heart failure, and major depressive disorder. Review of Minimum Data Set (MDS) 3.0 dated 03/02/26 reveled Resident #93 had a Brief Interview of Mental Status (BIMS) score of 12 indicative of cognitive impairment. Review of the MRR's provided by the facility revealed no MRRs for April, May, July, and August of 2025 for Resident #93. 2. Review of the medical record for Resident #99 revealed an admission date of 06/29/23 with diagnoses of, but not limited to, epilepsy, major depressive disorder, and unspecified systolic heart failure. Review of the MDS 3.0 dated 12/29/25 revealed Resident #99 had a BIMS score of 15 indicative of the resident being cognitively intact. Review of the MRR's provided by the facility revealed no MRRs for May, June, July, and August of 2025 for Resident #99. Interview with the Director of Nursing (DON) on 04/07/26 at 3:00 P.M. confirmed the facility did not have complete MRR records for April, May, June, and July of 2025. During an additional interview on 04/07/26 at 4:00 P.M. the DON confirmed Resident #99 also did not have an MRR for August of 2025. 3. Review of the medical record for Resident #3, revealed an admission date of 01/14/25. Diagnoses included but were not limited to fracture of left femur, cardiac arrest, atrial fibrillation, cognitive communication deficit, anxiety disorder, heart failure, and major depressive order. Review of the MDS 3.0 assessment dated [DATE] revealed a BIMS score of three, indicating cognitive impairment. Resident #3 received 5 days of insulin during the look back period. Resident #3 received antipsychotic, antidepressant, anticoagulant, antibiotic, antiplatelet, and anticonvulsant with indications documented. Review of the MRRs for the previous year revealed there were no pharmacy reviews with or without recommendations for the months of April, May, June, or July of 2025. Interview on 04/06/26 at 3:00 P.M. with the DON confirmed there were no MRR records available for April, May, June, or July 2025. 4. Review of Resident # 02's medical record revealed she was admitted on [DATE] with diagnoses that included anxiety, bipolar disorder, dementia and depression. Review of Resident # 02's MDS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. She was coded as receiving antipsychotic, antidepressant and antianxiety medications in the look back period with indications for usage for each. Review of MMRs for March 2025 to March 2026 revealed no resident reviews for April, May, June or July 2025. Interview on 04/06/26 at 3:00 P.M. with the DON confirmed there were no pharmacy medication regimen reviews available for April, May, June or July 2025. Review of the facility policy titled Medication Administration and Management, revised 06/2019, revealed the facility's nursing and pharmacy services will assess, monitor, and evaluate the effectiveness of the medication regimen.

Based on review of resident medical record, physician orders, medication administration record, interview, and policy review, the facility failed to follow physician orders for blood pressure medication. This affected one resident (Resident #93) of five reviewed for unnecessary medications. The facility census was 91.Findings include:Review of the medical record for Resident #93 revealed an admission date of 03/01/24 with diagnoses of, but not limited to hypertension, heart failure, and chronic atrial fibrillation.Review of Minimum Data Set (MDS) 3.0 dated 03/02/26 reveled Resident #93 had a Brief Interview of Mental Status (BIMS) score of 12 indicative of a moderate cognitive impairment.Review of the physician orders for Resident #93 revealed an order for metoprolol tartrate oral tablet 50 milligrams (MG) give one tablet by mouth two times a day for hypertension, with parameters to hold for a systolic blood pressure under 110 or heart rate under 60.Review of the Medication Administration Record (MAR) for January 2026 revealed the medication was administered during the following dates with the corresponding blood pressure readings: 01/01/26 with a blood pressure of 102/60, 01/06/26 with a blood pressure of 106/58, 01/19/26 with a blood pressure of 103/61, 01/20/26 with a blood pressure of 102/61, 01/24/26 with a blood pressure of 106/58, 01/25/26 with a blood pressure of 102/64, and 01/26/26 with a blood pressure of 109/65.Review of the MAR for February 2026 revealed the medication was administered during the following dates with the corresponding blood pressure readings: 02/02/26 with a blood pressure of 109/64, 02/03/26 with a blood pressure of 103/61, 02/12/26 with a blood pressure of 108/67, 02/13/26 with a blood pressure of 108/67, 02/23/26 with a blood pressure of 104/58, and 02/26/26 with a blood pressure of 108/68.Review of the MAR for March 2026 revealed the medication was administered during the following dates with the corresponding blood pressure readings: 03/07/26 with a blood pressure of 108/64, 03/13/26 with a blood pressure of 107/63, and 03/19/26 with a blood pressure of 107/62.Interview with Licensed Vocational Nurse (LVN) #319 on 04/06/26 at 9:09 A.M. revealed if a medication has parameters, the medication should be held if vitals are outside of the ordered parameters, and the physician should be notified. LVN #319 confirmed Resident #93's metoprolol tartrate should have been held on the days where her systolic blood pressure was below 110.Review of the facility policy titled, Medication Administration Management, revised 06/2019, revealed authorized staff administering medications are to identify and confirm the physician order prior to administering a medication.

Based on observation, medical record review, interviews and facility policy review, the facility failed to honor one resident's preference of no male caregivers. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's medical record revealed no plan of care addressing the resident's preference of no male caregivers. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. On 08/19/25 at 10:48 A.M., an observation of the resident's room during morning medication administration revealed a sign behind the resident's bed indicating she preferred to have no male caregivers. On 08/20/25 at 9:00 A.M. interview with Resident #17 revealed she preferred no male caregivers due to past physical and sexual abuse. The resident revealed the facility was aware of the preference however continued to assign the male Licensed Practical Nurse (LPN) #116 to the resident's room assignment. On 08/20/25 at 12:34 P.M., interview with LPN #116 revealed usual assignment consisted of Resident #17's care. The LPN revealed he was aware the resident preferred no male caregivers. On 08/20/25 at 10:52 A.M., interview with the Director of Nursing (DON) verified she was aware of the resident's preference of no male caregivers. The DON revealed she was unaware the sign specified aides and nurses. Review of the facility policy titled, Resident Rights, dated 04/24 revealed the facility protects and promotes the rights of each resident. The facility staff will uphold the resident's dignity and individuality providing care that fosters their quality of life in a respectful environment. This deficiency is a recite to the complaint and annual survey completed on 03/12/25.This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.

Based on observation, medical record review, interview and facility policy review, the facility failed to ensure one resident's bed was bariatric in size. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. On 08/19/25 at 9:00 A.M., observation of Resident #17 revealed the resident was obese and was too large for the standard bed she occupied. Interview with the resident at the time of the observation revealed she had asked for a larger bed, however the room was not large enough. On 08/20/25 at 1:05 P.M., an interview with Director of Nursing (DON) revealed every bed is capable to be a bariatric bed however the resident doesn't want her room moved around so they cannot accommodate the larger bed. Review of the facility policy titled, Resident Rights, dated 04/24 revealed the facility protects and promotes the rights of each resident. The facility will provide a clean, safe, comfortable and home like environment. This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.

Based on medical record review, interview and facility policy review, the facility failed to notify the power of attorney (POA) of a change in condition. This affected one resident (#43) of three residents reviewed for notification. The facility census was 83. Findings Include:Review of the medical record for Resident #43 revealed an initial admission date of 07/21/23 with the latest readmission of 03/21/24 with diagnoses including human immunodeficiency virus (HIV), psoriasis, protein calorie malnutrition, dysphagia, seizures, gastro-esophageal reflux disease, asthma, major depressive disorder and anxiety disorder. Review of the plan of care dated 02/15/24 revealed the resident had a seizure disorder. Interventions included give medications as ordered, monitor/document for effectiveness and side effects, give seizure medication as ordered by doctor, monitor/document side effects and effectiveness, obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated, post seizure treatment, turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro check, seizure documentation, location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity, seizure precautions, do not leave resident alone during a seizure, protect from injury, if resident is out of bed, help to the floor to prevent injury, remove or loosen tight clothing, don't attempt to restrain resident during a seizure as this could make the convulsions more severe, protect from onlookers, draw curtain. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident rejected care. The assessment indicated seizure disorder was a current diagnosis and received anticonvulsant medications. Review of the resident's monthly physician orders for August 2025 identified orders dated 08/13/25 Levetiracetam oral solution 100 milligrams (mg)/milliliter (ml) with the special instructions to give 10 ml via peg-tube three times a day for seizures. Review of the resident's progress note dated 07/21/25 at 7:09 P.M. revealed the resident had 35 second seizure at 8:42 A.M. Further review revealed no documented evidence the resident's representative was notified of the seizure activity. Review of the progress note dated 07/30/25 at 11:24 A.M. revealed the resident was noted with seizure activity that lasted for two minutes. The resident's physician was notified and no new orders were received. Review of the medical record revealed no documented evidence the resident's representative was made aware of the seizure activity. Review of the progress note dated 08/13/25 at 3:44 P.M. revealed the resident had seizure like activity in the form of hands shaking and stiffness that lasted for one minute and 30 seconds. A new order was obtained for Keppra 100 mg/ml three times a day through hospice nurse that was present. The resident was self-responsible and made aware as well as unit manager. Review of the change of condition progress note revealed the resident was having seizure like activity. The resident was noted to have some shaking and stiffness. The resident's physician was made aware as well as the resident being her own responsible party. Review of the resident's power of attorney (POA), dated 07/07/23 revealed the resident the resident's parents were the resident's POA. On 08/25/25 at 1:34 P.M., an interview with the Director of Nursing (DON) verified the resident's representative was not notified of the seizure activity. Review of the facility policy titled, Change in Condition Communication, last revised 06/19 revealed the purpose of the policy was to improve communication between physicians and nursing staff to promote optimal resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a resident's condition and provide guidance for the notification of the residents and their responsible party regarding changes in condition. The resident and the resident's family member/legal representative will be notified of any changes in medical condition or treatment plan. This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.

Based on closed medical record review, review of hospital records, staff interviews, and review of the facility policy, the facility failed to ensure Resident #99's continuity of care information from the hospital to the facility was reviewed and implemented. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcomes and/or death on [DATE] when Resident #99 returned from the hospital with injuries sustained from a fall including two new fractures of the spine, a closed head injury, a hematoma of the left thigh, and anemia which required ongoing evaluation and treatment which was not identified or implemented by facility staff. Consequently, the resident sustained an additional fall on [DATE] and was admitted to the hospital where he was found to have acute blood loss anemia requiring a transfusion with packed red blood cells. This affected one (Resident #99) of six residents reviewed for continuity of care upon return from the hospital. The facility census was 87. On [DATE] at 12:10 P.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #900 were notified Immediate Jeopardy began on [DATE] when Resident #99 returned to the facility from the hospital with injuries sustained from a fall and instructions for ongoing evaluation and treatment which were not identified or implemented by the facility. Licensed Practical Nurse (LPN) #501 re-admitted Resident #99 and failed to assess and provide continuity of care to Resident #99. Resident #99 had a closed head injury, two spinal fractures, laceration to right eye requiring glue to close it, a large hematoma to left proximal hamstring measuring 8.5 centimeters (cm) in length by 4 cm wide. The hospital recommended following up with the primary care physician within a day due to anemia and his hemoglobin needed to be closely monitored. There was no evidence the physician was updated on Resident #99's return to the facility and the physician never assessed the resident between [DATE] and [DATE]. LPN #501 wrote the only injury was laceration to the right eye and stated there were no other injuries. Upon interview with LPN #501, Administrator, and DON, they stated they were unaware of the hospitals' After Visit Summary (AVS) and were unaware LPN #501 stated she didn't have time to read the AVS which listed all the resident's injuries. The facility failed to identify multiple bruises on Resident #99's entire body from [DATE] to [DATE]. On [DATE], Resident #99 fell at the facility and was sent to the hospital due to injuries sustained. The emergency room notes identified Resident #99 had bruising over the entire body. Resident #99's anemia worsened and required a blood transfusion. The hospital note indicated that the anemia was probably caused by the large hematoma to the left proximal hamstring. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Resident #99 was sent to the hospital and did not return to the facility. On [DATE], the Administrator held a Quality Assurance and Performance Improvement (QAPI) meeting with the DON, and Medical Director #910 to discuss the Immediate Jeopardy template and plan of removal. On [DATE], RDCO #900 provided in-service training to the DON and Administrator on the facility's admission readmission process. The training included the importance of conducting accurate and thorough skin assessments upon admission or readmission, reviewing the hospital AVS to ensure that all new orders and recommendations are appropriately followed within 72 hours of admission, and promptly notifying the attending physician up on the resident's return to the facility. On [DATE], the Administrator reviewed the facility's Admission/readmission Checklist. No changes were made. Admission/readmission trends will be brought to the QAPI and reviewed monthly with Medical Director #910.I Beginning on [DATE], all residents who were admitted /readmitted to the facility will be reviewed during the next clinical meeting which was held Monday through Friday. The interdisciplinary team (IDT) will evaluate the admission admission/readmission, review documentation in the medical record to ensure skin impairments, including but not limited to bruising, lacerations, and discoloration are documented appropriately, and the AVS. The IDT members include the Administrator, DON, Social Worker, and Director of Rehabilitation. The DON/Designee will ensure all appropriate orders are in place within 72 hours of admission/readmission to the facility. The IDT will validate the skin assessment is documented correctly by rechecking the resident's skin the day after admission/readmission to the facility. Beginning on [DATE], the DON/designee will conduct random audits of five residents' records per week for four weeks to ensure ongoing compliance with skin assessments and documentation practice. Any discrepancies will be addressed immediately with re-education and corrective action as needed. Results of the audit will be reviewed weekly with the IDT. After the initial four-week period, the facility will evaluate compliance trends. If sustained compliance is demonstrated, monitoring will continue at a reduced frequency for an additional three months. On [DATE], the DON/Designee completed in-service training to all 22 licensed nurses on the completion of accurate skin assessments upon admission/readmission of the residents to the facility and reviewing AVS for any new orders or recommendations following any admission/readmission to the facility to ensure continuity of care and proper notification is provided to the physicians. New hires will receive training during orientation. The medical records for Resident #20, Resident #71, Resident #88, Resident #91 and Resident #101 were reviewed for readmission to the facility and continuity of care with no identified concerns. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Closed record review for Resident #99 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included metabolic encephalopathy, Parkinson's disease, muscle wasting and atrophy, muscle weakness, difficulty walking, history of falling, altered mental status, and glaucoma. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #99 had mildly impaired cognition. Review of the care plan dated [DATE] revealed Resident #99 was receiving anticoagulant therapy and was at risk for increased bleeding and bruising. The goal was for Resident #99 to be free of complications of increased bleeding, bruising, etc. over the next 90 days. Interventions included to monitor for increased bruising, bleeding, etc. and report to physician and monitor laboratory testing as ordered. Review of the physician's order, dated [DATE], revealed the resident was to be administered Eliquis (a blood thinning medication), five milligrams (mg) twice a day. Review of the Situation, Background, Assessment, and Recommendation (SBAR) follow up note, dated [DATE], revealed Resident #99 was sent to the hospital by emergency squad for a fall with a laceration to right eyelid and an injury to right knee following a fall in his room. Review of the hospital's AVS, dated [DATE], revealed multiple injuries were found today ([DATE]). Regarding the laceration near the eye, it was repaired with glue. There were two new back fractures. These will not need any intervention as they are not in a concerning area of the spine, but it will cause pain. There was a large collection of blood called hematoma in the muscle of the left hamstring. This was likely causing pain as well as difficulty walking. The resident should follow up with an orthopedic surgeon. If this starts to worsen or if the medical team feels that the bleeding is continuing, the resident needs to return to medical care for reevaluation. Likely related to this, the resident was anemic in the emergency room (ER). The resident should be seen by the primary care physician (PCP) to check the resident's hemoglobin over the next several days to ensure the resident does not have further bleeding. It is imperative that Resident #99 have no additional falls at this point as Resident #99 was on a blood thinner (Eliquis). If the resident has any worsening symptoms return to medical care immediately. There were instructions to see the PCP as soon as possible for a visit in one day (the note specified around [DATE]). The AVS [DATE] included details on how to provide care to the spine factures. Instructions included placing a cold pack on the painful area for 10 to 20 minutes at a time and try to do this every one to two hours for the next three days while awake. Make sure your paths in your home are clear so that you do not fall. The AVS also included details on how to care for the bruise. Instructions included to put ice or a cold pack on the sore area for 10 to 20 minutes at a time to stop swelling. If able, prop up the area on pillows as much as possible for the next few days. Try to keep the sore area above the level of the heart. Review of the physicians' orders dated [DATE] and [DATE] revealed no new orders for laboratory testing or follow-up care and monitoring were implemented following Resident #99's return from the hospital on [DATE]. Review of the nursing progress note, dated [DATE] and written by LPN #501, revealed Resident #99 came back from the hospital yesterday. No further concerns as the laceration around his eyes was glued up. There was no mention of Resident #99's injuries to the back and the large hematoma to the left hamstring. There was no evidence the physician was notified of Resident #99's return to the facility on [DATE] and there was no evidence Resident #99 was seen by the resident's physician on [DATE] and [DATE]. There was no evidence the aftercare instructions for the spine fractures and bruise were implemented. There were two weekly skin observation forms dated [DATE] that were completed. The one form timed at 6:08 A.M. revealed Resident #99 fell yesterday ([DATE]) and had a cut around his eyes as reported by the day shift nurse. He came back from the hospital and continues to be monitored. The second form timed at 7:09 A.M revealed the skin check was not refused by Resident #99. Resident #99 did not have skin intact and did have a new area that was not a pressure ulcer. The weekly skin observation form identified one laceration to the resident's right eye and stated it needed continuous monitoring. There were no additional comments made on the forms. No bruising was identified on the two skin observation forms. Review of the progress note, dated [DATE], revealed the resident had a fall and his wife insisted on him being taken to the hospital. The resident's right hand was swollen, there was a skin tear on the back of his head, and bruises on his right eye and right thigh. Resident #99 was transported to the hospital. Review of the hospital progress notes, dated [DATE] through [DATE], revealed Resident #99 was admitted to the hospital on [DATE] following frequent falls with subsequent bruising. Resident #99 had acute blood loss anemia with a hemoglobin (Hgb) level of 7.9 grams per deciliter (down from 9.6 grams per deciliter on [DATE]) which subsequently dropped and required a transfusion of packed red blood cells. The anemia appeared to be related to a left leg hematoma from a fall. The physician assessment dated [DATE] stated Resident #99 had bruising all over the body. During an interview on [DATE] at 10:15 A.M., the Administrator and Director of Nursing (DON) denied knowledge of any falls with major injuries occurring in the facility in the past three months. The Administrator stated she had just begun working at the facility a couple weeks prior and had asked specifically about falls with major injuries and was told there had not been any. Subsequent interviews with the Administrator and DON on [DATE] at 2:10 P.M. confirmed they were not aware of any injuries sustained by Resident #99 other than a laceration by the eye following his fall in the facility on [DATE]. They confirmed there was hospital paperwork uploaded into the resident's medical record which detailed injuries including two spinal fractures, a closed head injury, a hematoma to the left thigh, and anemia which required follow-up care and assessment by the facility. They confirmed no care or monitoring of the injuries had been provided as they were unaware of the injuries being present and did not know how they had missed the paperwork. During a telephone interview on [DATE] at 2:35 P.M., LPN #501 confirmed Resident #99 had returned to the facility from the hospital on [DATE] following a fall. LPN #501 denied knowledge of any injuries present other than a laceration by the resident's eye which was glued while the resident was at the hospital. LPN #501 confirmed she was unaware of any paperwork sent back from the hospital as she did not have time to look for it due to being busy caring for residents. Review of the facility policy titled Change in Condition Communication, revised 06/2019, revealed the physician was to be notified of a change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. This deficiency is an incidental finding identified during the complaint investigation. This deficiency is an example of continued non-compliance from the survey dated [DATE].

Based on medical record review, review of hospital records, review of fall investigations, staff interviews, and review of facility policy for falls, the facility failed to timely assess and develop comprehensive plans of care for residents with a history of falls prior to admission, failed to complete thorough fall investigations and implement timely and appropriate interventions for the residents with falls in the facility resulting in injuries. This resulted in Immediate Jeopardy when Resident #99 had four falls in eight days resulting in the resident being sent to the hospital on two occasions and suffering injuries including a closed head injury on 06/24/25, two fractures of the lumbar spine on 06/24/25, a large hematoma to the left thigh on 06/24/25, and acute blood loss anemia resulting from falls which required a blood transfusion on 06/26/25; and when Resident #88 had two falls in seven days resulting in the resident being admitted to the hospital on two separate occasions and suffering injuries including a closed head injury on 06/11/25, abrasions to the chin, shoulder and left face on 06/11/25, a shoulder with acute pain on 06/11/25. multiple rib fractures on 6/19/25, a fracture to the right humerus on 06/19/25, and an injury to the right axillary artery on 06/19/25. This affected three (Residents #88, #91, and #99) of six residents reviewed for falls. The facility census was 87. On 07/16/25 at 12:10 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #900 were notified Immediate Jeopardy began on 06/04/25 when Resident #99 was admitted to the facility with a history of falls and injuries and was not timely assessed and a comprehensive plan or care was not timely developed. Resident #99 fell four times at the facility on 06/18/25, 06/22/25, 06/24/25, and 06/26/25 without the facility completing thorough fall investigation, implementing timely and appropriate interventions, updating the care plan, and increasing the supervision of the resident.On 06/24/25, Resident #99 fell suffering a closed head injury, two fractures of the lumbar spine, and a large hematoma to the left thigh and on 06/26/25, acute blood loss anemia resulting from falls which required a blood transfusion. Resident #88 had multiple falls at the facility including on 06/11/25 and 06/19/25 without the facility completing thorough fall investigations to evaluate the root cause of the falls, implementing appropriate interventions, updating the care plan, and increasing the supervision of the resident. On 06/11/25, Resident #88 fell, sustaining a large hematoma on left side of forehead and cheek, abrasion of shoulder, unable to bear weight and required hospitalization from 06/11/25 to 06/17/25 to treat closed head injury, abrasions to chin, shoulder, left face, and shoulder with acute pain. On 06/19/25, Resident #88 fell again, sustaining a right humerus fracture, multiple rib fractures, and concern for right axillary artery injury and required hospitalization. The Immediate Jeopardy was removed on 07/18/25 when the facility implemented the following corrective actions: On 06/19/25, Resident #88 was sent to the hospital and did not return to the facility. On 06/26/25, Resident #99 was sent to the hospital and did not return to the facility. On 07/16/25, the Administrator held a Quality Assurance and Performance Improvement (QAPI) meeting with the DON and Medical Director #910 to discuss the Immediate Jeopardy template and plan of removal. On 07/16/25, Regional Minimum Data Set (MDS) Coordinator #920 educated MDS Coordinator #100 regarding the facility’s fall management program which included an individualized fall prevention for each resident identified at risk and updating the care plan with each fall event to ensure new interventions are implemented appropriately and the physician is notified of each fall event. On 07/16/25, MDS Coordinator #100 reviewed the care plans of 13 residents who were currently active in the facility and had experienced a fall in the last 30 days to ensure adequate interventions are in place and care plans are up to date with interventions. On 07/16/25, RDCO #900 educated the Administrator and DON on completing thorough fall investigations to include completing risk management, conducting witness interviews if applicable, updating care plans with appropriate fall interventions, identifying root cause analysis, and post fall interdisciplinary notes (IDT) for all fall events. On 07/16/25, the clinical interdisciplinary team (IDT) will review all residents who experience a fall event during the next scheduled clinical IDT meeting which is held Monday through Friday. This meeting includes the Administrator, DON, Social Worker, and Director of Rehabilitation. The clinical IDT will complete a thorough post-fall investigation, including a root cause analysis (RCA) to determine contributing factors and intervention opportunities. The clinical IDT will ensure the individualized intervention opportunity is updated to reflect in the fall care plan with the goal of reducing the recurrence. The DON with champion the meeting and ensure compliance with documentation, investigation/RCA determination, care plan updates, and intervention implementation. Any identified concerns will result in immediate staff training and, if appropriate, progressive disciplinary action. On 07/16/25, the Administrator reviewed the facility’s Fall Management and Care Plan Revision policies. No changes were made. Fall trends will be brought to QAPI and reviewed monthly with Medical Director #910. On 07/17/25, the DON/Designee completed in-service training for all 22 licensed nursing staff focused on fall management. This included completing a fall Situation, Background, Assessment, and Recommendation (SBAR), incident report within the medical record and fall related details. Nurses are responsible for the direct care of the resident at the time of the fall. The medical records for Resident #20, Resident #71, Resident #101 were reviewed for falls, appropriate fall follow up, appropriate fall interventions, and appropriate supervision with no identified concerns. Random interviews on 07/18/25 with Registered Nurse (RN) #150, Licensed Practical Nurse (LPN) #350, LPN #930, and MDS Coordinator #100 verified they had been in serviced on the fall management program and policy. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1 Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included metabolic encephalopathy, Parkinson’s disease, muscle wasting and atrophy, muscle weakness, difficulty walking, history of falling, altered mental status, and glaucoma. Review of the hospital progress note, dated 05/26/25, revealed Resident #99 presented to the hospital for confusion, hallucinations, and recurrent falls at home from standing height including one that morning while in the shower. No injuries were noted on extensive imaging. Review of the baseline care plan, dated 06/04/25, revealed Resident #99 was at risk for falls. Interventions were to anticipate needs-provide prompt assistance, ensure lighting was adequate, care areas were free of clutter, and ensure call light was within reach and answered promptly. Review of the facility’s Clinical Risk Assessment tool, dated 06/05/25, revealed Resident #99 was assessed at high risk for falls. The resident had not fallen in the three months prior to the assessment despite being documented to have fallen on the morning of 05/26/25. Review of the comprehensive care plan, dated 06/06/25, revealed Resident #99 was at risk for falls and injuries as evidenced by history of, may not always recognize own needs or limitations, metabolic encephalopathy, Parkinson’s disease, cognitive deficits, and history of amnesia. The goal was for Resident #99 to be free from falls/injuries over the next 90 days. The interventions did not change from the baseline care plan. Interventions dated 06/06/25 included to anticipate needs – provide prompt assistance, ensure lighting was adequate and areas were free of clutter, and ensure call light was within reach and answer promptly. No new goals or interventions were added to Resident #99’s care plan from 06/07/25 to 06/26/25. Review of the admission MDS assessment dated [DATE] revealed Resident #99 had mildly impaired cognition. Resident #99 did not have any falls since admission or in the month prior to admission to the facility. Review of the progress note, dated 06/18/25, revealed Resident #99 fell in the main lobby trying to sit down in a chair without assistance. The resident scraped his right elbow, and it was cleaned and left uncovered. The Power of Attorney (POA) was contacted, and a voice message was left, and the Nurse Practitioner (NP) #940 was notified. Resident #99 was in bed with the bed in its lowest position and the call light within reach. The facility completed two fall risk assessments on 06/18/25 for Resident #99. LPN #310 assessed Resident #99 at a high risk for falls and LPN #350 assessed Resident #99 at a risk for falls. Review of the facility’s Resident Fall Quality Assurance (QA) Checkoff Tool, completed on 06/19/25, revealed Resident #99 suffered a fall on 06/18/25 at 6:31 P.M. The root cause of the fall was the resident forgot to lock the wheeled walker and tried to sit down. The new intervention was for a visual reminder to lock the wheeled walker before sitting. The care plan was to be updated timely with new interventions added based on the cause of the fall. The fall was to be included in the monthly QA committee tracking with trends reviewed for repeated falls, location patterns, and staffing. No witness statements were provided with the fall investigation, and the care plan was not updated with new interventions following the fall. No QA committee minutes were available for review. Review of the progress note, dated 06/22/25, revealed staff notified the nurse Resident #99 was observed sitting on the floor in the room in front of the bed. The resident denied being in pain at the time. Resident #99 unable to explain what happened. Resident #99 had an abrasion to the left side of his nose. The abrasion was cleansed with normal saline, area dried, and triple antibiotic ointment was applied and then left open to air. Vital signs were within normal limits for Resident #99. Resident #99 was able to move all extremities. Physician and POA made aware. The intervention was to always keep in view of staff at nurse’s station. Review of the facility’s Resident Fall QA Checkoff Tool, not dated, revealed Resident #99 suffered a fall on 06/22/25 at 2:00 P.M. The root cause was Resident #99 was attempting to self-transfer. The new intervention was to keep Resident #99 within sight of staff while awake. The care plan was to be updated timely with new interventions added based on the cause of the fall. The fall was to be included in the monthly QA committee tracking with trends reviewed for repeated falls, location patterns, and staffing. The environment was not checked for hazards. No information regarding the location of the resident’s call light was included. No witness statements were provided with the fall investigation, and the care plan was not updated with new interventions following the fall. No QA committee minutes were available for review. Review of the SBAR (Change of Condition) Fall Event note, dated 06/24/25, revealed Resident #99 fell on [DATE] at 2:55 P.M. The location of the fall was in the room next to the bed and was unwitnessed. The resident had an “accident” and was trying to get wet clothes off when he fell off the bed and into the wall. Review of the hospital After Visit Summary notes, dated 06/24/25, revealed multiple injuries were found. The laceration near the eye was repaired with glue. There were two new back fractures, and they will not need any intervention as they were not in a concerning area of the spine but will cause pain. There was a large collection of blood called a hematoma in the muscle of the left hamstring which was likely causing pain as well as potential difficulty walking. Follow-up with an orthopedic surgeon. It was imperative no additional falls occurred as the resident was on blood thinning medication. Diagnoses included closed head injury, spine fracture, lacerations, anemia, and contusion. Review of the progress note, dated 06/25/25 at 6:30 A.M., revealed Resident #99 came back from the hospital the day prior. No further concerns as the laceration around his eye was glued up. Continue monitoring. Review of the facility’s Resident Fall QA Checkoff Tool, not dated, revealed Resident #99 suffered a fall on 06/24/25 at 2:55 P.M. The root cause was unsteady gait, urinary tract infection (UTI) being treated with antibiotic medication. Staff were not nearby or providing care at the time of the fall because they were at the nurse’s station. The new intervention was close observation and neuro-checks initiated after returning from the hospital. Keep within sight while awake. The care plan was to be updated with interventions based on the cause of the fall. The fall was to be included in the monthly QA committee tracking with trends reviewed for repeated falls, location patterns, and staffing. The environment was not checked for hazards. No information regarding the location of the resident’s call light was included. No witness statements were provided with the fall investigation, and the care plan was not updated with new interventions following the fall. No QA committee minutes were available for review. The fall was documented as not being related to toileting despite the resident falling while trying to remove wet clothing from an “accident”. The progress notes nor the QA Checkoff Tool explained what type of “accident” Resident #99 had. Review of the late entry SBAR (Change of Condition) note, dated 06/26/25, revealed Resident #99 had an unwitnessed fall in his room while attempting to ambulate without assistance. Review of the late entry progress note, dated 06/26/25, revealed Resident #99 had a fall with bruising and swelling to the right arm. Resident complaining of pain with a score of eight out of 10 (on a pain scale ranging from zero indicating no pain and ten being the most severe pain). Staff nurse administered as needed pain medication, and this nurse ordered STAT (urgent) X-ray to rule out fractures. Review of the progress note, dated 06/26/25, revealed Resident #99 fell and his wife insisted for him to be taken to the hospital. Resident #99’s right hand was swollen, and he had a skin tear on the back of his head, bruises on his right eye, and bruises on right thigh. Resident #99 was transported to hospital. Review of the hospital progress notes, dated 06/26/25 through 07/12/25, revealed Resident #99 was admitted to the hospital on [DATE] following frequent falls with subsequent bruising. Resident #99 had acute blood loss anemia with his Hemoglobin (Hgb) (a protein in red blood cells that carries oxygen throughout the body) level of 7.9 grams per deciliter (g/dl) dropping from the last hospitalization, which the Hgb went 9.6 on 06/24/25. Subsequently the Hgb dropped even further in the hospital on [DATE] and required a transfusion of packed red blood cells. The anemia appeared to be related to a left leg hematoma from a fall. Review of the facility Resident Fall QA Checkoff Tool, completed on 06/27/25, revealed Resident #99 suffered a fall on 06/26/25 at 6:30 P.M. The root cause was Resident #99 transferred himself without assistance after being placed in bed in a low position. The resident was transported to the hospital by request of his wife. The care plan was to be updated timely with new interventions added based on the cause of the fall. The fall was to be included in the monthly QA committee tracking with trends reviewed for repeated falls, location patterns, and staffing. The environment was not checked for hazards. No information regarding the location of the resident’s call light was included. No witness statements were provided with the fall investigation, and the care plan was not updated with new interventions following the fall. No QA committee minutes were available for review. During an interview on 07/14/25 at 10:15 A.M., the Administrator and DON denied knowledge of any falls with major injuries occurring in the facility in the past three months. The Administrator stated she had just begun working at the facility a couple weeks prior and had asked specifically about falls with major injuries and was told there had not been any. During an interview on 07/14/25 at 2:10 P.M., the Administrator and DON confirmed all falls were to be investigated with new interventions implemented based on the determined cause of the fall and interventions were to be added to the care plan. They confirmed there had not been any new interventions added to the care plans following Resident #99’s falls on 06/18/25, 06/22/25, or 06/24/25 before the resident was sent to the hospital on [DATE] following an additional fall. They confirmed Resident #99 had fallen on 06/24/25 and sustained injuries which included a closed head injury, two new back fractures, anemia, and a large hematoma in the left thigh muscle which they were not aware of. An incident report had not been completed for the fall Resident #99 sustained on 06/24/25 which resulted in the fall not being documented on the fall incident log and the fall care plan implemented for Resident #99 did not contain individualized interventions based on the resident was assessed to be at a fall risk. During an interview on 07/15/25 at 11:40 A.M., the Administrator and DON stated they could not locate QA meeting minutes for review. During an interview on 07/15/25 at 4:05 P.M., the DON confirmed she had taken over as the Director of Nursing for the facility around the beginning of June 2025. The DON stated the previous DON had handled resident fall incidents and she was still learning the process of what to do when residents fell. The DON confirmed the new intervention implemented following Resident #99’s fall on 06/24/25 did not address the resident having an “accident,” and it did not explain what type of accident that caused Resident #99 to be wet. 2 Review of the closed medical record for Resident #88 revealed an admission date of 12/31/24 and a discharge date of 06/19/25. Diagnoses included chronic respiratory failure, unspecified psychosis, mood disorder, chronic pancreatitis, and repeated falls. Review of the quarterly MDS assessment, dated 06/19/25, revealed Resident #88 had minimal cognitive impairment.Resident #88 had one fall with major injury and was assessed to require supervision or touching assistance with toileting, bathing and the use of a wheeled walker for ambulation. Review of Resident #88’s falls from 04/22/25 to 06/10/25 revealed Resident #88 fell on [DATE], 05/02/25, and 05/24/25 and sustained no major injuries. The facility did not have any fall investigations and did not implement timely and appropriate fall interventions for the falls on 05/02/25 and 05/24/25. Review of the fall risk observation tool dated 05/24/25 revealed Resident #88 was at high risk for falls following multiple fall events in the past. Review of the care plan dated 05/24/25 identified Resident #88 was at risk for falls due to decreased mobility and history of actual falls with a left shoulder fracture. The goal was for Resident #88 to not sustain major injury due to a fall. Interventions included to anticipate and meet the resident’s needs (01/01/25), call light within reach (01/01/25), encourage the resident to use call light for toileting needs (01/09/25), encourage the resident to lock wheelchair brakes during transfers (03/26/25), encourage to use wheelchair when feeling tired (03/14/25), ensure the resident was wearing appropriate footwear (01/01/25), follow facility fall protocol (01/01/25), new wheelchair provided (04/21/25), and visual reminder to use wheeled walker (03/05/25). Resident #88 also had a care plan in place for a fall with actual injuries. There were no additional interventions from 04/22/25 to 06/18/25. Review of the progress note dated 06/11/25 at 5:30 A.M. revealed Resident #88 was found lying on the floor in his bathroom, and the resident was unable to state what had happened.Resident #88 was assessed and had a large hematoma on the left side of his forehead, bruised and swollen cheek, and abrasion on the left shoulder. It also stated the resident was unable to bear weight when assisted off the floor. Review of the progress note dated 06/11/25 at 11:09 A.M. revealed the writer spoke with the emergency room (ER) nurse and Resident #88 was admitted to the hospital for observation. It stated he had a large hematoma on the left side of his face and a few lacerations. Resident #88 did not return to the facility from this hospital stay until 06/17/25. The facility was unable to provide a fall investigation for Resident #88’s fall on 06/11/25. It is unknown if the fall interventions were in place at the time of the fall and there were no witness statements and information on the last time he was checked on by staff to determine how long he laid in the bathroom, what type of footwear he was wearing at the time of the fall, if he used wheelchair or walker, and if his call light was activated for assistance. Review of the hospital records dated 06/17/25 revealed Resident #88 was admitted to the hospital due to fall and hyperglycemia (elevated blood sugar). Resident #88 hit his head and there was swelling to the left side of his face. His Glasgow Coma Scale (GCS) was 14 (indicating a mild acute traumatic brain injury) and was slow to respond to questions so they admitted Resident #88 to the hospital. CT imaging of head, thoracic, lumbar, chest and maxillofacial and x-rays of pelvic revealed no acute fractures. There was a hematoma in the left frontal skull, and a periorbital edema on the left side. There was 15 millimeters (mm) rounded area of increased attenuation within the face in the face on the left lateral to the maxilla, which could represent hematoma. There was minor blunt trauma to the chest, abdomen and pelvis. Resident #88 returned to the facility on [DATE]. There were no new interventions implemented for Resident #88 upon return from the hospital. The progress note dated 06/17/25 stated Resident #88 was walking with a wheeled walker. The progress note dated 06/18/25 at 7:52 P.M. revealed the facility nurse was called to the hallway leading to the dining room where Resident #88 was found on the floor bent over his walker leaning on the right side. Upon assessment, the resident’s range of motion to his upper and lower extremities were limited with an abrasion to his right elbow. Resident #88 was not wearing appropriate footwear at the time of the fall. There was a late entry progress note dated 06/24/25 at 9:02 A.M. which was written for 06/20/25 at 9:02 A.M. stated Resident #88 had been sent to the hospital for evaluation related to a shoulder fracture. The facility was unable to provide a fall investigation for Resident #88’s fall on 06/18/25. It is unknown if the fall interventions were in place at the time of the fall. Review of the hospital records dated 06/19/25 revealed Resident #88 was admitted to the hospital for management of a non-ST elevated myocardial infarction, closed fracture of multiple ribs on the right side, closed fracture of the right humeral neck, and injury to the right axillary artery. During an interview on 07/15/25 at 11:20 A.M., the Administrator and Director of Nursing (DON) verified fall investigations were not completed for Resident #88’s falls on 05/02/25, 05/24/25, 06/11/25 and 06/18/25. The DON stated she start working as the DON beginning of June of 2025. The DON confirmed the previous DON had handled resident fall incidents and she was still learning the process of what to do when residents fell. The DON stated she was not aware she needed to complete fall investigations. The Administrator and DON verified there were no witness statements obtained for the falls and no additional information could be provided related to Resident #88’s falls on 05/02/25, 05/24/25, 06/11/25, and 06/18/25. 3 Review of the closed medical record for Resident #91 revealed an admission date of 05/27/25. Resident discharged to home on [DATE]. Diagnoses included vascular dementia (moderate, with mood disturbance), chronic obstructive pulmonary disease (COPD), colostomy status, and protein-calorie malnutrition. Review of the therapy evaluation dated 05/28/25 identified Resident #91 had a history of five falls in the past year, including one with a head strike prior to entering the facility. Review of the fall prevention care plan initiated on 05/28/25 revealed Resident #91 was at risk for falling and injuries. Interventions included ensuring adequate lighting and a clutter-free environment, encouraging Resident #91 to ask for assistance, and ensuring the call light was within reach. The care plan was not updated after Resident #91 fell on [DATE]. Review of the progress dated 05/29/25 revealed Resident #91 sustained a fall at approximately 5:00 P.M. in her room after walking back from the bathroom. The fall was unwitnessed. A nurse’s progress note documented a change in condition, notification of the physician and responsible party, and recorded post-fall vital signs. Review of the fall risk assessment dated [DATE] at 6:35 P.M. revealed no fall had occurred and provided a risk score of five, indicating the resident was at risk for falls. This fall risk assessment was completed after the nursing progress note written stating Resident #91 fell in his bathroom. The facility was unable to provide a fall investigation for Resident #91’s fall on 05/29/25. Review of the admission MDS assessment dated [DATE] revealed Resident #91 had impaired cognition. Resident #91was totally dependent on staff for sit-to-lying, lying-to-sitting, chair-to-chair transfers, and toileting hygiene. Resident #91 had no history of falls in the last month prior to admission and did not have any falls since admission. The MDS assessment did not capture Resident #91’s fall on 05/29/25. Review of the care conference note dated 06/03/25 revealed it did not reference Resident #91’s fall and stated Resident #91 was ambulating safely and independently with a walker. During an interview on 07/16/25 at 9:07 A.M., the DON confirmed there was no fall investigation completed for Resident #91’s fall on 05/29/25., no new interventions were implemented, and the fall risk assessment was inaccurate as it should have been Resident #91 did have a fall. Review of the facility policy titled “Fall Management” revised 07/2024 revealed the facility will provide a safe environment for all residents by implementing a fall management program. This program includes fall risk assessments, individualized care plans, staff education, and post-fall evaluations. The facility will conduct fall risk assessments upon admission, quarterly, with fall events, and with significant changes. The resident’s care plan will be updated based on reassessment findings. Develop and individualized fall prevention plan for each resident identified at risk. Update the care plan with each fall event to ensure that any new risks or necessary interventions are addressed. Document the fall incident in the resident’s medical record, including the circumstances of the fall, injuries, and any interventions implemented. Complete an incident report as per facility policy. The IDT will review fall incidents to determine contributing factors, implement appropriate interventions, and adjust the resident’s care plan accordingly. IDT will review the fall incidents during Quality Assurance and Performance Improvement (QAPI) meetings. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00167114 and OH00166188. This deficiency is an example of continued non-compliance from the survey dated 03/12/25.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Nursing Home Guidance from the Centers for Disease Control (CDC), observations of staff and residents, medical record reviews, review of the facility Coronavirus (COVID-19) policies and staff and resident interviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy on 11/21/22 when 11 residents (Residents #2, #3, #12, #26, #36, #43, #44, #54, #65, #66, and #78) on the second floor tested positive for COVID-19. Residents #43 and #78 were roommates and each tested positive on 11/21/22. On 11/25/22, 17 additional residents (Residents #5, #15, #30, #39, #40, #41, #49, #50, #53, #57, #58, #67, #71, #72, #74, #77, and #87) tested positive for COVID-19. On 11/26/22, Resident #47 tested positive for COVID-19. On 11/26/22, Resident #45, who was Resident #47's roommate, was moved to another room and placed with Resident #37 who had not been exposed and had tested negative for COVID-19. The facility failed to place Resident #45 under quarantine due to exposure despite the facility's current COVID-19 outbreak. On 11/27/22, Resident #13 tested positive for COVID-19. Resident #55, who was Resident #13's roommate remained in a room with Resident #55 from 11/27/22 to 11/30/22. On 11/30/22, Resident #55 who was not vaccinated for COVID-19 and was Resident #13's roommate, was moved to another room with Resident #32, who was unvaccinated, had not been exposed to COVID-19, and had tested negative for COVID-19. The facility failed to place Resident #55 under quarantine due to exposure despite the facility's current COVID-19 outbreak. On 11/28/22, Resident #87, who tested positive for COVID-19 on 11/25/22, was transported to the hospital, where Resident #87 remained until 12/06/22. Furthermore, the facility failed to monitor a COVID-19 positive resident (Resident #43) during a smoke break to ensure he did not smoke with Resident #46 who was negative for COVID-19, failed to ensure staff properly utilized personal protective equipment (PPE), failed to dispose of PPE properly, and failed to ensure staff properly sanitized equipment. The lack of current effective infection control practices and prevalence of continued positive cases in the facility placed all 77 residents currently residing in the facility at potential risk for serious life-threatening harm, negative health outcomes/complications, and/or death related to the facility's failure to control the COVID-19 outbreak. On 12/01/22 at 5:47 P.M., Director of Operations (DOO) #195, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #172, and Regional Nurse/Infection Preventionist (RN/IP) #189 were notified Immediate Jeopardy began on 11/21/22 when 11 residents (Residents #2, #3, #12, #26, #36, #43, #44, #54, #65, #66, and #78) on the second floor tested positive for COVID-19. On 11/25/22, seventeen additional residents (Residents #5, #15, #30, #39, #40, #41, #49, #50, #53, #57, #58, #67, #71, #72, #74, #77, and #87), who resided on both the first and second floor, tested positive for COVID-19. Following the identification of the COVID-19 positive residents the facility failed to ensure effective infection control practices were implemented to prevent the cohorting of positive and negative residents, to ensure proper transmission-based precautions were implemented timely and failed to ensure staff utilized proper personal protective equipment when caring for residents. The Immediate Jeopardy was removed on 12/02/22 when the facility implemented the following corrective actions: On 12/01/22 by 6:31 P.M., DOO #195 educated all department heads on proper infection control practices, cohorting COVID-19 positive residents, proper practices for residents who are exposed to COVID-19, removal of Transmission Based Precautions (TBP), and proper isolation practices. On 12/01/22 at 6:40 P.M., Resident #46 was assessed for signs and symptoms of COVID-19 and the need for additional precautions due to Resident #46 being exposed to COVID-19 during smoking. Resident #46 remained in a private room. On 12/01/22 by 7:09 P.M., an ad hoc Quality Assurance Performance Improvement meeting was conducted to review proper infection control practices including TBP, personal protective equipment, COVID-19 cohorting, and smoking of COVID-19 positive residents. On 12/01/22 at 7:30 P.M., all COVID-19 positive residents who smoke were educated on the designated smoke times. On 12/01/22 by 8:45 P.M., a Root Cause Analysis was conducted for the identified issues regarding TBP, COVID-19 cohorting, COVID-19 exposures, and smoking of COVID-19 positive residents. On 12/01/22 by 9:55 P.M., RN/IP #189 reviewed all COVID-19 positive residents and COVID-19 exposed residents to ensure appropriate infection control practices were in place for COVID-19 positive residents and COVID-19 exposed residents. On 12/01/22 by 10:00 P.M., RN/IP #189 or designee educated all staff on proper infection control practices, donning and doffing of personal protective equipment, proper placement of masks and respirator straps, appropriate personal protective equipment (PPE) for COVID-19 positive residents, proper disposal of used PPE in resident rooms, and proper sanitization of equipment. All remaining staff including any agency staff will be educated prior to the start of their next shift. Any newly hired staff will be educated upon orientation, annually, and as needed. On 12/01/22 by 10:00 P.M., all staff were educated by the DON/designee on the smoking designation times for COVID-19 positive residents being different then the smoking designation times for COVID-19 negative residents. On 12/01/22 at 11:59 P.M., Resident #55 was moved to a private room due to being exposed to a COVID-19 positive resident. On 12/02/22, the DON, RN/IP #189, and/or Administrator began conducting audits to ensure all infection control practices regarding proper personal protective equipment, cohorting of residents, TBP, and smoking of COVID-19 positive residents were in place. The audits were conducted five to seven days for one week, then three times a week for three weeks. Observations conducted on 12/05/22 and 12/07/22 revealed the facility was implementing proper infection control procedures. Interview on 12/06/22 at 11:00 A.M. with Unit Manager #131, on 12/06/22 at 3:00 P.M. with Activities Director #90, and on 12/07/22 at 6:00 P.M. with Licensed Practical Nurse #140, revealed all the staff were knowledgeable regarding proper infection control protocols as well as the facilities infection control policies and procedures. Although the Immediate Jeopardy was removed on 12/02/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure ongoing compliance. Findings include: During the entrance conference on 11/30/22 at 10:43 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #97 revealed the facility currently had 32 residents who had tested positive for COVID-19. The first 11 residents (Residents #2, #3, #12, #26, #36, #43, #44, #54, #65, #66, and #78) tested positive on 11/21/22. An additional 17 residents (Residents #5, #15, #30, #39, #40, #41, #49, #50, #53, #57, #58, #67, #71, #72, #74, #77, and #87) tested positive for COVID-19 on 11/25/22. Resident #47 tested positive for COVID-19 on 11/26/22. Residents #13 and #70 tested positive for COVID-19 on 11/27/22. On 11/28/22, Resident #87, who tested positive for COVID-19, on 11/25/22, was sent to the hospital for treatment and remained in the hospital. Resident #60 tested positive for COVID-19 on 11/29/22. 1. Review of Resident #47's medical record revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set Assessment (MDS) assessment, dated 10/18/22, revealed Resident #47 had moderately impaired cognition. Resident #47 required extensive assistance from one staff to complete ADLs. Review of Resident #47's census revealed Resident #47 was in a semi-private room (with Resident #45 from 11/25/22 until 11/26/22 when Resident #45 changed rooms). Review of the Resident #47's progress notes revealed on 11/26/22 at 2:06 P.M., Resident #47 tested positive for COVID-19. Resident #47's son was notified. Review of Resident #45's medical record revealed an admitted [DATE]. Resident #45's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment, dated 09/11/22, revealed Resident #45 had intact cognition. Resident #45 required extensive assistance from one to two staff to complete ADLs. Review of Resident #45's census revealed on 11/25/22, Resident #45 was placed in a semi-private room with Resident #47 until 11/26/22 when Resident #45 was moved to another semi-private room (with Resident #37). Review of the progress notes revealed on 11/25/22 at 4:14 P.M., Resident #45 was tested for COVID-19 due to testing surveillance and the results were negative. On 11/26/22 at 2:49 P.M., Resident #45 was transferred to a different room due to Resident #45's roommate testing positive for COVID-19. There was no indication Resident #45 was placed under quarantine after being exposed to Resident #47 who tested positive for COVID-19 on 11/26/22. Review of Resident #37's medical record revealed an admitted on 11/07/22. Resident #37's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated 11/15/22, revealed Resident #37 had moderately impaired cognition. Resident #37 required limited assistance from one staff to complete ADLs. Review of Resident #37's census revealed from 11/26/22 through 12/01/22, Resident #37 resided in the same semi-private room as Resident #47. Review of Resident #37's progress notes revealed Resident #37 tested negative for COVID-19 on 11/21/22. Observations of Resident #37 and Resident #45's room, on 11/30/22 at 1:45 P.M and 3:35 P.M., and on 12/01/22 at 10:05 A.M., revealed Resident #37 and Resident #45 were not placed under quarantine/isolation despite Resident #45 having been exposed to COVID-19 by Resident #47, who had tested positive for COVID-19. Interview on 11/30/22 at 6:21 P.M. with the Director of Nursing (DON) and Regional Nurse/Infection Preventionist (RN/IP) #189 confirmed Resident #45 was not placed under quarantine following a known exposure to Resident #47 and was placed with Resident #37 who had not been exposed and tested negative for COVID-19. RN/IP #189 stated the current guidance from the Center for Disease Control (CDC) indicated exposed residents were not required to be placed under quarantine. Review of the facility undated policy titled Coronavirus (COVID-19) Policy and Procedure, revealed the policy indicated, asymptomatic patients do not require empiric use of Transmission-Based Precautions (TBP) while being evaluated for [CONDITION(S)]-CoV-2 following close contact with someone with [CONDITION(S)]-CoV-2 infection. Examples of when empiric TBP following close contact may be considered include: patient is moderately to severely immunocompromised, patient is residing on a unit with others who are moderately to severely immunocompromised, or patient is residing on a unit experiencing ongoing [CONDITION(S)]-CoV-2 transmission that is not controlled with initial interventions. The policy also stated, droplet precautions will be implemented for identified residents who are not up to date with COVID-19 vaccination with suspected Coronavirus until after day 10 following the exposure (day 0) if they do not develop symptoms. Review of CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 09/23/22, revealed examples of when empiric Transmission-Based Precautions following close contact may be considered include: Patient is unable to be tested or wear source control as recommended for the 10 days following their exposure. Patient is moderately to severely immunocompromised. Patient is residing on a unit with others who are moderately to severely immunocompromised. Patient is residing on a unit experiencing ongoing [CONDITION(S)]-CoV-2 transmission that is not controlled with initial interventions. 2. Review of Resident #13's medical record revealed an admitted [DATE]. Resident #13's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's census record revealed Resident #13 resided in the same room as Resident #55 from 11/27/22 through 11/30/22 when Resident #55 changed rooms. Review of Resident #13's progress notes revealed on 11/27/22 at 4:18 P.M., Resident #13 remained in a private room related to a positive COVID-19 test on 11/27/22. All services and meals were to be provided in the room. Review of the Medicare 5-Day MDS assessment, dated 12/01/22, revealed Resident #13 had moderately impaired cognition. Resident #13 required extensive assistance to total dependence from one to two staff to complete ADLs. Resident #13 was under isolation/quarantine. Review of Resident #55's medical record revealed an admitted [DATE]. Resident #55's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated 11/18/22, revealed Resident #55 had intact cognition. Resident #55 required supervision to limited assistance from one staff to complete ADLs. Review of Resident #55's census revealed the resident was admitted to a semi-private room, with Resident #13, on 11/08/22. Resident #55 remained in the room with Resident #13 from 11/27/22 through 11/30/22. On 11/30/22, Resident #55 was moved to another semi-private room with Resident #32, who was negative for COVID-19 and unvaccinated. Review of Resident #55's immunizations revealed the resident was unvaccinated for COVID-19. Review of Resident #55's progress notes, dated from 11/01/22 to 12/01/22, revealed there were not any notes related to the resident's room move or any indication Resident #55 had been placed under quarantine following exposure to Resident #13. Review of Resident #32's medical record revealed an admitted [DATE]. Resident #32's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated 10/31/22, revealed Resident #32 had severely impaired cognition. Resident #32 required extensive assistance from one staff to complete ADLs. Review of Resident #32's census revealed the resident was in a semi-private room with Resident #55 on 11/30/22 and 12/01/22. Review of Resident #32's immunizations revealed the resident was unvaccinated for COVID-19. Review of Resident #32's progress notes, revealed on 11/25/22 at 11:45 A.M. Resident #32 was noted to test negative for COVID-19. Observations on 11/30/22 at 1:45 P.M and 3:35 P.M., and on 12/01/22 at 10:05 A.M., confirmed Resident #32 and Resident #55 were roommates. There were no indications the room was under quarantine or any TBP were implemented. Interview on 11/30/22 at 1:55 P.M. with ADON #172 confirmed Resident #32 and Resident #55 were roommates. ADON #172 stated Resident #55 was moved to another room with Resident #32 when Resident #55's roommate, Resident #13, tested positive for COVID-19. ADON #172 confirmed Resident #32 and Resident #55's room was not under quarantine or any TBP. Interview on 11/30/22 at 6:21 P.M. with the Director of Nursing (DON) and Regional Nurse/Infection Preventionist (RN/IP) #189 confirmed Resident #55 was not placed under quarantine following a known exposure to Resident #13 and was moved into a room with Resident #32 who had not been exposed, was unvaccinated, and tested negative for COVID-19. RN/IP #189 stated the current guidance from the Center for Disease Control (CDC) indicated exposed residents were not required to be placed under quarantine. Information obtained via email on 12/01/22 at 12:23 P.M. from Regional Nurse/Infection Preventionist (RN/IP) #189 confirmed Resident #55 was unvaccinated for COVID-19. Review of the facility undated policy titled Coronavirus (COVID-19) Policy and Procedure, revealed the policy indicated asymptomatic patients do not require empiric use of Transmission-Based Precautions (TBP) while being evaluated for [CONDITION(S)]-CoV-2 following close contact with someone with [CONDITION(S)]-CoV-2 infection. Examples of when empiric TBP following close contact may be considered include: patient is moderately to severely immunocompromised, patient is residing on a unit with others who are moderately to severely immunocompromised, or patient is residing on a unit experiencing ongoing [CONDITION(S)]-CoV-2 transmission that is not controlled with initial interventions. The policy also stated, droplet precautions will be implemented for identified residents who are not up to date with COVID-19 vaccination with suspected Coronavirus until after day 10 following the exposure (day 0) if they do not develop symptoms. 3. On 11/30/22 at 1:45 P.M., STNA #182 was observed to enter Resident #47's room. The door of the room had a red sign posted on which indicated Droplet Precautions. There was a cart filled with personal protective equipment (PPE) placed outside of the Resident #47's door. STNA #182 did not don an isolation gown or gloves prior to entering the room. At 1:47 P.M., STNA #182 exited Resident #47's room with a meal tray and placed it on the meal cart. STNA #182 then used the hand sanitizer which was located on the wall in the hallway. Interview on 11/30/22 at 1:50 P.M., with STNA #182 revealed STNA #182 was an agency aide but had worked at the facility four or five previous times. STNA #182 confirmed she entered Resident #47's room without donning an isolation gown or gloves. STNA #182 confirmed the room door had a sign which indicated Droplet Precautions. STNA #182 stated she was told in report, Resident #47's roommate had tested positive for COVID-19 and had been moved to another room. STNA #182 stated she was not aware Resident #47 who resided in the room was positive for COVID-19. Review of the facility undated policy titled Coronavirus (COVID-19) Policy and Procedure, revealed the policy indicated Personal Protective Equipment included face mask (procedure or N95), face shield or goggles, gown, and gloves. For COVID-19 positive residents, staff should wear full PPE: N95 mask, gown, gloves, and face shields for care of residents who are known COVID positive for all resident contact. 4. Review of Resident #70's medical record revealed an admitted [DATE]. Resident #70's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare 5-day MDS 3.0 assessment, dated 11/28/22, revealed Resident #70 had mildly impaired cognition. Resident #70 required extensive assistance from one to two staff to complete ADLs. Resident #70 was in isolation/quarantine. Review of Resident #70's progress notes revealed on 11/27/22, Resident #70 tested positive for COVID-19. Resident #70's guardian was made aware. On 11/30/22 at 4:43 P.M. STNA #127 was observed to remove her N95 respirator and eye protection and placed them face down, with the front of the respirator and eye protection touching the top of the PPE cart. STNA #127 donned a new N95 respirator, gloves, isolation gown, and eye protection, and entered Resident #70's room, (a room of a resident in droplet precautions). At 4:45 P.M., STNA #127 exited room [ROOM NUMBER]. STNA #127 used hand sanitizer located on the wall in the hallway. STNA #127 then donned the N95 respirator and eye protection that had been laying on top of the PPE cart. STNA #127 did not sanitize the top of the PPE cart before placing the PPE on top of it or after re-donning the PPE. On 11/30/22 at 4:45 P.M., STNA #151 was observed to don gloves from the PPE cart, removed her N95 respirator and eye protection, and placed them along the hand railing outside of Resident #13's room, (the resident was in droplet precautions). With the same gloves on, STNA #151 then donned a new N95 respirator, isolation gown, and eye protection. STNA #151 then entered Resident #13's room. At 4:57 P.M., STNA #151 exited Resident #13's room without any PPE on. STNA #151 then donned a new N95 respirator and donned the eye protection that was laying against the hand railing. STNA #151 took the N95 respirator that had been laying against the railing in her hand and carried it to the nurse's station to throw it into a trash can and then washed her hands at the sink behind the nurse's station desk. STNA #151 did not sanitize the hand railing before placing the PPE against it or after removing the PPE. On 11/30/22 at 5:00 P.M., STNA #127 was observed to respond to a call light for Resident #70's room. STNA #127 removed her N95 respirator and eye protection and placed them face down, with the front of the respirator and eye protection touching the top of the PPE cart. STNA #127 donned a new N95 respirator, gloves, isolation gown, and eye protection. STNA #127 did not don the PPE in the proper sequence and did not sanitize the top of the PPE cart before placing PPE on top of the cart or after removing the PPE from the top of the cart. At 5:04 P.M., STNA #127 answered a call light for Resident #51's room, a resident who was not in any type of transmission-based precautions (TBP). Interview on 11/30/22 at 5:05 P.M. with STNA #127 and STNA #151 confirmed each STNA had donned PPE in the wrong sequence by donning gloves before donning all other PPE. Both STNAs confirmed the proper PPE sequence was posted on the isolation room door sign. STNA #127 and STNA #151 each confirmed they had not sanitized the top of the PPE cart or the hand railing before placing PPE on/against it and had not sanitized the same items after removing the PPE. Review of the facility undated policy titled Coronavirus (COVID-19) Policy and Procedure, revealed the policy indicated, standard cleaning and disinfection procedures (e.g., using cleaners in water to preclean surfaces prior to applying disinfectants to frequently touched surfaces or objects or indicated contact times) will be used for Coronavirus environmental control in all settings within the facility including those resident care areas in which aerosol generating procedures are performed. Review of undated CDC guidance titled Sequence for Putting On Personal Protective Equipment (PPE), revealed the type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE. The guidance listed the gown as number one and stated fully cover torso from neck to knees, arms to end of wrists, and wrap around back. Fasten in back of neck and waist. The guidance listed the mask or respirator as number two and stated secure ties or elastic bands at middle of head and neck. Fit flexible band to nose bridge. Fit snug to face and below chin. Fit-check respirator. The guidance listed goggles or a face shield as number three and noted place over face and eyes and adjust to fit. The guidance listed gloves as number four and noted extend to cover wrist of isolation gown. 5. On 11/30/22 at 6:30 P.M. two small trash cans were observed in Resident #70's room. One of the trash cans was located just inside Resident #70's door and the other was located across the room, underneath the window, closer to Resident #70's bed. Both trash cans had clear trash bags in them and were open. Both trash cans had used PPE in them which included isolation gowns, masks, and gloves. A large red biohazard bag was also observed to be open and laying on the floor inside Resident #70's door next to the unused bed in the room. There was used PPE in the large red biohazard bag including isolation gowns, masks, and gloves. There were no containers with lids present in Resident #70's room. None of the bags were tied closed at the time of the observation and PPE including masks and gloves were observed to have overflowed onto the floor. Interview with Resident #70 at the time of the observation confirmed the trash cans and contents of the cans and red bag were present in the room. Interview and observation on 11/30/22 at 6:55 P.M. with agency Licensed Practical Nurse (LPN) #197 confirmed there was used PPE in the open trashcans and the open red biohazard bag which was sitting on the floor. Interview and observation on 12/06/22 at 1:20 P.M. with Resident #70 revealed there was a large open red biohazard bag filled with used PPE which was sitting on top of the unused mattress on the spare bed in Resident #70's room. Interview and observation on 12/06/22 at 1:30 P.M. with STNA #127 confirmed there was used PPE in the large, open, red biohazard bag sitting on Resident #70's spare bed mattress. STNA #127 stated, it is not supposed to be like that. We are supposed to use yellow bags for linens/sheets/towels/washcloths and red bags for trash and used PPE. The bags are supposed to be in containers with either the bags tied shut or the containers should have lids. Review of the facility undated policy titled Coronavirus (COVID-19) Policy and Procedure, revealed the policy indicated management of laundry, food service utensils, and medical waste will also be performed in accordance with standard procedures. 6. On 12/01/22 at 9:40 A.M. Receptionist #147 was observed sitting at the front desk with her goggles sitting on the top of her head. The receptionist was talking with a visitor. The visitor left the desk area, and the surveyor approached the desk to sign-in. Receptionist #147 greeted the surveyor and talked for a couple of minutes while her goggles remained on the top of her head. Interview on 12/01/22 at 9:42 P.M. with Receptionist #147 confirmed she was not wearing her eye protection properly. The receptionist pulled the goggles down over her eyes after surveyor intervention. On 12/01/22 at 9:46 A.M. Housekeeper (HKP) #142 and Registered Nurse (RN) #154 were observed to have a surgical mask under their N95 respirator mask with both straps of their N95 respirators worn down around their necks. Interview on 12/01/22 at 9:48 A.M. with HKP #142 and RN #154 confirmed they had a surgical mask under their N95 respirator and both straps of the N95 respirators were worn down around their necks. On 12/01/22 at 9:50 A.M. HKP #145 was observed with a surgical mask under her N95 respirator with both straps of her N95 respirator mask worn down around her neck. Interview on 12/01/22 at 9:52 A.M. with HKP #145 confirmed she had a surgical mask under her N95 respirator and both straps of her N95 respirator were worn down around her neck. Review of the facility undated policy titled Coronavirus (COVID-19) Policy and Procedure, revealed the policy indicated, during the care of any resident, all staff shall adhere to standard precautions, which are the foundations for preventing transmission of infectious agents in all healthcare settings. Procedure mask or N95 (if potential for splash or contamination a procedure mask can be used to cover N95). Face shield or goggles to protect eyes and face as needed. For COVID-19 positive residents, staff should wear full PPE: N95 mask, gown, gloves, and face shields for care of residents who are known COVID positive for all resident contact. Review of CDC guidance titled How to Use Your N95 Respirator, last updated 03/16/22, revealed under section three titled Put on the N95, the guidance noted hold the N95 in your hand with the nose piece bar (or foam) at your fingertips. If yours does not have a nose piece, use the text written on it to be sure the top end is at your fingertips. Place the N95 under your chin with the nose piece bar at the top. Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted. Place your fingertips from both hands at the top of the nose piece. Press down on both sides of the nose piece to mold it to the shape of your nose. 7. Review of Resident #43's medical record revealed an admitted [DATE]. Resident #43's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare 5-Day MDS assessment, dated 11/24/22, revealed Resident #43 had mildly impaired cognition and Resident #43 was under isolation. On 12/01/22 at 10:35 A.M. observation during a smoke break revealed Resident #43, who tested positive for COVID-19 on 11/21/22 and who was in droplet precautions on this date, was outside on the smoking patio sitting on a bench. Another resident, (later identified as Resident #46), who was negative for COVID-19, was observed sitting in her wheelchair next to Resident #43. Resident #46 and Resident #43 were observed to be within three feet of each other. There was one staff person observed standing in front of Resident #43 and Resident #46 with a N95 respirator and eye protection in place. The staff was observed talking with the residents. There were no observed attempts to separate the residents. Resident #43 and Resident #46 were not wearing any PPE at the time of the observation. Interview on 12/01/22 at 10:40 A.M. with STNA #127 confirmed Resident #43 and Resident #46 were within three feet of each other. STNA #127 stated the two residents were not supposed to be smoking together but Resident #46 was non-compliant with the scheduled smoking breaks and wanted to go outside anytime she saw any other residents out on the smoking patio. STNA #127 stated since it is Resident #46's right to smoke, we let her smoke when she wants to. Review of the facility undated policy titled Coronavirus (COVID-19) Policy and Procedure, revealed the policy indicated For COVID-19 positive residents, residents with suspected or confirmed Coronavirus will be placed in a private room or area. The policy did not address smoking. This deficiency represents non-compliance investigated under Complaint Number OH 922.

Based on observation, interview, and record review the facility failed to ensure an environment free of accident hazards when bed rails were not assessed as being appropriate for a resident, failed to implement fall interventions, and failed to ensure a wanderguard was applied for a resident after elopement. This affected three residents (Residents #13, #59, and #66). The facility census was 84. Actual harm occurred to Resident #13 when the resident's bedrails were not appropriately assessed resulting in the resident falling and sustaining a chin laceration that required sutures for closure. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including [CONDITION(S)], Type two diabetes mellitus, persistent mood disorder, chronic pain syndrome, depression, dysphagia, [CONDITION(S)], and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had intact cognition. The resident required the extensive assistance of one person for bed mobility and was totally dependent on staff for transfers. Review of the plan of care dated 05/02/22 revealed Resident #13 was at risk for falls and potential injury related to [CONDITION(S)], [CONDITION(S)], muscle weakness, unsteadiness on feet, and difficulty walking. Interventions included dycem to wheelchair, encouraging the resident to sleep in the center of the bed, evaluating the appropriateness of the side rails, low bed, maintain clear pathway, and mat on floor next to bed. Review of the progress note dated 09/17/22 at 1:33 A.M. revealed the nurse found Resident #13 on the floor alert and awake with a bleeding laceration to the chin area. The resident complained of mild pain to the chin area upon assessment. The resident was unsure if he hit his head when he fell off the bed. The broken bed side rail was identified as the cause of the fall. The nurse called emergency services and Resident #13 was transferred to the hospital. Review of the progress note dated 09/17/22 at 7:37 A.M. revealed Resident #13 returned from the hospital with four stitches to the lower chin. Review of the progress note dated 09/18/22 revealed the resident fell on ce again. Review of the 09/17/22 fall investigation revealed Resident #13 fell at 12:27 A.M. A factor observed at the time of the fall was an equipment malfunction due to the right side rail coming off of the bed. He was found on the floor and had been rolling or sliding out of the bed. The resident stated he had been asleep when he fell , previous fall interventions were in place and the intervention was to reevaluate the effectiveness of the side rail. Review of the 09/18/22 fall investigation revealed Resident #13 fell at 5:30 A.M. He was found on the floor in his room and had rolled or slid out of the bed. The intervention was a fall mat. Review of the skin grid non-pressure dated 09/19/22 revealed the assessment was considered 'in progress.' Resident #13 had a skin tear on his chin obtained on 09/17/22. It was described as being a skin tear that was sutured closed. Interview on 09/27/22 at 11:49 A.M. and 2:54 P.M. and on 09/29/22 at 10:13 A.M. with Resident #13 revealed prior to his fall he had received a new bed frame; he did not think the bedside rail was original to the bed. Resident #13 stated it had been bolted on but was loose and could easily be moved back and forth. The resident stated on 09/17/22 he had been moving in the bed when his arm bumped the rail and fell off and due the momentum his body kept rolling. He was unsure where he hit his chin but he was sent to the hospital for it. Resident #13 stated someone told him it had been the wrong rail for the bed. Interview on 09/29/22 at 3:01 P.M. with Maintenance Director #148 and Housekeeping Supervisor #160 revealed Resident #13's bed side railing had been appropriate for his bed. The side rail had square teeth, it looked like the tooth broke on the rail itself. Both staff members said they were unsure what caused the railing to break. Observation on 09/26/22 at 12:45 P.M., 09/27/22 at 2:54 P.M., and 09/28/22 at 10:50 A.M. and 10:56 A.M. revealed no mat was observed next to Resident #13's bed or in his room. Interview on 09/28/22 at 10:50 A.M. with Resident #13 revealed he had never had a mat next to his bed. Interview on 09/28/22 at 10:56 A.M. with Licensed Practical Nurse (LPN) #119 confirmed there was no fall mat next to Resident #13's bed although it was in the care plan. Observation and interview on 10/03/22 at 10:40 A.M. revealed Resident #13 still did not have a fall mat next to his bed. Interview at that time Agency Aide #205 confirmed the observation. Interview on 10/03/22 at 4:57 P.M. and on 10/04/22 at 8:42 A.M. with Unit Manager LPN #120 revealed when Resident #13 fell he had been asleep, when he rolled, the bed rail broke. She stated she thought he had a bedrail due to his previous mattress. She reported for his 09/18/22 fall the staff had used a mattress to the bedside immediately because agency staff could not find a fall mat. A side rail evaluation for Resident #13 was requested on 10/04/22 at 8:42 A.M. and 4:20 P.M., no evaluation was provided. Review of the policy titled Falls and Fall risk, Managing dated December 2007, revealed the staff was to identify appropriate interventions to reduce the risk of falls. 2. Record review for Resident #59 revealed this resident was admitted to the facility on [DATE] and had diagnoses including [CONDITION(S)] disease, mild cognitive impairment, muscle weakness, violent behavior, unspecified dementia with behavioral disturbance, and depression. Review of the admission MDS assessment, dated 08/15/22, revealed this resident was assessed to have moderately impaired cognition evidenced by a BIMS assessment score of 04. This resident was assessed to require extensive assistance from one staff member for bed mobility and transfers and to be dependent on one staff member for toileting. Review of the care plan, dated 08/09/22, revealed this resident was at risk for elopement. Interventions included to follow facility elopement procedures. Review of the progress note, dated 09/15/22, revealed this resident was found outside in the front stating he was leaving and no one could stop him. Social Service Director, the Assistant Director of Nursing (ADON), and the Administrator assisted in getting the resident back into the building and the ADON stated the resident would need a wander guard placed. Observation on 10/03/22 at 12:15 P.M. revealed Resident #59 did not have a wander guard in place. The observation was verified with State tested Nursing Assistant (STNA) #201 at the time of the observation. Observation and interview with Maintenance Director #148 on 10/03/22 at 12:26 P.M. revealed the elevator located next to the conference room did not contain any sort of mechanism to prevent a resident without a wander guard from getting on it and going to the first floor of the facility, where the front door was unlocked during business hours. Interview with the Regional Director of Clinical Services #165 on 10/04/22 at 4:20 P.M. verified there were no orders for a wander guard in place for Resident #59. 3. Review of the medical record for Resident #66 revealed an initial admitted [DATE] and a re-entry date of 07/08/22. Diagnoses included Alzheimer's Disease, lumbar vertebra fracture, low back pain, muscle weakness, difficulty walking, dysphagia, unsteadiness on her feet, [CONDITION(S)], and severe protein-calorie malnutrition. Review of the comprehensive MDS assessment, dated 07/15/22, revealed the resident had moderately impaired cognition with no Brief Interview of Mental Status (BIMS) score due to the resident being rarely or never understood. There were no documented behaviors. The resident required extensive to total assistance of one staff for all Activities of daily Living (ADL's) except eating which she required set up and supervision. Review of the plan of care dated 06/24/22 revealed the resident was at risk for falls and potential injury with no listed reasoning. Interventions included DPM mattress to her bed, low bed, maintain clear pathway, mat on floor next to bed, non-slip material in her chair, resident education, room close to nurses' station, and turn and reposition. Review of the admission packet dated 06/24/22 revealed the resident was at risk for falls and potential injury related to being a new admission within 14 days, having impaired decision making, being visually impaired, needing assistance with ADL care, having an unsteady gait, suffering a fall within 31 to 180 days of the assessment, being on a narcotic and stool softener/[MEDICATION(S)] and having Alzheimer's Disease. The interventions included a low bed, clear pathway, non-slip material in chair, resident education, a room close to the nurses' station, and turn and reposition. The assessment did not acknowledge her hearing impairment. Review of the fall risk assessment dated [DATE] revealed the resident scored eight and the fall risk dated 07/13/22 revealed the resident scored seven indicating the resident was a possible fall risk. Review of the progress note dated 07/14/22 at 10:41 A.M. by Unit Manager #740 revealed the interdisciplinary team (IDT) discussion related to the resident's previous falls revealed the resident was alert and oriented to person, place, and time with periods of confusion, she was able to make her needs known to staff, was educated on the need to ask for assistance when needed and orientated to her call light. A floor mat was also placed next to the resident's bed. Observation on 09/26/22 at 2:46 P.M. and 10/03/22 at 11:46 A.M. revealed the resident was resting in bed without a mat next to her bed and her wheelchair did not have non-slip material on the cushion. Observation on 10/04/22 at 8:03 A.M. revealed the resident remained in bed without a mat next to the bed. The observation was immediately confirmed by STNA #108. Interview and observation on 10/04/22 at 8:04 A.M. and 8:35 A.M. with RN #125 confirmed there was no physicians order for a mat next to the resident's bed but confirmed the mat was in the resident's care plan, the resident was a fall risk, and the resident fell on [DATE] and 10/03/22 from her wheelchair but was unsure if non-slip cushion was in wheelchair at the time of her fall stating the resident's family kept switching her wheelchairs. Observation and interview on 10/04/22 at 8:44 A.M. with STNA #108 confirmed there was no non-slip material in the resident's chair, the resident was then propelled to the common area. Interview on 10/04/22 at 8:55 A.M. with RN #125 confirmed Resident #66 was in the same chair on 10/03/22 that she was in on 10/04/22 that did not include non-slip material on the cushion. Review of the email dated 10/05/22 at 4:56 P.M. from Regional Nurse #165 to the Surveyor revealed fall interventions in place for Resident #66 prior to her fall on 6/27/22, should have been a room closer to nurses station, non-slip material to chair, and maintenance of a clear pathway. Prior to Resident #66's fall on 09/27/22 the fall interventions which should have been in place included a DPM mattress, mat at bedside when in bed, a room closer to nurses station, non-slip material to chair, and maintenance of a clear pathway. Prior to Resident #66's fall on 10/03/22, the fall interventions which should have been in place included encourage snacks when resident becomes restless, a room closer to nurses station, non-slip material to chair, maintenance of a clear pathway, DPM mattress, and mat at bedside when in bed. Review of the facility policy titled, Falls and Fall Risk, Managing revised 12/2007 revealed in conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of [CONDITION(S)], as applicable) to try to minimize serious consequences of falling and if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

Based on observation, interview, and record review, the facility failed to ensure pain medication was available for administration for Resident #11, Resident #14, and Resident #246. This affected three residents (Residents #11, #14, and #246) of four residents reviewed for pain management. The facility census was 84. Actual harm occurred to Resident #14 who voiced and presented with reports of increased pain without adequate pain management. Findings include: 1. Interview on 09/26/22 at 1:01 P.M. and 1:40 P.M. with Resident #14 revealed the facility had been out of her pain medications for two days. She reported increased abdominal pain. Observation on 09/26/22 at 1:01 P.M. and 1:40 P.M. revealed Resident #14 inhaling sharply and grabbing her abdomen multiple times during her interview. Interview on 09/29/22 at 11:36 A.M. with Resident #14 revealed over the weekend when she was out of pain medications, she had experienced up to a pain of 10 (pain scale of 1-10) and could not sleep. She stated they had been out of her pain medications several times. Review of the medical record revealed Resident #14 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had intact cognition. Review of the plan of care dated 04/06/22 revealed Resident #14 was at risk for alteration in comfort, however, the care plan did not identify the cause. The interventions included calming music or television, medications as ordered, monitoring for adverse effects of pain medications, monitoring for effectiveness of interventions, monitoring for levels of increased pain and notifying the physician, and using a pain scale as reported by the resident. Review of Resident #14's physician's orders dated 05/05/22 revealed orders for [MEDICATION(S)] five milligrams two tablets by mouth every four hours as needed for severe pain rated eight to ten and one tablet by mouth every four hours as needed for moderate pain rated four to seven. Review of the controlled drug receipt record dated 08/09/22 revealed the facility received 60 tablets of [MEDICATION(S)] five milligrams for Resident #14 on 08/09/22 and the last one was used on 09/05/22 at 8:00 P.M. Review of the controlled drug receipt record dated 09/08/22 revealed the facility received 30 tablets of [MEDICATION(S)] five milligrams for Resident #14 on 09/08/22 the first dose was administered on 09/09/22 at 8:00 P.M. and the last dose was administered on 09/23/22 at 8:00 P.M. Review of the controlled drug receipt record dated 09/26/22 revealed the facility received 30 tablets of [MEDICATION(S)] five milligrams for Resident #14 on 09/26/22 the first dose was administered on 09/27/22 at 5:30 A.M. Review of Resident #14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] was administered on 09/27/22 at 5:30 A.M. for a pain of nine. Review of the pain level summary for September 2022 revealed Resident #14's pain was not assessed on 09/04/22, 09/06/22, 09/07/22, 09/08/22, 09/10/22, 09/11/22, 09/14/22, 09/17/22, 09/18/22, 09/20/22, 09/23/22, 09/24/22, 09/25/22, and 09/26/22. Interview on 09/29/22 at 1:43 P.M. with Unit Manager Licensed Practical Nurse (LPN) #120 revealed they had not been aware Resident #14 had been out of pain medication, on either occasion. She stated 'as needed' medications should be called or faxed to the pharmacy when they are three to four days away from running out. She reported the facility did have emergency medication kits, however, there was no evidence medication was pulled for Resident #14. Interview on 09/29/22 at 2:08 P.M. with Regional Director of Clinical Services #165 revealed Resident #14's pain should be monitored every shift. Review of the policy Pain Clinical Protocol revised June 2013, revealed the staff were to reassess the individual's pain and related consequences at regular intervals. At least each shift for acute pain or significant changes in chronic pain. 2. Record review for Resident #11 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 06/25/22, revealed this resident had intact cognition evidenced by a BIMS assessment score of 13. This resident was assessed to require supervision from one staff for bed mobility and toileting and to be independent with setup help only for transfers and eating. This resident was assessed to have had pain in the past five days which limited day to day activities. Review of care plan, revised 03/17/20, revealed this resident had the potential for an alteration in comfort. Interventions included to administer medications as ordered to manage pain. Review of the active physicians order, dated 06/16/22, revealed an order to administer one [MEDICATION(S)] 5-325 milligram tablet three times a day for chronic bilateral leg pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the narcotic count sheets for [MEDICATION(S)] 5 - 325 milligram tablets revealed the last dose was pulled from the narcotic card on 09/21/22 at 9:00 A.M. for administration and the next dose was pulled from a new narcotic card on 09/28/22 at 4:00 P.M. for administration. Interview with Resident #11 on 09/26/22 at 12:37 P.M. revealed the resident had not been administered [MEDICATION(S)] for several days due to the facility not having it and had experienced increased pain levels and vomiting due to the absence of the ordered pain medication. Interview with Licensed Practical Nurse (LPN) #120 on 09/28/22 at 2:15 P.M. verified the [MEDICATION(S)] ordered for Resident #11 had been unavailable for administration from 09/21/22 through 09/28/22. Review of the facility policy titled Pain - Clinical Protocol, revised 06/2013, revealed the physician would order appropriate non-pharmacological and medication interventions to address the individual's pain. 3. Review of the medical record for Resident #246 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment, dated 10/01/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment). The resident required up to extensive assistance of one to two or more staff for all Activities of daily Living (ADL's) except eating which he required set up and supervision. Further review of the MDS confirmed the resident had a known surgical wound that he received surgical wound care for and application of non-surgical dressings. Further review of the MDS confirmed the resident received Opioid medication three of the previous seven days prior to the completion of the MDS. Review of the After Visit Summary for 08/24/22 through 09/24/22 revealed the resident's wound vacuum (vac) to his abdomen was removed for transport to the facility but was to be replaced. Review of the plan of care dated 09/24/22 revealed the resident was at risk for an alteration in comfort with no listed reasoning. Interventions included medications to manage pain per orders. Review of the physician orders dated 09/24/22 revealed orders to give 0.5 tablet of [MEDICATION(S)] 15 mg by mouth every six hours as needed for moderate to severe pain. There was a second order placed on the same date for one tablet of [MEDICATION(S)] 15 mg by mouth every six hours as needed for moderate to severe pain. Review of the September Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . He received 0.5 tablet on 09/26/22 for a rating of 5 and 09/27/22 for a rating of 7. Review of the October EMAR revealed the resident received one tablet of [MEDICATION(S)] on 10/01/22 for a pain rating of 8 and on 10/02/22 for a pain rating of 7. He received 0.5 tablet on 10/04/22 for a rating of 8, 10/05/22 for a rating of 5 and again for a rating of zero, and 10/07/22 for a pain rating of 3. Interview and observation on 10/03/22 at 1:25 P.M. revealed Resident #246 sitting up in his wheelchair asking for [MEDICATION(S)] due to complaints of abdominal pain. Licensed Practical Nurse (LPN) #777 confirmed at 1:26 P.M. she was awaiting delivery of the [MEDICATION(S)] from the pharmacy and had none to administer to Resident #246 until then. Review of the progress note dated 10/03/22 at 6:11 P.M. by Licensed Practical Nurse (LPN) #777 revealed she contacted the nurse practitioner (NP) and informed the NP that LPN #777 had contacted the pharmacy to check on the delivery status of the resident's [MEDICATION(S)] when she was informed by the pharmacy that the prescription was for six tablets which had been filled and a new prescription was needed. Further review of the progress note confirmed the resident was complaining of abdominal pain at his wound site. LPN #777 then informed the NP of the two orders listed in the resident's chart for [MEDICATION(S)] to which the NP informed LPN #777 that the resident could not have been getting the two [MEDICATION(S)] orders and she would have to figure out which [MEDICATION(S)] order the resident was to receive. Review of the October 2022 EMAR revealed the resident received one tablet of [MEDICATION(S)] for a pain scale rating of seven out of 10 on 10/02/22 at 6:56 A.M. Resident #246 did not receive any pain medication on 10/03/22, and did not receive any more [MEDICATION(S)] until a half tablet was administered on 10/04/22 at 4:29 P.M. Interview on 10/04/22 at 9:36 A.M. with the Pharmacist confirmed Resident #246 needed a new prescription for [MEDICATION(S)] to be filled and delivered and one had not been received yet. Review of the email dated 10/04/22 at 1:25 P.M. from Regional Clinical Director #165 to the Surveyor confirmed the resident's [MEDICATION(S)] prescription was not sent to the pharmacy until 10/04/22 in the afternoon (specific time not identified). Review of the facility policy titled, Controlled Substances revised 12/2012 revealed the Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. Furthermore, controlled substances must be counted upon delivery and every shift.

Based on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure adequate assistance was provided with meal intake, failed to ensure weights were obtained and monitored, and failed to ensure meal intake was documented. This affected 10 residents (Residents #14, #28, #30, #32, #36, #51, #52, #55, #68, and #243) of the 10 residents reviewed for nutrition during the annual survey. The facility census was 84. Actual harm occurred to Resident #36 when assistance with meals was not adequately provided to the resident and the resident had a significant weight loss of 45.8 pounds (24.5 percent) from 04/22/22 to 10/05/22 (166 days). Findings include: 1. Record review for Resident #36 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/29/22, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 10. This resident was assessed to require extensive assistance from one staff member for bed mobility, extensive assistance from two staff members for transfers, and to be dependent upon one staff member for toileting and eating. This resident was assessed to have significant weight loss while not on prescribed weight-loss regimen. Review of the care plan, revised 09/18/22, revealed this resident was at risk for malnutrition. Interventions included adaptive equipment as ordered, assess for signs and symptoms of aspiration, assist with meals as needed, dysphagia guidelines as ordered, monitor consistency of diet served, monitor intake and output as ordered, monitor labs as ordered, obtain food preferences, and offer meal alternate if resident refuses, Review of the care plan, dated 08/23/22, revealed this resident had an Activities of Daily Living (ADL) self-care performance deficit. Interventions included resident dependent on one staff member for eating. Review of the documentation for amount of meal eaten for 09/2022 revealed there was no documentation present for breakfast, lunch, or dinner on 09/02/22, 09/03/22, 09/05/22, 09/06/22, 09/08/22, 09/10/22, 09/11/22, 09/12/22, 09/14/22, 09/15/22, 09/18/22, 09/19/22, 09/20/22, 09/22/22 through 09/26/22, or on 09/29/22. There was no documentation of the amount of the lunch meal consumed on 09/27/22. Review of the documentation for the amount of assistance provided with eating revealed there was no documentation present for 09/08/22, 09/10/22 through 09/12/22, 09/14/22, 09/15/22, or 09/18/22 through 09/29/22. Review of documented weights for this resident revealed on 04/22/22 the resident weighed 187.0 pounds, on 06/06/22 the resident weighed 165.0 pounds, on 07/13/22 the resident weighed 159.8 pounds, on 08/11/22 the resident weighed 150.4 pounds, on 09/14/22 the resident weighed 151.0 pounds, and on 10/05/22 the resident weighed 141.2 pounds. Observation on 09/27/22 at 12:15 P.M. revealed the lunch meal trays were delivered to the floor. Resident #52 was observed to be laying in bed sleeping. Two State tested Nursing Assistants (STNA's) were observed delivering lunch meal trays to other residents. The meal tray for Resident #52 was never removed from the cart during lunch meal service. Interview with STNA #212 on 09/27/22 at 12:38 P.M. revealed the employee stated Resident #36 had declined his lunch meal tray. Observation on 09/28/22 at 9:00 A.M. revealed Resident #36 was sitting up in his wheelchair in his room with his breakfast meal tray in front of him on a tray table. There were no staff members present in the room. The resident was observed having difficulty locating the food items on his meal tray. Observation on 09/29/22 at 8:45 A.M. revealed Resident #36 was lying in bed sleeping. The resident's breakfast meal tray was laying on the tray table located a foot away from the resident's bed. Interview with Resident #36 on 09/29/22 at 8:47 A.M. revealed the resident stated he was hungry but he had not been given his breakfast yet. Interview with STNA #215 on 09/29/22 at 9:00 A.M. revealed the employee did not take the breakfast meal tray into the room of Resident #36 as the employee had been passing meal trays at the end of the hallway. STNA #215 stated Resident #36 would normally eat most of his meal if a staff member sat down and assisted him consuming it. STNA #215 was then observed to enter the room of Resident #36, set him up to eat, and assist him to consume his breakfast meal. Interview with Registered Nurse (RN) #145 on 09/29/22 at 1:15 P.M. revealed Resident #36 had to have physical assistance from staff with consuming his meals due to being blind and cognitively impaired. RN #145 stated Resident #36 was able to put food in his mouth if it was handed to him, but had could not see adequately to get the food himself. 2. Record review for Resident #68 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 08/27/22, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 04. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting, extensive assistance from two staff members for transfers, and supervision with setup help only for eating. This resident was assessed to have significant weight loss while not on a prescribed weight-loss regimen. Review of the care plan, revised on 08/29/22, revealed this resident was at risk for malnutrition. Interventions included assist with meals as needed, elevate head of bed as ordered, honor food preferences as able, monitor intake/output as ordered, obtain food preferences, and weights as ordered. Review of documented weights for this resident revealed on 04/05/22 the resident weighed 245.0 pounds and on 10/02/22 the resident weighed 199.2 pounds (a weight loss of 45.8 pounds or 18.69 percent in 180 days). Review of the documentation for amount of meal eaten for 09/2022 revealed there was only documentation of the amount eaten for 14 meals during the month. Review of the Registered Dietitian progress note, dated 10/04/22, revealed the resident had a significant weight loss of 45.8 pounds in 180 days and typically consumed 75 to 100 percent of meals. Observation on 09/29/22 at 9:20 A.M. revealed Resident #68 was in bed with the breakfast meal tray in front of her on the tray table. The eggs and oatmeal on the residents tray had not been touched. Interview with Resident #68 on 09/29/22 at 9:06 A.M. revealed the resident did not care for eggs or oatmeal which was why the resident did not eat them. Resident #68 stated she was still hungry. Observation on 09/29/22 at 9:18 A.M. revealed STNA #215 entered the room of Resident #68 to pick up her breakfast meal tray. STNA #215 asked Resident #68 if she was finished and left the room without offering Resident #68 an alternate food selection, despite the eggs and oatmeal continuing to be left on the tray untouched. Observation and interview with STNA #215 on 09/29/22 at 9:20 A.M. verified the resident's meal ticket did not include any listed dislikes or food preferences on the ticket. Telephone interview with Registered Dietitian (RD) #175 on 10/03/22 at 3:04 P.M. revealed if there was at least a half a month of meal intake documentation present she could get an idea of residents intake patterns but would ideally like more. RD #175 reported it was difficult to determine average intakes for cognitively impaired residents if less than half the months meal intakes were documented. 3. Record review for Resident #52 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 08/17/22, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 08. This resident was assessed to require extensive assistance from one staff member for bed mobility, to be dependent upon two staff members for transfers, to be dependent upon one staff member for eating, toileting, and bathing. Review of the care plan, revised 09/20/22, revealed this resident was at risk of malnutrition/dehydration. Interventions included to encourage compliance with diet guidelines, record intake and output as needed, tube feeding as ordered, and weights as ordered. Review of the active physicians order, dated 08/02/22, revealed this resident was ordered a pureed diet with thin liquids. Review of the documentation for amount of meal eaten from 09/07/22 through 10/05/22 revealed there was only documentation of the amount eaten for eight meals during the month. Telephone interview with Registered Dietitian (RD) #175 on 10/03/22 at 3:04 P.M. revealed if there was at least a half a month of meal intake documentation present she could get an idea of residents intake patterns but would ideally like more. RD #175 reported it was difficult to determine average intakes for cognitively impaired residents if less than half the months meal intakes were documented. 4. Record review for Resident #32 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 07/06/22, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 04. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and to be independent with setup help only for eating. Review of the documented weights for this resident revealed on 07/13/22 the resident weighted 115.0 pounds, on 08/05/22 the resident weighed 112.5 pounds, and on 09/16/22 the resident weighed 162.2 pounds. There were not additional weights documented from 09/16/22 through 10/05/22. Review of the Registered Dietitian progress note, dated 09/20/22, revealed there was a weight discrepancy of 162.2 pounds documented on 09/16/22 and a recommendation was made to re-weigh. Review of the progress notes, dated 09/20/22 through 10/05/22, revealed no documentation of the resident refusing to be weighed. Telephone interview with RD #175 on 10/03/22 at 3:04 P.M. revealed she visited the facility once a week for 10 to 12 hours, requested reweighs verbally or through email, and would ideally like the reweighs obtained by the next visit to the facility. RD #175 stated she provided lists of missing weights to the facility and it could be a struggle to get them. Review of the facility policy titled Weight Assessment and Intervention, revised 09/2008, revealed any weight change of five percent or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 5. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #28 had a severe cognitive impairment. She required supervision with one-person physical assistance for eating. Review of the plan of care dated 07/04/22 revealed Resident #28 was at risk for malnutrition or dehydration related to diagnoses, obesity, vision impairments, diuretic usage, and antidepressant usage. Weight fluctuations had been noted the last one was on 06/22/22 was a significant weight gain over 30 days and increased nutrient intakes were identified. Interventions included assisting with meals as needed, encouraging the resident to dine in the dining room, medications as ordered, obtaining food preferences, occupational therapist as needed, and weights as needed. Review of the physician's orders for Resident #28 revealed an order dated 02/19/21 for a regular diet with regular texture the instructions revealed a food first program, an order dated 01/19/22 for house pudding supplement 120 ml three times a day, and an order dated 01/19/22 for house supplement plus 120 ml three times a day. Review of Resident #28's weights revealed on 02/08/22 she was 170.8 pounds, on 02/18/22 she was 170.8 pounds, on 02/24/22, she was 171.2 pounds, on 04/12/22 she was 162.5 pounds, on 05/09/22 she was 173.6 pounds, on 06/01/22 she was 174.5 pounds, on 06/13/22 she was 184.6 pounds, and on 08/08/22 she was 167 pounds. Her last weight of 167 pounds was a 9.5 % weight loss over 30 days. Review of Resident #28's intake records for September 2022 revealed intake was documented on two days for the entire month. On 09/01/22 Resident #28 consumed 51-75% of all three meals, on 09/08/22 Resident #28 consumed 76-100% of all three meals. Review of the progress note dated 06/23/22 revealed Resident #28's weight of 184.6 was a 5.8% increase in 30 days. The resident was on a regular diet with a food first program with all meals, average meal intakes of 50-75%, with supplements in place. No increased [CONDITION(S)] was reported at that time. Weight gain was suspected to be related to a combination of fluid shifts and increased intakes, no new recommendations were made. Review of the progress note dated 07/11/22 revealed a care conference took place, the family was concerned that Resident #28 was not eating due to not having teeth and that she had been trying to feed herself. Review of the progress note dated 08/08/22 revealed Resident #28's body weight of 167 pounds was a 9.5% weight loss from her previous weight. The note indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A supplement regimen was in place to compensate for variable intake, no recommendations were made. Review of the occupational therapy discharge summary dated 08/13/22 revealed Resident #28 was to be up in a wheelchair for all meals. She was to use adaptive equipment to increase with self-feeding. She was to receive stand by staff assistance after set up with meals. Observation on 09/27/22 from 9:40 A.M. to 10:00 A.M. revealed Resident #28 was in the resident lounge with her breakfast tray in front of her. She was asleep and no staff were present. Observation on 09/27/22 at 12:50 P.M. revealed STNA #131 set up Resident #28's tray, put silverware in her hands, and explained what was on the tray. STNA #131 then left the dining room. Interview on 09/27/22 at 12:50 P.M. with STNA #131 revealed Resident #28 did not require assistance with eating, she needed oriented to her tray, and silverware placed in her hand. Observation on 09/27/22 at 12:57 P.M. revealed Resident #28 was observed using her hands to eat and licking mashed potatoes off of her fingers. Observation on 09/28/22 starting at 12:30 P.M. revealed Licensed Practical Nurse (LPN) #119 brought Resident #28 her lunch tray in bed, he provided set up assistance and left the room. At 12:42 P.M. Resident #28 was observed using her hands to feel the different foods in the divided plate and eating mashed potatoes. At 12:45 P.M. 50% of the meal on her tray (meat, vegetables, and mashed potatoes) was observed to be absent there was a bowl of pudding on the left side of the tray that had been untouched. At 12:47 P.M. State tested Nursing Aide (STNA) #108 asked the resident if she was done eating and the resident indicated she was. STNA #108 asked the resident if she was sure she did not want her pudding, Resident #28 revealed she was unaware the pudding had been there. Interview on 09/28/22 at 12:47 P.M. with STNA #108 confirmed Resident #28 had been eating food with her hands and had a divided plate. STNA #108 revealed she was not working her usual hallway and was unfamiliar with the resident's needs at meals. Interview on 09/28/22 at 2:13 P.M. with LPN #119 confirmed he had provided Resident #119 with set up assistance at lunch. He reported Resident #28 required set up assistance and oriented to what was on the plate. He confirmed he had seen Resident #28 eat with her hands before. Observation on 09/29/22 from 8:50 A.M. to 9:23 A.M. of the breakfast meal revealed Resident #28 sleeping with her food in front of her. Resident #28's food was in bowls, she had consumed her oatmeal, but had not touched the eggs, coffee, or orange juice. Resident #28 did not receive assistance or queuing during the observation. Further observation at 9:28 A.M. revealed Agency Aide #203 removing Resident #28's tray without asking her if she was done. Agency Aide #203 returned the tray to the dietary cart and confirmed the resident had only consumed the oatmeal. She then grabbed the orange juice and returned it to Resident #28. Observation on 09/29/22 from 9:28 A.M. to 10:00 A.M. revealed Resident #28 drank the entire glass of orange juice. Interview on 09/28/22 at 3:12 P.M. with Occupational Therapist (OT) #181 confirmed the information in the 08/13/22 discharge summary. OT #181 stated Resident #28 was to sit in a chair at meals because the positioning was better for her, she required adaptive equipment at meals which was to mean food in bowls, and the staff should be with her at meals after set up to que her due to her poor eye sight and memory. She reported she works in the evenings, so she lets the nurses know her recommendations and they are to obtain and enter orders. Interview on 10/03/22 at 3:04 P.M. with Registered Dietitian (RD) #175 revealed she provided nursing management with lists of weekly weights and missing weights every week when she visits, however, it could a struggle to obtain the weights. RD #175 stated she would ideally like more intake documentation, she revealed if there was half a month of intake documentation, she could get an idea of their intake patterns. She reported with cognitively impaired residents if less than half of the intakes were documented it was difficult to determine their intakes, as she was only sometimes able to get information from staff on how the resident was doing. RD #175 confirmed Resident #28's weights were inconsistent and missing. She additionally revealed the food first program the resident was in meant they were to receive fortified foods. Interview on 10/03/22 at 3:45 P.M. with Dietary Manager #161 revealed he did not know what the food first program was and had no residents receiving fortified foods. Review of the policy titled Weight Assessment and Intervention dated September 2008, revealed after admission weights, weights were to be obtained monthly thereafter. Weights were to be recorded in the individuals medical record. 6. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and was on [CONDITION(S)]. She weighed 191 pounds and had no significant weight changes; Resident #30 was on a therapeutic diet. Review of the plan of care dated 06/23/22 revealed Resident #30 was at risk for malnutrition and dehydration related to medical diagnoses, a body mass index (BMI) above 25, therapeutic and mechanically altered diet, diuretic use and [CONDITION(S)] with anticipated weight fluctuations, and increased metabolic requirements with hemodialysis. As of 06/22/22 she had significant weight loss that was suspected to be related to fluid shifts and [CONDITION(S)]. Interventions included assessing and reporting signs of [CONDITION(S)] to physician, assisting with meals as needed, providing medications as ordered, providing diet as ordered, and weights as ordered. Review of the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's weights revealed she was last weighed on 06/21/22 and was 191 pounds. Review of meal intake records from 09/01/22 to 09/27/22 revealed intake was documented for three meals on 09/01/22, two meals on 09/03/22, three meals on 09/08/22, one meal on 09/09/22, and two meals on 09/17/22. Review of the progress note dated 06/23/22 revealed Resident #30's weight of 191.1 pounds. Review of the nutrition evaluation dated 07/24/22 revealed Resident #30's weight was 191.1 pounds on 06/21/22. A weight variance was identified and addressed previously. No thirty-day change was available with weight history. The resident remained at increased risk for malnutrition due to diagnoses, BMI, and therapeutic diet. The resident remained on hemodialysis three times a week. Her current diet remained appropriate with supplementation due to increased needs, the dietitian's plan was to monitor and follow up as needed. Interview on 10/03/22 at 3:04 P.M. with Registered Dietitian (RD) #175 revealed she provided nursing management with lists of weekly weights and missing weights every week when she visits, however, it could a struggle to obtain the weights. RD #175 stated she would ideally like more intake documentation, she revealed if there was half a month of intake documentation, she could get an idea of their intake patterns. Review of the policy titled Weight Assessment and Intervention dated September 2008, revealed after admission weights, weights were to be obtained monthly thereafter. Weights were to be recorded in the individuals medical record. 7. Review of the medical record revealed Resident #14 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had intact cognition and received [CONDITION(S)]. Resident #14 weighed 229 pounds, had no significant weight changes, and were on a mechanically altered and therapeutic diet. Review of the plan of care dated 07/06/22 revealed Resident #14 was at risk for malnutrition and dehydration related to medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included assessing and reporting signs of [CONDITION(S)] to the physician, assisting with meals as needed, consulting with the [CONDITION(S)] dietitian as needed, educating the resident on diet and risk factors, medications as ordered, and providing diet, supplements, and weights as ordered. Review of Resident #14's weights on 09/26/22 revealed her last weight obtained was 224.3 pounds on 08/12/22. Interview on 10/03/22 at 3:04 P.M. with Registered Dietitian (RD) #175 revealed she provided nursing management with lists of weekly weights and missing weights every week when she visits, however, it could a struggle to obtain the weights. RD #175 stated she would ideally like more intake documentation, she revealed if there was half a month of intake documentation, she could get an idea of their intake patterns. Review of the policy titled Weight Assessment and Intervention dated September 2008, revealed after admission weights, weights were to be obtained monthly thereafter. Weights were to be recorded in the individuals medical record. 8. Review of the medical record for Resident #55 revealed an admitted [DATE] revealed an admitted chronic diastolic heart failure, type two diabetes mellitus, [CONDITION(S)] stage two, depression, unspecified dementia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had severely impaired cognition. Review of the plan of care dated 09/18/22 revealed Resident #55 was at risk for malnutrition and dehydration related to diagnoses, a body mass index (BMI) above 25, diuretic use, psychoactive medication use, [CONDITION(S)] on admission, a therapeutic and mechanically altered diet and as of 09/18/22 she had lost a significant amount of weight over 30 and 90 days. Review of the physician order dated 06/15/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55 weighed 148.7 pounds for 09/16/22, and 09/19/22 through 09/22/22. Resident #55 weighed 148.3 pounds for 09/23/22, 09/24/22 and 09/27/22 through 09/29/22. Daily weight was not obtained on 09/11/22, 09/12/22, 09/17/22, 09/18/22, 09/25/22, 09/26/22, and 09/30/22. Review of Resident #55's monthly weights revealed she weighed 236 pounds on 05/24/22, 202.2 pounds on 06/24/22, 171.2 pounds on 07/24/22, 144.9 pounds on 08/25/22, and 148.3 pounds on 09/24/22 which was a 26.6% loss over 90 days. Review of the dietary progress note dated 09/18/22 revealed Resident #55 weighed 148.7 pounds which was a significant weight loss over 30 and 90 days. Weight loss was attributed to diuretic treatment, variable oral intakes at times, [CONDITION(S)] and diagnoses. The dietitian recommended adding frozen nutritional supplements twice a day. Review of Resident #55's oral intakes for September 2022 revealed no intake was documented. Interview on 10/03/22 at 3:04 P.M. with Registered Dietitian (RD) #175 revealed she provided nursing management with lists of weekly weights and missing weights every week when she visits, however, it could a struggle to obtain the weights. RD #175 stated she would ideally like more intake documentation, she revealed if there was half a month of intake documentation, she could get an idea of their intake patterns. RD #175 revealed Resident #55 had significant fluid shifts. Review of the policy titled Weight Assessment and Intervention dated September 2008, revealed after admission weights, weights were to be obtained monthly thereafter. Weights were to be recorded in the individuals medical record. 9a . Review of the medical record for Resident #51 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment, dated 08/17/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no documented behaviors. The resident required limited to extensive assistance of one to two or more staff for all Activities of daily Living (ADL's). Review of the resident's weights revealed he was weighed per facility policy on admission which measured 168 pounds (lbs.), but no weight was obtained the next day per policy. Further review of the resident's weights revealed the resident was not weighted again after admission until 12 days later, 08/22/22 when he weighed 168.8 lbs. despite the facility policy stating the resident was to be weighed weekly for two weeks following admission. His third weight was 170.2 lbs. and was not obtained for 22 days after admission and 10 days from the second weight. Further review of the resident's weights revealed he was weighed again on 09/02/22 when his weight remained the same (170.2 lbs.) and again on 09/03/22 when he lost 9.6 lbs. and weighed 160.6 lbs. There was no re-weight documented per facility policy. The next and final documented weight was dated 10/01/22 when the resident lost an additional 5.6 lbs. and weighed 155 lbs. There was no re-weight per facility policy the following day. Review of the email dated 10/06/22 at 11:45 A.M. from Regional RN #165 to the Surveyor confirmed Resident #51 was missing required weights per the facility's policy. 9b. Review of the nutritional evaluation dated 08/15/22 revealed Resident #51 required a regular with mechanic soft textured diet. His weight as of 08/10/22 was 168 pounds (lbs.) and he had no known weight loss or gain. The resident had loss of liquids/solids from his mouth when eating, held food in his mouth/cheeks or residual food in his mouth after meals, and complained of difficulty or pain when swallowing. Further review of the assessment revealed the resident required assistance with eating. Review of physician orders for October 2022 identified orders dated 08/10/22 for monthly weight every shift starting on the 1st and ending on the 3rd every month, 08/17/22 for a regular diet, pureed texture, regular (thin liquids) consistency per the resident request for diet downgrade, the order was discontinued on 08/18/22 when a new order for regular diet, mechanical soft texture, regular (thin liquids) consistency was placed. Review of the progress note dated 09/06/22 at 5:46 P.M. by Dietician #999 revealed the resident had a significant weight loss of five percent over 30 days. Further review of the note revealed adding a house supplement three times per day was recommended to prevent further weight loss and compensate for intake. Review of the physician's order dated 09/08/22 revealed 240 milliliters (ml) of house supplement was ordered two times per day, to promote weight gain. Review of the physician's order dated 09/28/22 (22 days after Dietician #999's recommendation for house supplement three times per day and 20 days after the house supplement was ordered two times per day) for house supplement at bedtime for weight gain. Review of the plan of care dated 08/15/22 and revised 10/04/22 revealed the resident had the potential for alteration in nutrition and hydration related to a recent [CONDITION(S)] with L side weakness, heart disease, [CONDITION(S)], need for an altered diet, and on 10/4/22 had a significant weight loss over 30 days. Interventions included assistance with meals as needed, weights/diet/supplements per orders, and offer food alternatives/preferences. Observation and interview on 09/26/22 at 12:45 P.M. with Resident #51 revealed he needed to be handed his built-up spoon so he could eat, and his plate guard was not on his plate but was laying on his tray. Resident #51 confirmed he needed assistance with eating but was not assisted routinely, was not sure how long his food had been next to him and confirmed he like to use the plate guard. Interview on 10/04/22 at 3:05 P.M. with Resident #51's mother revealed the resident needed assistance with meals but was often left to eat independently and open his food items without help. She confirmed he had visibly lost weight. Review of the task titled, Amount Eaten for 30 days prior to 10/05/22 revealed there was only documented intake for 09/12/22 which revealed the resident ate between 26-50 percent (%) for dinner and 51-75% for breakfast and lunch. Review of the facility provided intakes for the resident revealed one additiona [TRUNCATED]

Based on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure skin assessments were completed, failed to monitor and remove sutures timely and as ordered, failed to initiate wound care and failed to arrange transportation for a follow up appointment. This affected seven residents (Residents #13, #52, #233, and #246) of 29 residents reviewed during the annual survey. The facility census was 84. Actual harm occurred to Resident #52 when the facility failed to assess the resident's skin and Resident #52 developed two new vascular wounds to his feet resulting in the resident experiencing pain and additional medical treatment. Findings include: 1. Record review for Resident #52 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/17/22, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 08. This resident was assessed to require extensive assistance from one staff member for bed mobility, to be dependent upon two staff members for transfers, and to be dependent upon one staff member for eating, toileting, and bathing. Review of the care plan, most recently revised on 08/11/21, revealed this resident was at risk for impaired skin integrity. Interventions included skin assessments as ordered. Review of the care plan, most recently revised on 06/09/22, revealed this resident had actual impairment to skin integrity related to gangrenous ulcer to left great toe. Interventions included provide wound treatment as ordered, skin assessments per facility policy, and complete skin documentation per facility policy. Review of the physicians order, dated 06/27/22, revealed apply Triad cream to end of the left great toe to protect/continue to debride site of eschar/slough, apply every three days. Review of the physicians order, dated 09/12/22, revealed skin assessment to be completed every Wednesday. Please fill out weekly skin assessment in evaluation tab. Review of facility Skin Assessment Weekly evaluations, located in the evaluation tab of the resident's electronic health record, revealed there had not been a Skin Assessment evaluation completed since 08/10/22. Review of the active physician's order, dated 10/03/22, revealed to apply skin prep to bilateral toes every shift for vascular wound. Review of the active physician's order, dated 10/03/22, revealed to cleanse area to left lateral foot with normal saline, apply calcium alginate to wound bed, and apply clean foam dressing every three days for vascular wound. Review of the facility Skin Grid Non-Pressure evaluation, dated 10/03/22, revealed there was a new wound to the posterior right great toe which measured 3.0 centimeters (cm) wide by 1.5 cm long by 0 cm deep and was documented to be reddish dark maroon in color. Review of the facility Skin Grid Non-Pressure evaluation, dated 10/03/22, revealed there was a new vascular wound to the lateral side of the residents left foot which measured 1.5 cm long by 2.5 cm wide by 0.3 cm deep which had a moderate amount of drainage, exposed bone, and macerated edges. Review of the progress notes, dated 08/10/22 through 10/02/22, revealed there was no documentation of new wounds to the resident's feet. Observation on 10/03/22 at 11:00 A.M. of Resident #52 revealed the resident had a dark area of skin located on the bottom of the right great toe. The resident had a bandage to the left great toe which was observed to be dry and intact and there was a wound to the lateral side of the resident's left foot which was covered with brown drainage. There was a moderate amount of brown drainage observed to be on the pillow located under the left foot of Resident #52 and on the prevalon boot which had been applied to the resident's left foot. The resident was observed to grimace and moan when State tested Nursing Assistant (STNA) #201 maneuvered the resident's feet. Interview with STNA #201 on 10/03/22 at 11:00 A.M. verified Resident #52 was observed to exhibit signs of pain when the resident's feet were moved or handled. Interview with Licensed Practical Nurse (LPN) #100 on 10/03/22 at 11:05 A.M. revealed the employee denied knowledge of any wounds present on Resident #52's feet. LPN #100 stated there was not always time to complete weekly skin assessments for all residents. Observation and interview with Regional Director of Clinical Services #165 on 10/03/22 at 11:20 A.M. verified there were wounds present to the lateral side of the left foot and bottom of the right great toe of Resident #52. Interview with Regional Director of Clinical Services #165 on 10/03/22 at 11:35 A.M. verified there was no evidence weekly skin assessments were completed and documented in the resident's electronic medical record as ordered since 08/10/22. 2. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had intact cognition. The resident required the extensive assistance of one person for bed mobility, was totally dependent on staff for transfers and bathing, and required the extensive assistance of two persons for personal hygiene. Review of the plan of care dated 09/19/22 revealed Resident #13 had an impaired skin integrity related to a Stage 3 pressure injury on his right medial thigh and a laceration on his chin. Interventions included administering medications per physician orders, air mattress to bed, monitoring laceration and removing stitches as ordered, notifying physician of deterioration of wound, observing for signs of infection, and providing wound care per physician's orders. Review of Resident #13's September and October 2022 physician's orders revealed no orders for skin treatment. Review of the progress note dated 09/17/22 at 7:37 A.M. revealed Resident #13 returned from the hospital after he received four stitches to his lower chin. Review of Resident #13's evaluations for September 2022 revealed no evidence of weekly skin assessments. Review of the skin grid non-pressure dated 09/19/22 revealed the assessment was considered in progress. Resident #13 had a skin tear on his chin obtained on 09/17/22. The area was described as being a skin tear that was sutured closed. Review of the hospital paperwork dated 09/17/22 revealed Resident #13's discharge instructions indicated his stitches would need taken out in four to five days. Interview on 09/26/22 at 12:45 P.M. with Resident #13 revealed he had skin concerns along his thighs and on his abdomen. Resident #13 called these areas boils, he stated he had them since he was admitted and revealed no treatment was in place for them. Observation on 10/04/22 at 12:10 P.M. of Resident #13 with State tested Nursing Aide (STNA) #132 revealed the area to the left and right groin, lower left and right buttocks, and right side of the abdomen were observed to have multiple areas of excoriation in which the skin was not intact. Resident #13 reported the areas were painful and had been present for a while. STNA #132 verified the observation and reported the areas had been present when Resident #13 had been moved to her hallway approximately three weeks prior. Interview on 09/27/22 at 11:49 A.M. and on 09/29/22 at 10:13 A.M. with Resident #13 revealed he had stitches to his chin, he reported they were still in place, and he did not think they were supposed to be. He was concerned about the potential of his skin healing around the stitches. Resident #13 reported due to his stitches he could not shave, and he like to be clean shaven. Observation on 09/29/22 at 10:13 A.M. of Resident #13 revealed he had a facial hair providing a thick covering of the lower half of his face. Observation of his chin revealed two to three stitches in place. Interview on 09/29/22 at 10:30 A.M. with Licensed Practical Nurse (LPN) #119 verified Resident #13's stitches were still in place and the hospital paperwork (dated 09/17/22) stated they should be removed in four to five days. Interview on 10/04/22 at 2:18 P.M. with Unit Manager LPN #120 revealed she was unaware of the area on Resident #13's abdomen. She reported he did have Moisture-Associated Skin Damage on and off, but it was hard to treat as he was often absent from the facility. Review of the policy Prevention of Pressure Ulcers and Injuries revised July 2017, revealed monitoring included evaluating, reporting, and documenting potential changes in the skin. The interventions and strategies should be reviewed for effectiveness on an ongoing basis. 3. Review of the medical record for Resident #233 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment, dated 10/03/22, revealed the assessment was in progress and did not have any categories completed outside of K (swallowing and nutritional status). Review of the plan of care dated 09/25/22 revealed the resident did not have any care plans related to pain or wound care. Interview and observation on 09/26/22 at 12:58 P.M. with Resident #233 revealed she was admitted on [DATE] and she had not had pin care or a dressing change to her right leg. There was no visible date on the dressing on her right leg. Review of physician orders for October 2022 identified an order dated 09/28/22 at 11:32 P.M. (three days after the resident's admission) for the dressing to her right leg to be changed nightly, stiches to the inside of her right ankle to be cleansed nightly with normal saline and an oil emulsion wrap placed over area, screw placed by her knee was to be cleaned with normal saline then dried, and cover the entire leg with acrylic wrap, every night shift for a dressing change. Review of the September 2022 Electronic Treatment Administration Record (E TAR) revealed the dressing was not signed off as completed until 09/29/22 (four days after the resident's admission) when the order started. Interview and observation on 10/04/22 at 11:45 A.M. with Resident #233 revealed her right leg dressing was dated 10/03/22. The resident stated she changed her own dressing since the nurses were not doing it. Supplies were observed at bedside. The resident stated the staff had only changed her dressing three times since she had been at the facility. She stated no sutures had been removed from her left leg per orders by the surgeon who also provided the order to leave her left leg wrapped until her follow up appointment which she missed on 10/03/22 due to the facility not setting up transportation. She also stated the social worker told her that she was unsure how the facility missed scheduling transportation for her follow up appointment since it was in her hospital discharge instructions. Interview on 10/04/22 at 12:07 P.M. with Human Resources (HR) #124 revealed she was scheduling appointments now that the Business Office Manager (BOM) was no longer at the facility. She confirmed the resident had a follow up appointment with her orthopedic surgeon scheduled on 10/03/22 in her discharge instructions from the hospital but she stated she had no knowledge of Resident #233 needing transportation arranged for the appointment. Interview was attempted on 10/04/22 at 12:04 P.M. and 10/06/22 at 1:05 P.M. with Registered Nurse (RN) #115 (regarding Resident #233 dressing when she worked on 10/03/22 night shift) when a voicemail was left requesting a return call at the provided number. No return contact was received. Interview on 10/04/22 at 12:10 P.M. with Office Staff #111 revealed she did not receive a form indicating the need to schedule an appointment for Resident #233. She confirmed residents often missed appointments due to lack of communication and inability to schedule transportation. She also confirmed Resident #233 had a follow up appointment with her orthopedic surgeon scheduled on 10/03/22 in her discharge instructions from the hospital that could have been scheduled well before her appointment since transportation only needed 48 hours' notice of the transportation need. Review of the email dated 10/11/22 at 2:22 P.M. from the Administrator to the Surveyor revealed Resident #233 did not have a dressing order in place for her right leg from 09/25/22 until 09/29/22 (four days) until the resident requested a dressing change since her continuity from the hospital instructed the facility to keep the dressing in placed until her follow up appointment. Review of Resident #233's After Visit Summary (from the hospital) printed on 09/25/22 at 5:21 P.M. revealed the resident had a follow up appointment scheduled on 10/03/22 where her left leg sutures would be removed. Her discharge summary revealed her left leg dressing was to remain intact until seen at her follow up appointment on 10/03/22. Further review of the summary revealed the resident's right leg had wound care instructions to change the dressing twice daily if recommended, apply [MEDICATION(S)] ointment over the incision twice daily, gently cleanse the wound one to two times per day with cool water, and use mild soap to clean around the wound. The facility provided no further information when the hospital continuity with the ordered right leg dressing order was highlighted and sent to the Administrator, Regional Director of Clinical Services #165, and Unit Manager LPN #120 on 10/11/22 at 3:25 P.M. Review of the facility policy titled, Transportation revised 10/2020 revealed inquiries concerning transportation was to be referred to the transportation designee who then was to assist the resident in obtaining transportation. Review of the facility policy titled, Wound Care revised 10/2010 revealed wound care was to be completed per orders and completed to promote wound healing. 4. Review of the medical record for Resident #246 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment, dated 10/01/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment). The resident required up to extensive assistance of one to two or more staff for all Activities of daily Living (ADL's) except eating which he required set up and supervision. Further review of the MDS confirmed the resident had a known surgical wound that he received surgical wound care for and application of non-surgical dressings. Review of the After Visit Summary for 08/24/22 through 09/24/22 revealed the resident's wound vacuum (vac) to his abdomen was removed for transport to the facility but was to be replaced. Review of the plan of care dated 09/24/22 revealed the resident had an alteration in health maintenance with no listed reasoning. Interventions included treatments per order. Review of the physician orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Electronic Treatment Administration Record (ETAR) for September and October 2022 revealed the order for the wound vac was signed off 09/26/22 (facility had not received the wound vac per proof of delivery), 09/28/22, and 09/30/22. Interview and observation on 09/26/22 at 3:07 P.M. with Resident #246 revealed his call light was turned on by himself to request his abdominal dressing to be changed. Observation of his abdominal dressing revealed it was undated and falling off. On 09/26/22 at 3:46 P.M. interview and observation with Registered Nurse (RN) #125 confirmed the resident did not have a date/time on the dressing, the dressing was falling off, and there was no order for a treatment to his abdomen prior to 09/25/22 because the staff was awaiting the delivery of the wound vac. Review of the Proof of Delivery revealed the resident's wound vac was delivered on 09/27/22 at 9:32 A.M. but review of the progress note dated 09/28/22 at 5:15 P.M. by Licensed Practical Nurse (LPN) #136 revealed the resident's wound vac was placed, over 24 hours after receiving the wound vac, by the RN on duty. Interview on 10/04/22 at 2:17 P.M. with Unit Manager LPN #120 confirmed Resident #246's wound vac was delivered on 09/27/22 at 9:32 A.M. (three days after his admission) but not placed until 09/28/22 (four days after his admission and 32 hours after receiving the wound vac) per the progress note. Review of the facility policy titled, Wound Care revised 10/2010 revealed the dressing was to be marked with initials, time, and date and was to be completed per physician orders.

Based on closed medical record review, facility staff interview and wound clinic staff interview the facility failed to comprehensively assess, provide ongoing monitoring and ensure appropriate treatment was provided for wounds caused by [CONDITION(S)] related to [CONDITION(S)] for Resident #73. Actual Harm occurred when Resident #73, who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound to the left toe and the maggots were discovered by the wound clinic at the visit on 06/23/21. There was no documentation by the facility before or after the wound clinic visit on 06/23/21 describing any new wounds to the resident's toes. The facility failed to comprehensively assess, provide ongoing monitoring and ensure appropriate treatment was provided for wounds caused by [CONDITION(S)]. This affected one resident (#73) of three residents reviewed for pressure ulcers/wounds. Findings include: Review of Resident #73's closed medical record revealed discharge notes from the hospital, prior to admission to the facility, dated 05/24/21 and signed by Medical Director #333 from the wound clinic. The plan for the resident was for Venelex (ointment used to promote wound healing) to be applied to open wounds on both the resident's legs, then restore silver to the dorsal foot, and Optilock (super absorbent dressing) to the calf and leg. The wounds were caused by [CONDITION(S)]. The resident was to be seen weekly at the wound clinic. Further review of Resident #73's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged [DATE] to the hospital. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing progress note, dated 06/11/21 revealed the resident's anterior left lower leg had [CONDITION(S)] with deflated blisters, large amount clear drainage and his anterior right lower leg had [CONDITION(S)] with deflated blisters and a large amount of clear drainage. Progress notes written by the Assistant Director of Nursing (ADON) dated 06/13/21 revealed the resident was out of the facility to the wound clinic. Another note was added on 06/13/21 by the ADON revealing a skin assessment was completed and no new findings were documented. Review of the encounter note, dated 06/16/21 written by the Nurse Practitioner (NP) #654 revealed she examined the venous ulcer wounds on the resident's bilateral lower extremities (BLE) and documented the wound bed was pink with serous drainage and the peri wound was fragile, excoriated and weeping. The NP wrote in her notes to apply Unna boots for seven days (an Unna boot is a compression dressing made by wrapping layers of gauze around the leg and foot. It is often used to protect an ulcer or open wound. The compression of the dressing helps improve blood flow in the lower leg. Compression also helps decrease swelling and pain). Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #73's Treatment Administration Record (TAR) for June 2021 revealed the Unna boot treatment was signed off as completed by LPN #765 on 06/17/21 on night shift. The skin assessment, dated 06/21/21 revealed ADON #759 observed the resident's BLE's and noted decreased [CONDITION(S)] and drainage. The progress note dated 06/23/21 at 8:00 A.M. revealed the ADON charted the resident was out of the facility at the wound clinic for an appointment. Review of the notes from the wound clinic visit on 06/23/21 at 10:22 A.M. revealed Resident #73 presented to the clinic with maggots that were removed from his left great toe wound (the Unna boot would have been in place upon arrival to the clinic from when it was applied on 06/17/21 by the facility). The notes also revealed a new order to apply [MEDICATION(S)] Ointment 2 % (antibiotic ointment) to the left great toe topically daily. The wound clinic notes from 06/23/21 also revealed an order to apply restore contact layer to bilateral anterior feet shallow areas, apply abdominal pad dressing, Kerlix, change the wound dressings twice a day, and apply a gentle ace wrap. The wound clinic notes revealed the resident's right circumferential lower leg was to have abdominal pads secured to the leg with Kerlix and the left circumferential leg was to have an ace wrap from the base of the toes to back of the knee (BLE. not too tight). The progress note dated 06/23/21 at 2:21 P.M. revealed a skin assessment was completed by the ADON, but did not reveal any new wounds. The facility physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. was written to cleanse the resident's right lower leg and left lower leg with soap and water, with the instructions to not remove the restore contact silver layer since it is completed at the wound clinic, pat dry, cover with abdominal pad dressing, wrap with Kerlix and then Coban every shift. Review of the skin and wound evaluation dated 06/27/21 revealed the resident presented with wounds on bilateral legs that were swollen and leaking moderate amount of fluid. There was no mention of any new wounds to the left or right great toe. The progress note dated 06/30/21 revealed a skin assessment was completed but there was no description of the wounds. Review of the weekly skin grid non-pressure dated 07/01/21 revealed ADON #759 documented for the right lower leg, right dorsal foot and the left lower leg orders from wound care to not remove silver dressing. Unable to obtain measurements at this time. Large amount of clear drainage leaking from leg. Review of the skin and wound evaluation dated 07/06/21 revealed it was unfinished by ADON #759. Review of the notes from Resident #73's wound care clinic visit, dated 07/07/21 at 10:15 A.M. revealed the resident was seen in the office and the orders for his BLE changed to cleanse the wounds with gentle/unscented soap, apply restore contact layer silver to all open areas of the legs (those was to be changed weekly or biweekly), apply abdominal pad and secure the dressing with Kerlix roll twice a day. The notes also stated the resident no longer needed to follow up with the clinic, but those orders were never inputted. Interview on 07/19/21 at 11:28 A.M. with MDS LPN #437 and the Administrator revealed there were no skin assessment measurements for the resident's legs or great toe by the wound nurse practitioner (NP) that rounded weekly. Weekly skin assessments were completed to determine any new skin abnormalities and continue to monitor current wounds. On 07/20/21 at 1:41 P.M. interview with Nurse Manager #989 from the wound clinic confirmed Resident #73 was seen in the office on 07/07/21 where his wound was observed, cleaned, and a new dressing was applied. She revealed when the resident came in for an appointment on 06/23/21, he came in as a new patient from the facility with maggots on his toe. On 07/20/21 at 4:00 P.M. interview with the Administrator and ADON revealed both were unaware of the maggots being found in the toe wound by the wound clinic on 06/23/21. The Administrator also revealed ADON #759 started after the maggots were found and was unable to state if the Unna boots were applied covering the toes or if the toes were open and visible. ADON #759 revealed the 07/06/21 skin assessment was not completed since she was pulled away for something else and forgot to complete the assessment but stated she did not look at the resident's toes. Interview on 07/20/21 at 5:30 P.M. with LPN #765 confirmed she applied the resident's Unna boots one time but could not recall the date or if his toes were covered or left open. On 07/21/21 at 9:01 A.M. interview with Wound Clinic Nurse Manager #989 revealed the resident came into the clinic on 06/23/21 with an Unna boot on. She specifically recalled the toe being covered with an undated, large band aide, and when the band aide was removed from the toe it revealed three fourths of his toenail was missing and maggots were present that were about the size of a half a grain of rice. She stated the maggots were so small, it was likely they just hatched. On 07/21/21 at 2:33 P.M. interview with the Administrator revealed LPN #5555 signed off the treatment to Resident #73's BLE on 07/07/21 on nights. That would have been the last dressing change prior to his most recent hospitalization . He also stated he would attempt to find a description of the wounds from the dressing change on 07/07/21 night shift. He never provided this information despite several attempts to obtain the information. On 07/22/21 at 5:30 P.M. interview with the Administrator, DON #999, the ADON, and Quality Assurance (QA) Nurse #987 revealed the facility was unaware of the great toe injury that was discovered at the wound clinic with maggots. The administrative staff also confirmed they were unsure if the right toe or the left toe was affected (since the facility order stated right great toe but the wound clinic notes stated left great toe), and no treatment was ordered for the great toe wound prior to being seen at the wound clinic. The ADON #759 revealed she started her position on 06/21/21. Resident #73's great toe wound was discovered on 06/23/21 by the wound clinic. She had only seen the nurse dress the wound after 06/23/21 and was unsure when the toe wound occurred. There was no investigation completed to determine why the wound on the toe was not identified prior to 06/23/21. This deficiency substantiates Complaint Number OH 058. This deficiency is also an example of continued non-compliance from the survey dated 06/24/21.

Based on medical record review, review of hospital records, review of the facility Change in Resident Condition-Notification and Blood Sugar Testing and Parameters policy, review of Emergency Medical Services (EMS) report, hospital records, and interviews with facility staff, the facility failed to monitor blood sugars for Resident #50 who was determined to have abnormally low blood sugars. The facility failed to monitor blood sugars and failed to properly assess or provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy on 06/11/21 at 9:40 P.M. when Resident #50 was found unresponsive with a blood sugar of 41 mg/dL (normal 100 mg/dL). Licensed Practical Nurse (LPN) #103 called emergency services following his blood sugar but did not notify the physician, assess his vitals further, or provide treatment. The resident's last blood sugar check was 96 mg/dL at breakfast, and insulin was marked as having been given. There was no evidence the resident's blood sugar was assessed at lunch or dinner when the resident received insulin. The resident required hospitalization , hospital records dated 06/11/21 revealed the resident was hypoxic and had lactic metabolic acidosis. Additional concerns were identified when the facility failed to monitor blood sugars for diabetic residents receiving insulin. This affected five (#25, #50, #53, #57, and #78) of 15 residents (#9, #10, #25, #28, #36, #41, #50, #53, #57, #58, #59, #76, #77, #78, and #79) reviewed for diabetic monitoring with insulin. Furthermore, concerns were identified that did not rise to the level of Immediate Jeopardy when the facility failed to properly monitor and apply compression stockings for Resident #45 and Resident #80, and failed to thoroughly monitor and treat Resident #18's skin impairments. This affected three residents (Resident #18, Resident #45, and Resident #80) of four residents reviewed for quality of care. On 06/17/21 at 3:59 P.M. the Administrator and Regional Quality Assurance (QA) Nurse #120 were notified Immediate Jeopardy began on 06/11/21 at 9:40 P.M. when Resident #50 was found unresponsive with a blood sugar of 41 mg/dL with no evidence the residents blood sugar had monitored since breakfast that morning. Resident #50 received insulin at breakfast, lunch, and dinner, with no recorded blood sugar monitoring for lunch and dinner. LPN #103 called emergency services following the low blood sugar, but did not notify the physician, assess vitals further, or provide treatment. Resident #50 required hospitalization and was found to be hypoxic and have lactic metabolic acidosis. The Immediate Jeopardy was removed on 06/17/21 at 8:00 P.M. when the facility implemented the following corrective actions: · On 06/17/21 at 4:10 P.M. the Regional QA Nurse #120 initiated an audit of all diabetic residents. The facility identified 23 residents with diabetes, of these, 15 residents (#9, #10, #25, #28, #36, #41, #50, #53, #57, #58, #59, #76, #77, #78, and #79) were identified as receiving insulin and having the potential to be affected. The audit included obtaining a fasting blood sugar, observing for any signs and symptoms of [CONDITION(S)] or [CONDITION(S)], observation for change in condition, documentation, ensuring an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . · On 06/17/21 at 4:20 P.M. the Regional QA Nurse #120 began obtaining fasting blood sugars for residents with diabetes. · On 06/17/21 at 4:25 P.M. a Quality Assurance and Performance Improvement (QAPI) meeting was held with the following attendees present: the Administrator, Regional QA Nurse #120, and the Medical Director. In the meeting they reviewed and approved policies for blood sugar testing and parameters and [CONDITION(S)] protocols. Additionally, verbal orders were obtained for fasting blood sugars in the morning and at night to establish a baseline for any diabetic without a current order. Verbal orders were also obtained for call parameters for blood sugars unless specifically ordered otherwise. The new call parameters indicated the physician should be notified if blood sugars were below 60 mg/dL or above 300 mg/dL. An ongoing audit will be completed by the Regional QA Nurse or designee three times weekly for four weeks and then randomly thereafter. · On 06/17/21 at 4:30 P.M. the Regional QA Nurse #120 initiated education to direct care staff (22 State tested Nursing Aides and 14 nurses) related to change in condition and notification, blood sugar testing and parameters, [CONDITION(S)], insulin administration, documentation of blood sugars, documenting meal intakes, and what to do if blood sugars were low. A plan was implemented to ensure staff not educated as of midnight on 06/17/21 would not be permitted to work until receiving education. · On 06/17/21 at 6:00 P.M. facility staff completed obtaining all diabetic residents fasting blood sugars, observations for signs and symptoms of [CONDITION(S)] or [CONDITION(S)], and assessing for change in condition. · On 06/17/21 at 8:00 P.M. the Regional QA Nurse #120 completed the audit. · On 06/21/21 from 8:12 A.M. to 8:26 A.M. interview with Licensed Practical Nurse (LPN) #101, Registered Nurse (RN) #102, and Clinical Coordinator LPN #105 revealed staff were knowledgeable of the facility policy related to blood sugar checks, insulin administration, documentation, and [CONDITION(S)]. Although the Immediate Jeopardy was removed on 06/17/21, the facility remained out of compliance as the facility was in process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident impaired cognition. The assessment revealed the resident received insulin seven out of seven days of the lookback period. Review of the care plan dated 02/25/21 revealed the resident was at risk for hypoglycemic or hyperglycemic episodes related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included monitoring blood sugars as ordered, monitoring for signs and symptoms of [CONDITION(S)], following facility procedures for hypoglycemic and hyperglycemic episodes, and providing insulin as ordered Review of the physician's order for June 2021 revealed an order dated 02/23/21 to 06/17/21 for Insulin [MEDICATION(S)] Solution Pen-injector 200 unit/mL to inject 18 units subcutaneously before meals, the order included a scheduled blood sugar check at each meal. Additional review revealed an order dated 02/23/21 to 06/17/21 for [MEDICATION(S)] KwikPen Solution 100 unit/mL to inject 42 units subcutaneously at bedtime, the order included a scheduled blood sugar check. Review of the Medication Administration Record (MAR) for June 2021 revealed at breakfast on 06/11/21 the residents blood sugar was 96 mg/dL it was indicated the resident was given insulin at that time. Further review of 06/11/21 revealed for lunch and dinner the resident's blood sugars were marked as not applicable and it was indicated that insulin was given at those times. Review of the progress note dated 06/11/21 at 9:40 P.M. revealed LPN #103 found Resident #50 unresponsive during medication pass . The resident exhibited signs of [CONDITION(S)] and it was found that his blood sugar was 41 mg/dl and his heart rate was low. The nurse called the paramedics and the resident was transported to the emergency room . The noted further indicated the family was notified. Review of the EMS report dated 06/11/21 revealed EMS was called 9:25 P.M., arrived to the resident at 9:33 P.M., and arrived to the emergency room at 9:58 P.M. Upon initial assessment the resident remained unresponsive to sternal rub and vitals were obtained, the glucose meter indicated Resident #50's blood sugar was too low to be quantified. EMS administered 100 milliliters of 10% [MEDICATION(S)] twice prior to arriving to the hospital. Review of Resident #50's hospital record dated 06/11/21 revealed the Emergency Medical Technician's (EMT) reported the resident's glucose had been 29g/dL and 10% [MEDICATION(S)] had been provided. The emergency room physician stated the resident was hypoxic was on room air at 85% and was kept on two liters of oxygen. On 06/11/21 at 1:15 P.M. the resident's [MEDICATION(S)] was critical at 5.7 mMol/L, the physician documented Resident #50's laboratory results indicated lactic metabolic acidosis. On 06/17/21 at 11:40 A.M. interview via telephone with LPN #103 revealed he found Resident #50 unresponsive around 9:40 P.M. LPN #103 revealed his shift began at 7:00 P.M. he was given report by the Director of Nursing who indicated the resident's blood sugar had been low for the resident in the morning. LPN #103 stated nothing further was said about the resident's blood sugars throughout the day. The LPN revealed he not seen the resident prior to noticing he was unresponsive. LPN #103 stated he had been working his way down the hallway for medication administration and when he went to give Resident #50's roommate his medication he noticed Resident #50 was not moving. Upon touching the resident to wake him up and LPN #103 noticed he was cold and did not respond to the touch. When LPN #103 took his blood sugar he found it to be low and he immediately tried to give the resident juice, but he was not awake and did not drink any. The LPN indicated he then had someone call the squad and stayed with the resident. LPN #103 stated he did not take any more vitals or assess the resident further and the low heart rate mentioned in his progress note was obtained by the EMT's. When prompted LPN #103 stated he thought he asked someone to get him [MEDICATION(S)] but none was given to the resident. LPN #103 stated he did not recall notifying the physician about the incident. LPN# 103 stated he was unsure why not applicable would be used to document blood sugars. On 06/17/21 at 12:38 P.M. and 1:57 P.M. interview vita telephone with the Medical Director revealed she had not been notified of Resident #50's low blood sugar and subsequent hospitalization until the next day. The Medical Director indicated if a resident was unresponsive, she would expect the facility staff to call for help, call 911, check their vitals and notify the physician. She said if it was found the resident's blood sugar was low the staff should follow the same protocol but should administer [MEDICATION(S)]. The Medical Director indicated without intervention for low blood sugars vitals could be at risk. The Medical Director stated blood sugars continue to go down and when they reach the 10's and 20's breathing can be affected and could stop entirely. The Medical Director indicated she would have given Resident #50 [MEDICATION(S)]. On 06/17/21 at 1:50 P.M. interview with Regional QA Nurse #120 revealed there was no facility protocol for [CONDITION(S)] or blood sugar testing and parameters. She stated [CONDITION(S)] should be addressed in individual resident's orders. On 06/17/21 at 2:00 P.M. and 2:05 P.M. with MDS Coordinator LPN #106 and LPN #101 revealed they were unsure why 'not applicable' would be used in the MAR's. LPN #101 revealed blood sugars should be completed as ordered and if there were something unusual or a blood sugar was unable to be obtained a progress note should be created. Review of the undated facility policy titled Status Change in Resident Condition-Notification revealed the nurse must notify the resident's attending physician for directive when there is a significant change in the resident's physical, mental, or psychosocial status. The notifications were to be made within twenty-four hours of a change occurring except in cases of medical emergencies. 2. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's admission MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the care plan dated 06/08/21 revealed it was silent of nursing services related to diabetes and insulin. Review of the physician's orders for June 2021 revealed an order dated 06/02/21 to 06/17/21 for Insulin [MEDICATION(S)] Solution 100 unit/Ml injected per sliding scale, with a scheduled blood sugar check at each meal. Review of the MAR's for Resident #57 for June 2021 revealed on 06/05/21 the record was silent for blood sugar checks and insulin administration at lunch and dinner. On 06/07/21, 06/09/21, 06/10/21, 06/12/21, 06/14/21, 06/18/21, and 06/19/21, the record was silent for blood sugar checks and insulin administration at dinner. On 06/17/21 the record was silent for blood sugar checks and insulin administration at all meals. On 06/20/21 the record was silent for blood sugar checks and insulin administration for lunch or dinner, for breakfast the blood sugar was listed as not applicable and the insulin was coded to refer to the nurse's notes Review of the progress notes dated 06/01/21 to 06/20/21 revealed no documentation related to missing blood sugars or medications. On 06/17/21, interview at 2:00 P.M. and 2:05 P.M. with MDS Coordinator LPN #106 and LPN #101 revealed they were unsure why 'not applicable' would be used in the MAR's. LPN #101 revealed blood sugars should be completed as ordered and if there were something unusual or a blood sugar was unable to be obtained a progress note should be created. Interview on 06/21/21 at 2:18 P.M. with the Regional QA Nurse #120 confirmed the missing documentation, and was unsure of the cause. 3. Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #25's admission MDS assessment dated [DATE] revealed the resident had intact cognition. Review of the care plan dated 06/01/21 revealed the resident was at risk for [CONDITION(S)] and [CONDITION(S)] related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders for May 2021 and June 2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR's for May 2021 and June 2021 revealed blood sugar checks were not completed from 05/24/21 to 06/17/21. Review of the Resident #25's medical record revealed evidence his blood sugar had been checked two times, the day of admission on 05/24/21 at 5:34 P.M. and on 06/10/21 when the resident was short of breath. On 06/17/21 at 4:55 P.M. interview with Resident #25 revealed the facility had not been checking his blood sugars before administering insulin. Resident #25 indicated the facility had checked his blood sugar a few times but he had been monitoring it himself just to be safe. Interview on 06/21/21 at 2:18 P.M. with the Regional QA Nurse #120 confirmed the missing documentation, she was unsure of the cause, but revealed the resident's blood sugars should have been monitored. 4. Review Resident #78's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating the resident was cognitively intact. Review of the plan of care dated 06/03/21 revealed it was silent of nursing services related to diabetes and insulin. Review of the physician's orders for June 2021 revealed an order dated 06/03/21 to 06/05/21 for Insulin [MEDICATION(S)] Solution 100 unit/Ml injected 20 units subcutaneously two times a day, with a scheduled blood sugar check in the morning and at night. In addition, an order dated 06/06/21 to 06/17/21 for Insulin [MEDICATION(S)] Solution 100 unit/Ml injected 10 units subcutaneously two times a day, with a scheduled blood sugar check in the morning and at night. Review of the MAR's for June 2021 revealed Insulin [MEDICATION(S)] Solution 100 unit/Ml injected 20 units was administered 06/03/21 through 06/05/21, and the medical record was silent of checking the resident's blood sugar. Further review revealed the medical record was silent of blood sugar checks when Insulin [MEDICATION(S)] Solution 100 unit/Ml injected 10 units was administered on 06/08/21 in the morning and evening, on 06/11/21 in the evening, and on 06/14/21 in the morning. On 06/20/21, the resident's morning blood sugar was not documented and the MAR indicated insulin was not given and nursing notes should be reviewed. Review of the progress notes revealed nothing related to insulin administration on 06/20/21 or blood sugars on the missing dates. On 06/17/21 at 2:10 P.M. interview with Resident #78 revealed the nursing staff did not always check his blood sugar prior to administering insulin. On 06/21/21 at 1:50 P.M. interview with LPN #101 revealed he believed the blood sugar checks were not included in Resident #78's insulin order prior to 06/05/21. Interview on 06/21/21 at 2:18 P.M. with the Regional QA Nurse #120 confirmed the missing documentation, she was unsure of the cause. Review of the policy created 06/17/21, titled Blood Sugar Testing and Parameters revealed accuchecks were to be performed according to physician's orders and recorded on the MAR. 5. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed the resident was cognitively intact. Review of the plan of care dated 10/25/18 revealed the resident was at risk for hypoglycemic and hyperglycemic episodes related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders for June 2021 revealed an order dated 03/16/21 to 06/17/21 for Insulin [MEDICATION(S)] Solution 100 unit/ml six units injected at bedtime and 10 units injected in the morning, with scheduled blood sugar checks with each instance. Further review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR's for June 2021 revealed [MEDICATION(S)] Solution 100 unit/mL two units injected one time a day was administered from 06/01/21 through 06/17/21 at 12:00 P.M. without blood sugar checks. On 06/03/21 review of Insulin [MEDICATION(S)] Solution 100 unit/ml 6 units injected at bedtime revealed blood sugars were marked as not applicable and documentation indicated insulin was given. On 06/11/21 review of the 4:00 P.M. administration of [MEDICATION(S)] Solution 100 unit/Ml 4 units revealed blood sugars were marked as not applicable and documentation indicated insulin was given. Review of the vitals revealed the resident's blood sugar was checked between 11:00 A.M. and 1:00 P.M. on 06/11/21, 06/10/21, and 06/06/21. Although blood sugar checks were completed on these dates, it could not be confirmed they were correlated with insulin administration. Review of the progress notes dated 06/01/21 to 06/17/21 revealed nothing related to the documentation of insulin administration and blood sugar checks. On 06/17/21 at 2:00 P.M. and 2:05 P.M. with MDS Coordinator LPN #106 and LPN #101 revealed they were unsure why 'not applicable' would be used in the MAR's. LPN #101 revealed blood sugars should be completed as ordered and if there were something unusual or a blood sugar was unable to be obtained a progress note should be created. Interview on 06/21/21 at 2:18 P.M. with the Regional QA Nurse #120 confirmed the missing documentation, she was unsure of the cause. 6. Review of the closed medical record for Resident #80 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set assessment completed 05/14/21 revealed the resident had a brief interview for mental status score of six, indicating severe cognitive impairment. The resident was totally dependent upon staff for personal hygiene. Review of a weekly skin assessment dated [DATE] revealed the resident was noted to have a three by two (no indication if it was centimeters, inches, etc) skin tear to the right lower leg. There was no further documentation on the skin assessment or in the nurses notes to describe the area or to indicate what caused the skin tear to the lower leg. Interview with Licensed Practical Nurse (LPN)/Clinical Coordinator #105 on 06/21/21 at 11:12 A.M. revealed the skin tear on Resident #80's right lower leg on 06/02/21 was caused from her [CONDITION(S)]-[CONDITION(S)] (blood clot) deterrent stockings (TED hose). TED hose are compression stockings that administer pressure on the lower part of the leg and feet-with the most compression occurring at the calf muscle. Review of the closed medical record for Resident #80 revealed no evidence of any physician's order for TED hose or that there was any monitoring of the use of TED hose. The care plan was silent to the use of TED hose. Interview with LPN/Clinical Coordinator #105 on 06/21/21 at 11:12 A.M. revealed Resident #80 had worn TED hose since her admission. She confirmed there was no physician's order for the use of TED hose or that any monitoring of the TED hose was done. She stated there was no way to know long the resident wore the TED hose (removed at night or left on all the time). 7. Review of the medical record for Resident #18 revealed an admitted [DATE]. Review of an admission assessment dated [DATE] and signed 06/05/21 revealed the resident had multiple wounds on his right and left lower legs. (no further descriptions or measurements). Review of a skin and wound evaluation dated 06/09/21 revealed the resident had a venous wound on the right calf measuring 6.7 centimeters (cm) long by 4.5 cm wide. Record review revealed a treatment was ordered 06/05/21 to cleanse wounds on both lower legs, apply dressing, and wrap with gauze daily. However, the treatment was discontinued on 06/17/21. There was no evidence of any further treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no further measurements or descriptions of the right lower leg wound after 06/09/21. Observations on 06/17/21 at 1:15 P.M. revealed Resident #18 to be in bed with heel protector boots on both feet that extended up the lower legs. The resident's wife was present and took off the heel protector boot from the right leg. The resident was noted to have three dime size open areas on the right lower leg that were bleeding. There was no dressing or padding covering the open wounds and there was dried, dark drainage on the inside of the protector boot where it would have touched the open areas on the right lower leg. Record review did not reveal any physician's orders for the use of heel protector boots for Resident #18. Interview with Registered Nurse #102 on 06/17/21 at 1:34 P.M. confirmed the resident had open, bleeding wounds on the right lower leg. She stated she did not know how long the wounds had been there and confirmed there was no treatment or dressing ordered for the right lower leg. Interview with LPN/Clinical Coordinator #105 on 06/21/21 at 3:15 P.M. revealed Resident #18 had scabs only on his right lower leg on 06/16/21, therefore, no treatment was continued for this leg. She confirmed there was no documentation regarding the condition of the right lower leg after 06/09/21. She confirmed heel protector boots were being used for the resident. However, there was no physician's order for the use of the boots. An undated policy titled Weekly Wound Tracking stated a weekly wound tracking form was to be completed to monitor progress from week to week. 8. The facility provided a list of residents with physician's orders for [CONDITION(S)]-[CONDITION(S)] (blood clot) deterrent stockings (TED hose). The list stated Resident #45 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #45 revealed an admitted [DATE]. The resident had a physician's order for TED hose on 23 hours a day-may remove for bathing dated 10/30/20. Review of a Minimum Data Set assessment completed 05/03/21 revealed the resident had a brief interview for mental status score of five, indicating severe cognitive impairment. It indicated the resident required extensive assistance from staff for dressing and was totally dependent upon staff for bathing. Observations on 06/17/21 at 2:00 P.M. revealed Resident #45 to be in bed without TED hose on. Interview with LPN #111 on 06/17/21 at 2:00 P.M. revealed she was a staffing agency nurse and did not know anything about TED hose for Resident #45. Interview with State tested Nursing Assistant #110 on 06/17/21 at 2:00 P.M. revealed Resident #45 had not had TED hose on at all that day but she did not know why. Observations on 06/21/21 at 8:09 A.M. revealed Resident #45 to be in bed without TED hose on. This was confirmed through interview with LPN #112 on 06/21/21 at 8:45 A.M. This deficiency substantiated Complaint Control Number OH 321 and OH 061.

Based on observations, medical record review, policy review, and staff interview, the facility failed to provide the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm for Resident #74 who developed a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on the left heel in the facility. This affected three of three residents reviewed for pressure ulcers. The facility census was 79. Findings include: 1. Review of the medical record for Resident #74 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set assessment completed 05/14/21 revealed the resident had a brief interview for mental status score of six, indicating severe cognitive impairment. It indicated the resident required extensive assistance from two staff with bed mobility and transfers. It indicated the resident had no pressure ulcers upon admission. There was no evidence of any pressure ulcer risk assessments being completed. On 05/07/21 the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/26/21 the resident was noted to have a deep tissue pressure ulcer to the left heel identified as in house acquired measuring 2.5 centimeters (cm) long by 1.7 cm wide. However, a weekly skin assessment completed on 05/29/21 did not indicate any skin issues. Resident #74 was seen by the wound nurse practitioner on 05/26/21 and was noted to have a new deep tissue injury pressure ulcer to the left heel with purple discoloration. A treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no evidence a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/02/21 a skin and wound evaluation indicated the deep tissue injury on the left heel measured 1.9 cm long by 1.6 cm wide. The resident was seen by the wound nurse practitioner on 06/02/21 for a deep tissue injury pressure ulcer to the left heel with purple discoloration. A treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no evidence a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/09/21 a skin and wound evaluation indicated the deep tissue injury on the left heel measured 3.5 cm long by 2.5 cm wide. The resident was seen by the wound nurse practitioner on 06/16/21. The left heel was noted to be a stage two pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible). The note also stated it was a clear, fluid filled blister. There were no measurements of the area after 06/09/21. There was no evidence a treatment was ordered for the left heel until 06/17/21 (the day the surveyors entered for a survey). On 06/17/21 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/21/21 pressure relieving boots were ordered for both feet as tolerated. Observations on 06/17/21 at 2:15 P.M. revealed Resident #74 to be sitting in a wheelchair in her room. The resident had on gripper socks and her feet were resting on the floor. Interview with Licensed Practical Nurse (LPN)/Clinical Coordinator #105 on 06/21/21 at 8:20 A.M. revealed Resident #74 had been wearing pressure relieving boots since the area on her heel developed. However, she had forgotten to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 06/21/21 at 8:32 A.M. revealed therapy staff to be pushing Resident #74 in a wheelchair to the therapy room. The resident did not have pressure relieving boots on. Interview with State tested Nursing Assistant #113 on 06/21/21 at 8:40 A.M. revealed she was a staffing agency nursing assistant. She stated she had gotten the resident up and dressed that morning. She stated she was not aware of the resident having any pressure ulcers and was not aware of the resident utilizing any pressure relieving boots. Interview with LPN/Clinical Coordinator #105 on 06/21/21 at 3:00 P.M. confirmed Resident #74 developed the deep tissue injury pressure ulcer in the facility on 05/26/21. She confirmed there was no evidence of weekly monitoring of the skin between 05/07/21 and 05/26/21. She confirmed that, although a treatment was recommended on 05/26/21, it was not started until 06/17/21. She confirmed the area had not been measured since 06/09/21. She confirmed there was no evidence any pressure ulcer risk assessments had been completed for this resident. She stated pressure ulcer risk assessments should be completed every week for the first four weeks and then quarterly thereafter. Observations on 06/21/21 at 12:23 P.M. and 3:40 P.M. revealed Resident #74 to be up in a wheelchair in her room. Her feet were resting on the floor with no pressure relieving boots on. Observations on 06/21/21 at 4:35 P.M. revealed Resident #74 to be in bed. Her heels were resting on the mattress. The resident did not have on any pressure relieving boots. Interview with Registered Nurse #107 on 06/22/21 at 7:10 A.M. revealed she was a staffing agency nurse and had cared for Resident #74 on the night shift that night. She was not aware of the resident having any pressure relieving boots. Observations on 06/22/21 at 7:00 A.M. revealed Resident #74 up in a wheelchair in her room. Her feet were resting on the floor with no pressure relieving boots on. On 06/22/21 at 7:10 A.M. the resident was observed trying to propel herself with her feet in the wheelchair and stated she had to use the bathroom. She had no pressure relieving boots on. Observations on 06/22/21 at 7:55 A.M. of Resident #74's left heel revealed a dark brown area measuring 4.0 cm log by 3.1 cm wide. The resident expressed pain in the heel while it was being measured by LPN #101. LPN #101 stated, at that time, that the resident should wear the pressure relieving boots at all times. He then applied the boots. He confirmed the resident did not have the boots on when in bed on 06/21/21 at 4:35 P.M. He also confirmed there was no evidence the resident had refused to wear the pressure relieving boots. Review of the undated facility policy titled Pressure Ulcer Prevention and Risk Identification revealed the licensed nurse would complete a Braden Scale risk assessment for each resident upon admission weekly times four weeks, then quarterly and with significant change thereafter. Preventative measures will be implemented based upon the resident's assessed need and risk score. The licensed nurse will perform a head to toe skin assessment upon admission and every seven days thereafter to identify any new skin areas. The licensed nurse will document findings in the electronic health record. The licensed nurse will pay close attention to surfaces of the skin that come in contact with the bed or chair, bony prominences, surfaces of the skin that come in contact with orthotic devices, and skin folds. If a new skin area is identified on this assessment or during any other type of care or service, the licensed nurse will initiate a skin grid/measurement flow record. The skin grid will be updated every seven days until the area is resolved. The physician and responsible party will be notified by the licensed nurse promptly of the newly identified skin area and a treatment will be initiated according to the physician order. 2. Review of the medical record for Resident #18 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence a pressure ulcer risk assessment was completed. An admission skin assessment on 06/04/21 stated the resident had a pressure ulcer on the left hip measuring two cm by two cm with a whole in the center with a depth of 0.4 cm. There was no evidence a treatment was obtained for the left hip pressure ulcer. On 06/09/21 a skin and wound evaluation indicated the resident had an unstageable pressure ulcer on the right hip (this was not accurate as the wound was on the resident's left hip) with slough/and or eschar present upon admission measuring 4.2 cm long by 2.8 cm wide by 2.0 cm deep. (Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed.) (Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur.) The wound evaluation dated 06/09/21 revealed there was no further description to explain if the wound had slough or eschar. Resident #18 was seen by the wound nurse practitioner on 06/16/21 and was noted to have an unstageable pressure ulcer with slough on the left hip. A daily treatment was recommended at that time. Review of a skin and wound evaluation on 06/16/21 revealed the resident had an unstageable pressure ulcer on the left hip with slough and/or eschar measuring 1.4 cm long by 0.9 cm wide. No depth was documented. No further description was provided. On 06/17/21 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The day the surveyors entered the facility for the survey). Observations on 06/17/21 at 1:15 P.M. revealed the resident was in the process of being transferred to the hospital for an elevated temperature. The resident did not return to the facility during the survey. Therefore, the surveyor was unable to observe the pressure ulcer on the left hip. Interview with LPN/Clinical Coordinator #105 on 06/21/21 at 3:15 P.M. confirmed a pressure ulcer risk assessment was not completed for Resident #18. She further confirmed that, although the skin and wound evaluation on 06/09/21 indicated slough and/or eschar, a depth was included. She stated the skin and wound evaluation on 06/16/21 did not include a depth due to the presence of slough and/or eschar. She confirmed the resident was admitted with the left hip pressure ulcer on 06/04/21 and had no evidence of any treatment provided to the area until 06/17/21. Review of the undated facility policy titled Pressure Ulcer Prevention and Risk Identification revealed the licensed nurse would complete a Braden Scale risk assessment for each resident upon admission weekly times four weeks, then quarterly and with significant change thereafter. Preventative measures will be implemented based upon the resident's assessed need and risk score. 3. Review of the closed medical record for Resident #80 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set assessment completed 05/14/21 revealed the resident had a brief interview for mental status score of 6, indicating severe cognitive impairment. It indicated the resident required extensive assistance from staff with bed mobility and toileting, was incontinent of bowel and bladder, and was totally dependent for transfers. There was no evidence of any pressure ulcer risk assessments being completed. Review of an admission skin assessment on 05/07/21 revealed it identified the resident as having a pressure ulcer on the right inner foot. (This area was classified by the wound nurse practitioner on 05/12/21 as a diabetic foot ulcer). No other pressure ulcers were noted on admission. On 05/12/21 the resident was seen by the wound nurse practitioner and moisture associated [CONDITION(S)] of bilateral buttocks was identified. There were no measurements of the areas. Moisture barrier was recommended. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/19/21 the wound nurse practitioner indicated the moisture associated [CONDITION(S)] of the bilateral buttocks was improved. There were no measurements of the areas. On 05/26/21 a skin and wound evaluation form indicated the resident now had an unstageable pressure ulcer with slough and/or eschar on the sacrum measuring 12.9 cm long by 7.6 cm wide. No depth included. There was no further description of the ulcer on the wound evaluation form to indicate if it was slough or eschar. However, review of a note from the wound nurse practitioner on 05/26/21 revealed she described the sacrum as deteriorating, but a stage two with pink tissue in the wound bed. Triad [MEDICATION(S)] cream was ordered. Interview with LPN/Clinical Coordinator #105 on 06/21/21 at 11:12 A.M. revealed she completed the skin and wound evaluation form on 05/26/21 that identified an unstageable ulcer with slough and/or eschar. She confirmed the wound nurse practitioner described the ulcer as a stage two with pink tissue on the same day. She stated that she (meaning herself) may have documented in error. Besides the cream that was ordered, there was no evidence of any changes in the treatment plan or care plan related to the decline in the resident's skin condition. Review of skin and wound evaluations on 06/02/21, Resident #80 was noted to have an unstageable pressure ulcer with slough/and or eschar on the sacrum measuring 9.2 cm long by 6.1 cm wide. No depth documented. No further description documented to indicate if it was slough or eschar. The resident was also now noted to have a deep tissue injury pressure ulcer on the right heel measuring 3.3 cm long by 2.6 cm wide. There was no further description of the area on the wound evaluation form. The resident was seen by the wound nurse practitioner on 06/02/21. She noted an unstageable pressure ulcer on the sacrum with pink tissue. She recommended to gently clean the wound and wound bed, pat dry, cover the wound bed with Santyl, and apply clean dressing daily. There was no evidence this treatment was implemented prior to the resident being discharged on [DATE]. She also noted a new deep tissue injury pressure ulcer with purple discoloration on the right heel. [MEDICATION(S)] on the wound daily was recommended. There was no evidence this treatment was implemented prior to the resident being discharged on [DATE]. Interview with LPN/Clinical Coordinator #105 on 06/21/21 at 11:12 A.M. confirmed there was no evidence of any pressure ulcer risk assessments being completed for this resident. She confirmed there were no measurements of the moisture associated [CONDITION(S)] prior to the pressure ulcer on the sacrum being identified. She confirmed there was no evidence the plan of care to prevent pressure ulcers was revised after 05/11/21. She confirmed the plan of care did not indicate any actual pressure ulcers. She confirmed the treatments recommended by the wound nurse practitioner on 06/02/21 were not implemented prior to the resident being discharged on [DATE]. Review of the undated facility policy titled Pressure Ulcer Prevention and Risk Identification revealed the licensed nurse would complete a Braden Scale risk assessment for each resident upon admission weekly times four weeks, then quarterly and with significant change thereafter. Preventative measures will be implemented based upon the resident's assessed need and risk score. This deficiency substantiated Complaint Control Number OH 321 and OH 061.

Based on observation, record review and interview the facility failed to ensure one resident (Resident #9), assessed as a high risk for falls, received adequate supervision to prevent a fall. Actual Harm occurred on 12/13/18 when staff failed to timely respond to an interior door alarm sounding and Resident #9 sustained a fall down a flight of steps resulting in a leg laceration and hospitalization . This affected one of three residents reviewed for falls. Findings include: Review of the medical record for Resident #9 revealed an original admission date of [DATE] with the latest readmission of 12/16/18. [DIAGNOSES REDACTED]. Review of the plan of care, dated 10/23/17 revealed the resident was at risk for falls due to generalized weakness, decreased strength and endurance, impaired cognition and incontinence. Interventions included to add resident to early riser list, encourage to toilet every two hours, assist of one staff for ambulation, bed stabilizers to lock bed, dycem to wheelchair, encourage the resident to sit up in his wheelchair, non-skid footwear at all times, encourage to lay down after meals, have commonly used articles within easy reach, call light within reach when in bed, new alarm placed in stair well doors, provide rest periods, assist with repositioning in wheelchair and wheelchair adjusted for height/positioning. Review of the fall risk assessment dated [DATE] revealed the resident was assessed to be at high risk for falls with a score of 11. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of four. The resident required extensive assist of one staff for transfers, bed mobility and ambulation. The MDS indicated the resident required limited assistance from one staff for locomotion on the unit. The MDS also indicated the resident had sustained one fall with an injury during the assessment period. Review of Resident #9's nursing progress notes, dated 12/13/18 at 11:50 A.M. and authored by Licensed Practical Nurse (LPN) #100 revealed the nurse noted the door alarm to the emergency exit to the stairwell sounding. The door was opened, and the resident was on the floor with his wheelchair flipped over. The resident was assessed for injuries and found to have scattered discoloration/bruising to his lower back and a laceration to his leg. The resident was subsequently transferred to the hospital for evaluation and treatment. Review of the facility fall investigation, dated 12/13/18 revealed Resident #9 was unable to explain what he was trying to do at the time of the fall. As a result of the investigation, the facility concluded the cause of the fall was the resident was attempting to take the stairs without assistance due to confusion. Following the incident, the facility implemented a wanderguard device to the resident's wheelchair and a louder secondary door alarm. Record review revealed an acute care hospital discharge summary dated, 12/15/18 which revealed the resident was admitted for pneumonia and a right lower leg laceration from a fall at the facility. A physician's orders [REDACTED]. The order indicated to cleanse area with soap and water, pat dry, cover with [MEDICATION NAME] daily. Review of the resident's comprehensive admission screener dated 12/16/18 at 1:18 A.M. by Registered Nurse (RN) #206 revealed the resident was readmitted to the facility with some right leg abrasions measuring 14.7 centimeters (cm) by 2.5 cm and 5 cm by 2.9 cm. Review of the resident's five-day MDS 3.0 assessment, dated 12/20/18, revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a BIMS score of four. The resident did not wander, required extensive assistance with transfers and supervision with locomotion on the unit. On 01/13/19 at 12:54 P.M. a phone interview was conducted with LPN #100 regarding the resident's fall on 12/13/18. The LPN revealed she was at the end of the unit in the group of rooms that were referred to as the pod. She said she had just walked out of a resident's room from administering a breathing treatment and heard a door alarming. She said she opened the door and observed Resident #9 laying at the bottom of the full flight of stairs. The LPN indicated the resident had fallen down the entire flight of stairs. She said she did not see any staff in the area when she exited the room and heard the alarm sounding. On 01/13/18 at 1:45 P.M. observation of the exit stairwell area and door that the resident had fallen in revealed an alarm sounded when the metal door with a door handle was pushed on. After 15 seconds, the door released and a secondary alarm sounded that was louder than the first alarm. On 01/13/19 at 1:51 P.M. interview with Assistant Director of Nursing (ADON) #237 revealed upon entry to the stairwell Resident #9 was observed by staff laying on the landing at the bottom of the full flight of stairs with his wheelchair halfway on him. The resident was subsequently transferred to the emergency room where he received treatment for [REDACTED]. During the interview, ADON #237 revealed Resident #9 was not safe to be in a facility stairwell due to his cognitive impairment and verified the door was kept locked but would alarm when someone attempted to open it and then would continue to alarm and release after 15 seconds of pulling on the door handle. The ADON revealed following the resident's fall, a second alarming device was applied to the door to alert staff it had been opened. Review of the facility's Fall Prevention Policy, dated 01/02/13 revealed the policy was to promote resident safety and identify measures to be taken to prevent resident falls. This deficiency substantiates Complaint Number OH 955.

Based on observation, record review and interview the facility failed to provide the necessary care/treatment and services to prevent the worsening of Resident #66's pressure ulcer. The facility also failed to ensure dressing changes were completed as ordered and implemented timely. Actual harm occurred, when Resident #66 was assessed to have a deterioration to a right heel wound and the wound became infected. The resident was placed on antibiotics for the infection. This affected one resident (Resident #66) of three residents reviewed for pressure ulcers. Findings include: A review of Resident #66's record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A review of the skin assessment, dated 10/26/15 revealed the resident developed a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer to the right heel. The area measured 1.5 centimeters (cm) in length by 1.2 cm in width and 0.1 cm in depth. A review of the physician order [REDACTED]. A review of the skin assessment completed on 01/29/16 revealed the pressure ulcer to the right heel was now documented as a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer and measured 2.7 cm in length by 3.1 cm in width with 0.2 cm in depth. There were no changes made to the treatment order at that time. Review of the Treatment Administration Record (TAR) revealed the dressing was changed on 02/01/16. The treatment was due to be changed on 02/04/16, however, there was no evidence the dressing change was completed at that time. A skin assessment, dated 02/05/16 revealed the pressure ulcer was now documented as unstageable. The ulcer was assessed to measure 2 cm in width by 2.6 cm in length with no depth. The pressure ulcer was noted to have a moderate odor. Record review revealed no culture was ordered to evaluate for possible infection related to the presence of odor at that time. Review of the narrative wound progress note revealed no indication a new dressing was applied or what dressing was applied after the wound was assessed. Review of the TAR revealed no evidence a dressing was applied on 02/05/16. Record review revealed a new order was written, 02/05/16 to cleanse the pressure ulcer with wound cleanser, apply [MEDICATION NAME]/Santyl (an antibiotic dressing) ointment and then cover with silver cell and a Allevyn dressing daily. Record review revealed the new treatment was not implemented until 02/07/16, two days after it was ordered. A skin assessment, dated 02/12/16 revealed the pressure ulcer was still documented as unstageable ulcer and measured 3.3 cm in length by 3.2 cm in width and no depth. An odor was still present on 02/12/16. A recommendation was made, per the wound nurse, to change the dressing to cleanse with wound cleanser, cover with silver cell and cover with Allevyn dressing every 3 days. Record review revealed this order was not implemented until 02/14/16, two days after the order was received. Record review revealed a physician order, dated 02/14/16 for an oral antibiotic, Keflex 500 milligrams four times per day for a heel wound infection. The medication was scheduled to be administered at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the Medication Administration Record [REDACTED].M. The resident also received the 6:00 A.M. dose. However, there was no evidence the 12:00 P.M. or 6:00 P.M. dose were administered on 02/15/16 as ordered. There was no evidence contained on the administration record or in the nursing progress notes related to why the antibiotic medication was not administered as ordered. Record review revealed the resident was transferred to the hospital on [DATE] related to a change in condition. The resident was diagnosed with [REDACTED]. Additional review of the hospital history and physical documentation, dated 02/15/16 revealed the resident's right heel was assessed. The emergency room physician indicated the heel appeared to have slight infection. Drainage from the pressure ulcer was going to be cultured and podiatry/wound nurse consultation would be made. An interview on 03/10/16 at 11:41 P.M. with Registered Nurse (RN) #600 revealed the skin assessments done on 01/29/16, 02/05/16 and 02/12/16 were completed by her and an outside wound management consultant nurse. RN #600 further revealed the dressing changes suggested on 02/05/16 and 02/12/16 were suggested by the wound care nurse and ordered by the resident's physician. RN #600 further confirmed the order written on 02/05/16 for the [MEDICATION NAME]/Santyl (antibiotic cream) had not been started until 02/07/16. The RN verified that even though the medication had to come from the pharmacy, it should not have taken two days to arrive at the facility. RN #600 further confirmed the lack of evidence of the resident's dressing change being done as ordered from 02/02/16 until 02/05/16 and was not able to recall what dressing was applied after the assessment was completed on 02/05/16. RN #600 revealed the dressing was not changed from 02/05/16 until 02/07/16. RN #600 also confirmed the resident's heel wound had deteriorated from a Stage II pressure ulcer to an unstageable pressure ulcer while the resident resided in the facility due to the presence of eschar/slough tissue covering the ulcer. RN #600 also verified the pressure ulcer deteriorated in February 2016 related to the presence of a possible wound infection and verified the resident had been ordered both topical and oral antibiotics, although no wound culture had been obtained by the facility. On 03/10/16 at 12:10 P.M., RN #600 was observed completing the dressing to Resident #66's right heel. After entering the room, RN #600 was observed to wash her hands and applied clean gloves. RN #600 removed the old dressing. RN #600 proceeded to cleanse the area to the right heel with normal saline (NS) solution. RN #600 then measured the area. The area was assessed to be 1.8 cm in length by 1.8 cm in width with no depth. RN #600 then removed her gloves and washer her hands. RN #600 applied silver alginate and covered the area with an Allevyn dressing. RN #600 then removed her gloves and washed her hands. An interview on 03/10/16 at 12:25 P.M. with RN #600 confirmed the current wound care order was to cleanse the pressure ulcer with wound cleanser and then apply silver alginate and cover with an Allevyn dressing. RN #600 confirmed she cleansed the wound with NS and not the ordered wound cleanser. RN #600 stated it was easier to use the NS to irrigate the wound bed. RN #600 was not able to find any wound cleanser on the treatment cart. This deficiency substantiates Complaint Number OH 699.

Based on record review and interview the facility failed to ensure timely and appropriate care was provided to Resident #66 following a change in condition. Harm occurred, when Resident #66, was transferred to the hospital on [DATE] at the request of family. The resident, who was noted to have an acute change in condition on 02/15/16 around breakfast time, was not transferred to the hospital until 02/15/16 at 6:09 P.M. and subsequently admitted to the hospital with [REDACTED]. This affected one resident (Resident #66) of three residents reviewed for care and services provided. Findings include: A review of Resident #66's record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Record review revealed the resident did not utilize oxygen. Record review revealed the resident was seen by the nurse practitioner on 02/10/16. The assessment note revealed the resident's lung sounds were diminished at that time with abnormal sounds, crackles noted. No new orders or treatment was provided at that time. Review of nursing progress notes between 02/10/16 and 02/15/16 revealed no information related to the resident's lung sounds or respiratory status. A review of the nursing progress notes revealed a note dated 02/15/16 at 7:54 A.M. that indicated Registered Nurse (RN) #22 checked the residents blood sugar which was 145(normal range is 70-130). The next nurse's notes on this date, dated 02/15/16 at 12:05 P.M. revealed RN #22 checked the residents blood sugar again and it was 88. The next entry in the nurse's progress note was dated 02/15/16 at 3:17 P.M. and written by RN #22. The note indicated Resident #66 was refusing assistance out of bed for activities and the resident was difficult to arouse. The resident had a non-productive cough, elevated temperature at 101.8, was refusing A.M. meds and meal. The note indicated the resident was usually dressed and attended daily activities of choice. Nurse will give Tylenol at this time. Will obtain chest x-ray (two view) and urinalysis with culture stat as ordered from primary care physician. The note also indicated, will review labs (routine lab work) that had been drawn earlier this AM. Will continue to offer fluids and update family. Vital signs documented at that time included pulse 74, oxygen saturation 91%, blood pressure 129/74 and respirations 18. Review of the above nursing progress note revealed no comprehensive assessment of the resident's lung/breath sounds were completed or of the resident's urine based on the recommendation for a chest x-ray and urine culture. Additionally, review of the Medication Administration Record [REDACTED].M. medications as they were all signed that they had been administered. The next nursing progress note, dated 02/15/16 at 4:04 P.M., also written by RN #22 revealed the resident's oxygen level was 98% on two liters of oxygen via a nasal cannula. The note indicated the resident received a [MEDICATION NAME] aerosol (aerosol treatment used for shortness of breath) treatment, one time. The note also indicated the x-ray was not done correctly on the first attempt and x-ray company was contacted to come back to the facility to complete what was ordered. Review of the above nursing progress note revealed no comprehensive assessment of the resident's lung/breath sounds were completed based on the recommendation for a chest x-ray and need for the [MEDICATION NAME] aerosol. Additionally, there was no evidence the urine specimen had been obtained as ordered. Review of the Medication Administration Record [REDACTED]. The next nursing progress note, dated 02/15/16 at 4:54 P.M. written by RN #22 revealed the resident's blood sugar was 108. The next nursing progress note, dated 02/15/16 at 7:05 P.M. written by RN #22 revealed Resident #66's chest x-ray showed right basilar airspace disease consistent with pneumonia. The note further stated the resident's family was in the facility visiting and requested the resident be sent out to the hospital for evaluation. Record review revealed there was no evidence noted in the nursing progress note related to what time the resident actually left the facility or what her condition was at the time she left. Record review revealed the resident was admitted to the hospital with [REDACTED]. Review of hospital documentation revealed information provided by the daughter revealed the resident had a cough for approximately the past week. The resident had a fever, loss of appetite, slight shortness of breath and her oxygen level was 70% on room air. The resident remained hospitalized until 02/19/16, at which time she was readmitted to the facility. Review of emergency medical system (EMS) documentation revealed emergency responders were dispatched to the facility on [DATE] at 5:16 P.M. and arrived onsite at 5:34 P.M. Upon assessment, the resident's oxygen level was 76% on two liters of oxygen. Emergency responders applied oxygen at ten liters via a non-rebreather mask. The resident was assessed to mumble/groan with care. Her skin was assessed to be hot and dry, her sheets drenched despite her skin being dry. The resident's extremities were flaccid and her breathing shallow. The resident left the faciity on [DATE] at 6:09 P.M. via EMS. Additional record review revealed a written physician telephone order, dated 02/16/16 to transport the resident to the emergency room for an evaluation and an order dated 02/21/16 for a [MEDICATION NAME] treatment one time and supplemental oxygen at 2 liters nasal cannula. The telephone order did not included a signature of the nurse who obtained the order or the date/time it was obtained. Record review revealed both of these orders were written after the resident left the facility with EMS on 02/15/16. On 03/10/16 at 12:30 P.M. interview with the resident's daughter revealed she received a call from RN #22 during the afternoon (unable to recall exact time) of 02/15/15 to let her know there had been a change in her mother's condition. The daughter indicated she told the nurse that she would be over to the facility after work. The daughter indicated she arrived to the facility around 4:00 P.M. and was extremely concerned related to the condition she found her mother. The daughter stated the resident was very lethargic, could not be aroused, her tongue was sticking out and her eyes were rolled back in her head. The resident's daughter expressed concern that she felt care had not been provided timely to the resident related to her current condition. The daughter stated she insisted the resident be sent to the hospital, at which time per her request, the ambulance was called. The daughter indicated the resident was subsequently admitted to the hospital with [REDACTED]. An interview on 03/10/16 at 2:03 P.M. with RN #22 revealed he was assigned to care for Resident #66 on 02/15/16 and had previously provided care to the resident so he was familiar with her care needs routine. RN #22 stated on 02/15/16, the State tested nursing assistants (STNAs) had reported to him that the resident did not want to get out bed on 02/15/16 for breakfast. RN #22 stated he told staff to just leave the resident in bed as it was normal for some residents to not want to get up in the morning. RN #22 stated at lunch time the STNA notified him that the resident, was still in bed and did not eat much. RN #22 stated he went to Resident #66's room to check on her and check her vital signs. RN #22 stated he recalled the resident's oxygen saturation was low at 88% (normal range is 90% to 100), he placed oxygen on the resident with a nasal cannula and the resident felt warm. RN #22 stated he left the room and called the doctor and received an order for [REDACTED].#22 stated he recalled this all occurring around 12:00 P.M., but verified he did not document any of this at the actual time it had occurred. RN #22 stated he recalled calling the x-ray company at 12:22 P.M. to come to the facility and perform the two view chest x-ray. RN #22 stated he recalled at 2:22 P.M. having to call the x-ray company back to have them come back to the facility to perform the correct x-ray ordered as the company had only completed a single view chest x-ray the first time and not a two view. RN #22 stated he recalled he called the resident's daughter around noon and then again at 3:00 P.M. and left a message. Again, RN #22 verified the above timeline, including notification of the resident's daughter was not documented at the time it occurred. RN #22 also verified the lack of evidence a comprehensive assessment, including an assessment of the resident's lung sounds and urine were completed. Continued interview with RN #22 revealed he recalled it was around 5:30 P.M. or 6:00 P.M., Resident #66's daughter was at the bedside and was requesting the resident be sent to the hospital. RN #22 stated he called for transport after the daughter requested the resident be sent out to the hospital for evaluation. During the interview, RN #22 confirmed that the Tylenol, [MEDICATION NAME] and oxygen provided to Resident #66 were not documented and the RN was not able to produce documentation to support the medications and oxygen were administered. RN #22 further confirmed that the nursing progress notes were not documented at the times the events occurred and also verified the notes did not reflect the incidents as he recalled them during the interview. RN #22 stated he remembered assessing the resident when he came on shift the morning of 02/15/16 but did not document any of his assessment. RN #22 confirmed the nurse's notes were not documented at the actual time of completion and that the physician order [REDACTED]. An interview on 03/10/16 at 2:38 P.M. with RN #600 revealed she was the nursing unit manager. RN #600 indicated she was doing rounds on 02/15/16 around 12:00 P.M. and RN #22 asked her to obtain urine from Resident #66 because she was acting funny. RN #600 stated she went to the resident's room, saw she was different, checked the resident's oxygen saturation and it was 77% on room air. RN #600 stated she applied oxygen on the resident at two liters via nasal cannula. RN #600 stated she notified RN #22 of the resident's low oxygen saturation and RN #22 was going to call the doctor. RN #600 stated RN #22 notified the doctor and obtained an order for [REDACTED].#600 further stated the x-ray company was already in the building and completed the chest x-ray at her request. RN #600 stated when she obtained Resident #66's oxygen saturation she listened to Resident #66's lungs and they were diminished (less air moving through the lungs). RN #600 indicated she did not document any of her assessment or care provided by her to Resident #66 in the resident's medical record. RN #600 indicated she performed a straight catheterization (procedure to obtain urine from the bladder) to obtain urine and the urine sample was given to RN #22 to send to the lab. RN #600 indicated she then left the residents room (time unknown). RN #600 stated she only worked until 3:30 P.M. or 4:00 P.M. that day and had no more contact with Resident #66 after the above interaction that she recalled during this interview. RN #600 confirmed that the assessment she performed should have been documented in Resident #66's record. On 03/10/16 at 2:38 P.M. during the interview with RN #600, the RN verified she was aware Resident #66's oxygen level was low, in the 70's when she went in to see the resident around noon. There was no evidence she assisted RN #22 in ensuring the resident received timely and appropriate care and services throughout the course of 02/15/16. RN #600 verified their was no documentation of the administration of Tylenol, [MEDICATION NAME] or oxygen on the administration record for the resident. Following this incident, the resident's daughter requested to meet with administrative staff. The daughter indicated she felt the staff were neglectful in the care provided to Resident #66 on 02/15/16 which resulted in a decline in her condition, and subsequent four day hospitalization for treatment of [REDACTED]. On 02/17/16 the facility met with the resident's daughter and initiated an investigation. However, the investigation failed to identify the lack of comprehensive evidence to ensure the care provided to Resident #66 was provided timely and to meet the needs of the resident. The investigation did not identify orders written, were not written at the time they occurred, administration records were not completed to reflect the medications provided and nursing staff who provided care did not document the status of the resident or care provided at the time it actually occurred thus resulting in information obtained by the surveyor on 03/10/16 being obtained as a result of the recollection of RN #22 and RN #600. This deficiency substantiates Complaint Number OH 699.

Based on observation, medical record review, review of staffing schedules, resident, family, and staff interviews, the facility failed to provide sufficient and adequate licensed nursing and direct care staff to ensure all residents received the necessary care and services to attain their highest level of well-being. This lack of sufficient and adequate staff resulted in medications not being administered according to physician orders [REDACTED]. This resulted in Immediate Jeopardy when the facility identified a total of fifteen residents with 26 in-house acquired pressure ulcers (Residents #1, #7, #17, #30, #37, #38, #43, #45, #46, #51, #57, #66, #67, #69, #79,) and 35 residents at risk for pressure ulcers residing in the facility. Additionally, the facility failed to administer medications as prescribed by a physician for eight (#8, #11, #23, #35, #37, #38, #39 and #58) residents. The facility identified all 90 residents residing in the facility receiving medications administered by facility staff. The Administrator and Director of Nursing (DON) #78 were notified on 10/05/15 at 11:35 A.M. the Immediate Jeopardy began on 09/08/15 when Resident #37 was assessed to have an in-facility acquired unstageable pressure ulcer to the right heel. Review of the treatment administration record (TAR) revealed the treatments to the right heel were not completed as the physician ordered. Observations revealed pressure relieving interventions were not in place and the unstageable pressure ulcer had increased in size. On 09/23/15 the facility received information from the emergency room that Resident #200 was found to have multiple pressure ulcers that the facility had not previously identified. A whole house skin sweep was completed on 09/24/15 and 09/25/15. The facility identified a total of 15 residents (#1, #7, #17, #30, #37, #38, #43, #45, #46, #51, #57, #66, #67, #69 and #79) with in-house acquired pressure ulcers. The Immediate Jeopardy continued on 10/01/15 when three residents (#8, #23 and #37) did not receive as needed pain medications in a timely manner after the residents ' request which resulted in the residents suffering uncontrolled pain. Furthermore, on 10/01/15 during medication administration observation, three residents (#8, #35 and #58) were observed receiving their physician ordered medications two to three hours late and two residents (#38 and #39) did not receive any scheduled physician ordered medications on the 7:00 A.M. to 7:00 P.M. shift due to lack of experienced staff as well as knowledge related to responsibility. The Immediate Jeopardy was removed on 10/14/15 when the facility hired an interim Director of Nursing and when the facility implemented the following corrective actions: · On 10/01/15, the corporate area recruiter met with a State-tested Nursing Aide (STNA) class and two new DON candidates were screened. · On 10/01/15, training was completed for all nurses on skin and wound management policies and procedures and skin and bath sheets by Licensed Practical Nurse (LPN) #83 and LPN #84. Any nursing staff who were not able to complete the training, will not return to work until training is completed. · On 10/02/15, two nurses and one STNA was hired and scheduled to begin orientation on 10/06/15. · On 10/02/15, the Registered Nurse Wound Certified (RNWC) initiated nurse education related to wound management program, quick reference guide, staging, identification and treatment. All nurses currently providing treatments had 1:1 training and on 10/05/15, all nurses were made aware of where to locate policy and procedures and quick reference guides. This will be continued by the DON/Designee regarding staging of pressure, completion of braden assessments, and interventions to put in place. Any nursing staff who were not able to complete the training, will not return to work until training is completed. · On 10/05/15, training was completed by Registered Nurse (RN) #79, RN #80, RN #81, and RN #82 for All STNA ' s on urinary catheter care, turning and positioning, and skin and bath sheets. Any STNA ' s who were not able to complete training, will not return to work until training is completed. · On 10/05/15, a recruitment meeting was held with the Vice President of Human Resources (VPHR), Area Recruiter (AR), the Director of Recruiting (DR) and Vice President of Operations (VPO) to implement a recruiting strategy to include employee referral bonus, identifying community networks, direct mailings and readjusting the current open interview schedule. A hiring fair was scheduled for October 21, 2015 to be held at the facility. · On 10/06/15 and 10/07/15, additional in-servicing was provided to licensed nurses regarding the policies and procedures for timely and safe administration of medications without medication errors by the DON and designee. Any nursing staff who were not able to complete the training, will not return to work until training is completed. · On 10/06/15, additional in-services was provided for licensed nurse on ordering and receiving controlled medications and pain management program by the Vice President of Health Care and Interim DON. Any nursing staff who were not able to complete the training, will not return to work until training is completed. · On 10/06/15, six staff development coordinator Nurse Candidates were screened by recruiters; one Registered Nurse (RN) unit manager for the first floor was offered and accepted the position with orientation to begin 10/13/15. Ten new nurse applications were received and screened. · On 10/06/15, an interim DON was brought in from a sister center who was familiar with the facility ' s policies and procedures. · On 10/07/15, a second floor unit manager was hired with training projected to begin on 10/18/15. · On 10/08/15, open interviews occurred with several candidates interviewed. Open interviews were scheduled to occur twice weekly beginning 10/14/15 and 10/15/15 and would be held for four hours each Wednesday morning and Thursday afternoon, and are scheduled to continue until open positions are filled. · On 10/09/15, Staff scheduler reviewed and revised nursing department schedules. · On 10/09/15, Revision of monitoring process to have additional supervision on the 3:00 P.M. to 7:00 A.M. shift. There will be one additional nurse in the facility from 7:00 A.M. until 11:00 P.M. daily. The additional nurse will be interviewing staff to ensure that the education is effective and determine if additional education is necessary. Education will be provided on the spot as necessary. · On 10/10/15, Staffing offers were extended and accepted for a full time (FT) Licensed Practical Nurse (LPN) one FT State-tested Nurse Aide (STNA) and one as needed STNA. · On 10/11/15, Staffing interview completed and job offer extended to a fulltime administrative assistant. · On 10/12/15, Facility held a recruiting meeting with the VPHR, AR, DR, VPO, and Licensed Nursing Home Administrator (LNHA). · On 10/12/15, staffing offers included two LPN ' s who accepted employment. · On 10/13/15, Life Enrichment Director and RN unit manager scheduled to begin orientation. · On 10/13/15, four interim unit managers (LPN #45, RN #78, RN #79, and RN #80) were implemented to provide oversight until the two new unit managers have completed orientation. · On 10/13/15, Two DON interviews are scheduled with the LNHA. · On 10/14/15, additional nurse monitors will be in place for four weeks, seven days a week and they will additional assist with training the night shift nurses on supervisory skills and expectations. Nurse Managers will continue to perform monitoring on off shifts. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy), as the facility still needs to hire a Director of Nursing, three floor nurses, and eight STNAs. The Staff Development Coordinator will start the week of November 8, 2015. Findings include: 1. Medical records review revealed Residents #1, #7, #17, #30, #37, #38, #43, #45, #46, #51, #57, #66, #67, #69 and #79 were identified with in-house acquired pressure ulcers. There were a total of 26 in-house pressure ulcers identified including the following: 1) Seven unstageable pressure ulcers (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore category/stage, cannot be determined); 2) Five deep tissue injuries (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear); 3) One Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar maybe present on some parts of the wound bed. Often include undermining and tunneling); 4) Two Stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat maybe visible but bone, tendon, or muscle is not exposed. Slough maybe present but does not obscure the depth of tissue loss); 5) Ten Stage II pressure ulcers (Partial thickness loss of dermis presenting a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister); and 6) One Stage I pressure ulcer (Intact skin with non-blanchable redness of a localized area usually over a bony prominence). Observations on 10/01/15 through 10/04/15 revealed staff were not providing treatments as ordered and were not ensuring pressure relieving interventions were in place including but not limited to turning and repositioning for Residents #1, #37, #38, #45, #46, #57 and #67. On 10/01/15 at 1:40 P.M., interview with the Administrator and DON #78 revealed the former DON resigned on 09/22/15 and was relieved of her duties the same day. On 09/23/15 after speaking to the hospital ER, the Administrator received the paperwork identifying Resident #200 had multiple areas of pressure ulcers which the facility had not identified prior to the hospitalization . The Administrator stated this prompted them to complete a skin assessment on all the residents in the facility on 09/23/15 and 09/24/15. During the sweep, they identified nine residents with 17 newly identified in-house acquired pressure ulcers. The facility identified 15 residents with in-house acquired pressure ulcers involving a total of 26 areas. The Administrator stated currently they needed to hire a Director of Nursing, a Staff Development Coordinator, two unit managers, three floor nurses, and eight State tested Nurse aides (STNAs). She further stated they have a high turnover staffing rate and they are using agency nursing staff at this time. Interview on 10/02/15 at 2:00 P.M. with LPN #65 revealed he was unaware if Resident #57 had an open area to the coccyx. LPN #65 stated he did not know as he was new and had only been at the facility for one week. LPN #65 stated he did not receive any information during shift change regarding Resident #57 ' s pressure ulcer nor was there any information about the pressure ulcers on his assignment sheet. When questioned about how he was providing Resident #57 ' s care since 7:00 A.M., including monitoring her care if he was unaware of her pressure ulcers, LPN #65 stated he was unsure. LPN #65 also stated he was unsure if he was the nurse responsible for Resident #37 and #38. Interview with LPN #48 on 10/02/15 at 4:00 P.M. revealed she was unaware if she was the nurse for Resident #37 and #38. Review of the staffing schedules for 10/02/15 revealed nine of the 35 nursing staff were agency nursing staff including five nurses and four STNA ' s. Review of the staffing schedules on 10/03/15 revealed nine of the 30 nursing staff were agency staff which included five nurses and four STNA ' s. Review of the staffing schedules on 10/04/15 revealed nine of 35 nursing staff were agency nursing staff including five nurses and four STNA ' s. Interview with RN #60 on 10/03/15 at 1:24 P.M. revealed he felt there has been so much agency nursing staff working in the facility that the agency staff was not aware if the residents that had pressure ulcers were new or old and agency staff were failing to notify the facility nurse or start treatments to the pressure ulcers. Interview with STNA #49 on 10/04/15 at 11:35 A.M. verified Residents #37 and #38 were on her assignment and she had not provided any morning care including turning and repositioning and toileting until 10:35 A.M. for Resident #38 and 10:58 A.M. for Resident #37. The STNA stated she went into the resident ' s room at the beginning of her shift around 7:00 A.M. but did not provide care. The STNA said she had to get other residents on her assignment dressed, to the dining room, and feed the residents their breakfast on her assignment before she would be able to provide care to Residents #37 and #38. STNA #49 stated the next time she planned to turn and reposition the two residents was at 1:30 P.M. Interview on 10/06/15 at 8:30 A.M. with LPN #45 revealed agency staff were supposed to come into the facility 30 minutes prior to the start of their shift to get their name badges and to be in-serviced on the computer system. LPN #45 stated agency staff do not always come in early as they are supposed to and verified that is the only training they receive as there is no formal orientation process. Interview on 10/07/15 at 8:45 A.M. with Vice President of Operations (VPO) #72 revealed agency staff didn't get orientation to amount to anything. She stated our main problem is agency nursing and we need to hire and concentrate on the nurses. VPO #72 also stated addressing staffing issues with the STNAs would be a long term solution. Interview on 10/07/15 at 11:15 A.M. with LPN #74 revealed she was an agency nurse and she didn ' t really know the patients she was providing care for including whether or not they had any pressure ulcers. 2. Review of Resident #23 ' s medical record revealed the resident requested physician ordered pain medication on 09/29/15 upon arrival to the facility and was not administered the medication, [MEDICATION NAME] 5-325 milligrams (mg) by mouth until 09/30/15 at 10:33 A.M., twelve hours after requested. The resident rated his pain as nine out of 10, with 0 being no pain and 10 being the worst possible, unbearable, excruciating pain. The resident was also not assessed for pain after verbalizing the need for the medication. Two additional residents (#8 and #37) were identified as not receiving as needed pain medications when Resident #37 was observed crying, moaning and grimacing and did not receive any pain medication for three hours after being reported to the staff nurse two times. Resident #8 was observed on 10/02/15 requesting an as needed pain medication from the staff nurse and received no pain medication on 10/02/15 when requested. Observations of three residents (#8, #35 and #58) on 10/01/15 during medication administration revealed the residents received their physician ordered medications one hour and forty minutes to three hours late and three residents (#37, #38 and #39) did not receive any scheduled physician ordered medications on the 7:00 A.M. to 7:00 P.M. shift. Interviews with Residents #8, #23 and #48 on 10/01/15 from 9:00 A.M. through 10:00 A.M. revealed they felt there was not adequate nursing staff to provide care to the residents. Resident #8 stated he had waited up to forty minutes for his call light to be answered. Resident #23 stated when he was admitted to the facility he did not see any staff member until two hours and eight minutes after he arrived in the facility from the hospital. Resident #23 also stated that it took six hours to meet his assigned nurse after arriving in the facility. Interview with a friend of Resident #122 on 10/01/15 at 10:20 A.M. revealed his medications come late all the time. The friend stated there was not adequate staffing at the facility and he often feels the resident has to wait too long to receive care. Interview with the Administrator and DON on 10/01/15 at 1:40 P.M. revealed they need to hire a Director of Nursing, Staff Development Coordinator, two unit managers, three floor nurses, and eight STNAs. She further stated they have a high turnover staffing rate and are using agency nursing staff at this time. Interview with LPN #48 on 10/02/15 at 4:00 P.M. revealed she was not aware she had Residents #37, #38 and #39 as part of her assignment. She stated she was a home health nurse that worked for the company but had never worked in the facility before today. RN #67 was standing by the medication cart at the time and stated to the nurse, does this mean these residents have not received any medications today? She stated she had not given them medications because she was unaware they were on her assignment. LPN #48 verified Residents #37, #38 and #39 had not received any medications for the day. Interview with RN #73, who was an agency nurse, on 10/03/15 at 12:23 P.M. revealed she was running behind with medication pass because she had to be educated on their computer system. Interview on 10/07/15 at 8:45 A.M. with VPO #72 revealed agency staff didn't get orientation to amount to anything. She stated our main problem is agency nursing and we need to hire and concentrate on the nurses VPO #72 also stated addressing the staffing issue with the STNA ' s would be a long term solution. Review of Resident Council minutes revealed on 08/13/15 and 09/10/15 the residents voiced concerns about staffing, call light response time, and the need to hire more STNAs to work on the floor. This deficiency substantiates Complaint Number OH 664.

Based on observation, medical record review, staff, resident and physician interviews, facility policy review, and review of the National Pressure Ulcer Advisory Panel (NPUAP) information for pressure ulcers, the facility failed to appropriately assess, treat and consistently provide pressure reduction interventions for in facility acquired pressure ulcers for three residents (Residents #37, #1 and #46). In addition, the facility failed to complete thorough assessments of pressure ulcers for five residents (Residents #38, #45, #57, #67 and #200). This indicated a systemic failure to prevent, identify and treat pressure areas. This resulted in Immediate Jeopardy for three residents, Resident #37 who developed an unstageable pressure ulcer (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) on the right heel, with no evidence treatments were being done as ordered and no evidence pressure reduction interventions were consistently in place; Resident #1 who developed an unstageable pressure ulcer to the left and right heels that declined with no evidence treatments were being done as ordered and no evidence pressure reduction interventions were consistently in place; and, Resident #46 who developed an unstageable pressure ulcer to the left and right heels with no evidence of appropriate assessment and treatments being done as ordered or pressure reduction interventions were consistently in place. This deficienct practice affected eight of eight residents reviewed for pressure ulcers with a total of fifteen residents identified by the facility with in-house acquired pressure ulcers (Residents #1, #7, #17, #30, #37, #38, #43, #45, #46, #51, #57, #66, #67, #69, #79,). The facility census was 90. On 10/01/15 at 5:45 P.M., The Administrator and Director of Nursing (DON) #78 were notified Immediate Jeopardy existed. The Immediate Jeopardy began on 09/08/15 when Resident #37 was assessed to have an in-facility acquired unstageable pressure ulcer to the right heel. Review of the treatment administration record (TAR) revealed the treatments to the right heel were not completed as the physician ordered. Observations revealed pressure relieving interventions were not in place and the unstageable pressure ulcer had increased in size. Resident #1 was assessed to have two in-house acquired unstageable pressure ulcers on 09/24/15. Review of the TAR and observation of Resident #1 revealed the pressure ulcer treatments were not being completed as ordered by the physician and the two wounds had increased in size. Resident #46's wounds were initially assessed inaccurately, and on 09/24/15, the resident was reassessed to have two unstageable pressure ulcers to the left bottom foot and left heel. Review of Resident #46's TAR revealed the treatments were not completed as ordered and observations revealed an increase in size of the left heel wound and pressure relieving interventions were not in place. The Immediate Jeopardy was removed on 10/14/15 when the facility implemented the following corrective actions: · On 09/24/15 and 09/25/15, a full house skin sweep was completed. A progress note or skin and wound progress notes were updated to include changes to current treatments and/or new treatments. Physician orders [REDACTED]. Care plans were updated and family and physicians were notified. · On 09/24/15 and 09/25/15, during the full house skin sweep, Registered Nurse (RN) #67, RN #79, RN #50 and RN #51 evaluated positioning devices to identify residents who needed pressure ulcer reduction cushions in wheelchairs and recliners. In addition, pressure reduction devices were evaluated for residents to elevate heels and reduce pressure ulcers. · On 09/30/15 through 10/05/15 training was completed for all 34 State tested Nursing Aides (STNA) on urinary catheter care, turning and repositioning, and skin and bath sheets. This training was given by RN #79, RN#80, RN #81, and RN #82. · On 10/01/15, training was completed for all nurses except two on skin and wound management policies and procedures and skin and bath sheets. The facility was unable to contact Licensed Practical Nurses (LPN) #83 and #84 and they will not be released to work the floor until the education is completed. · On 10/01/15, daily skin and bath sheets were implemented for all STNA ' s on each shift. The daily skin and bath sheets are to be turned into the charge nurse on each shift who signs the sheet for accuracy. The sheets are then reviewed by the DON and/or designee to ensure any new areas have physician orders [REDACTED]. · On 10/03/15, a new position was added for a full time, seven days a week treatment nurse for the second floor of the facility. LPN #47 and LPN #305 were currently filling this position but the facility plan is to hire full time treatment nurses. · On 10/05/15, RN #85 who is a wound care certified nurse, initiated education related to wound management including a quick reference guide for staging a pressure ulcer, identification and treatment of [REDACTED].#85. All nurses were made aware of where to locate the policy and procedures and quick reference guides. · On 10/06/15, DON #77 completed new Braden Skin Assessments on all residents with pressure ulcers. This included Residents #1, #6, #7, #11, #28, #30, #33, #37, #38, #43, #45, #46, #51, #57, #66, #67 and #69. · On 10/06/15, RN #67 and RN #72 completed three random skin assessments for residents who had bath and shower sheets indicating they had no skin breakdown (Residents #15, #39 and #82). Random skin assessments will continue to be completed for two residents on each of the two units five days per week by the DON and/or designee. · On 10/06/15, new body pillows were added for Residents #33, #37, #38, #45, #46, #64 and #89. · On 10/06/15, RN #85 added a wedge cushion to the bed for Resident #51 for positioning. The turn and reposition schedules were changed for Residents #37, #46 and #51 to turn side to side due to the residents contractures. The turn and reposition schedule was changed for Resident #38 to back and right side only due to the resident having an amputation and [MEDICAL CONDITION] to the left side. · On 10/07/15, residents who had pressure ulcers had their care plans updated to include risk factors for developing a pressure ulcer by LPN #45. · On 10/07/15, a wound certified nurse practitioner from a local hospital was contacted by Vice President of Operations #72 for additional consultation for wound management at the facility. On 10/08/15, Wound Certified Nurse Practitioner (CNP) #86 provided the facility consultation on Residents #1 and #45. Wound CNP #86 is scheduled once weekly for six months. · On 10/05/15 through 10/07/15, therapy staff screened or evaluated residents with current pressure ulcers for appropriate positioning and pressure reduction devices. The residents that were reviewed and had recommendations for pressure relieving devices as needed were Residents #1, #6, #13, #17, #30, #38, #39, #43, #45, #46, #51, #53, #54, #57, #67, #69 and #96. Resident #11 was on the therapy schedule to be screened. · On 10/08/15, Residents #1, #4, #6, #7, #9, #10, #11, #15, #16, #17, #24, #28, #33, #36, #37, #38, #41, #42, #43, #45, #46, #51, #54, #58, #64, #65, #67, #71, #73, #78, #82, #83, #86 and #95 were identified by the facility to be at risk for skin breakdown. · On 10/08/15, DON #77 initiated education to the nurses and STNAs related to how to complete head to toe skin assessments, bath and skin reports, pressure points of the body, skin temperature and assessment of individuals with dark skin. · On 10/13/15, DON #77 evaluated and reviewed resident shower schedules to coincide with the nurses weekly skin assessments. · On 10/13/15, DON #77 provided education to all nursing staff related to ted hose placement. DON #77 will provide continued education regarding staging of pressure, completion of Braden skin assessments, and interventions put in place. · On 10/13/15, RN #85 will completed investigations of the origination of facility acquired pressure ulcers. · On 10/14/15, a monitoring tool was created by DON #77 to monitor employee education and resident monitoring to verify care is being provided. This monitoring tool will be completed by the DON and/or designee on two residents/2 employees, five times a week per unit for six weeks. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as all staff had not been in-serviced on skin and wound management and the facility was in the process of implementing weekly audits to monitor for on-going compliance. Findings include: 1. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of Resident #37's skin plan of care dated 06/30/15 revealed the resident was at a potential for alteration in skin with a goal to maintain skin integrity. Interventions included float heels off bed/mattress as needed, observe skin routinely during personal care and pressure reduction mattress on bed. Review of the most recent quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #37 had severe cognitive impairment and was assessed as being totally dependent with two person physical assistance for bed mobility and transfers. The MDS also revealed the resident was at risk for developing pressure ulcers. Review of the most recent Skin Risks assessment dated [DATE] revealed the resident was at a high risk for skin breakdown. Skin and ulcer interventions included pressure reducing device for chair and bed, turning and repositioning program, nutrition or hydration intervention, and application of non-surgical dressings. Review of the skin condition/wound progression notes revealed on 09/08/15 the resident developed an in-house acquired suspected deep tissue injury on the right heel and the right bottom of the foot. The right heel measured 6.0 centimeters (cm.) in length, 4.0 cm. wide and was described as not blanchable and no odor or drainage was apparent. The right bottom of the foot measured 3.1 cm. wide and 2.0 cm in length and was described as not blanchable and no odor or drainage was apparent. The right bottom of the foot was healed on 09/21/15. The right heel measured 1.3 cm in length and 0.5 cm wide on 09/28/15. Review of the Treatment Administration Record (TAR) revealed for September 2015 Resident #37 was to receive moon boots to bilateral lower extremities at all times. There was no documented evidence this was completed on nine days. Further review of the TAR revealed the heels were to be floated every twelve hours and there was no documented evidence this was completed on nine days in September, 2015. The September, 2015 TAR indicated Resident #37 was to receive skin prep to the right lateral foot twice a day due to a deep tissue injury and was not documented as completed twice daily on five days and one of the twice daily treatments was documented on 10 days. Review of the September, 2015 TAR revealed staff was to complete circulation and skin checks to right upper extremity and bilateral lower extremity every twelve hours and there was no documented evidence this was completed on nine days. A new skin plan of care was developed on 09/24/15 identifying Resident #37 had a new pressure area to the right heel. Interventions included to assess and document wound size, depth, color, and drainage, weekly and as needed, check and change every two hours, heel protectors on bilateral heels, perform treatment as ordered to the area, and reposition every two hours. Observation of Resident #37 on 10/04/15 at 7:48 A.M. revealed she was lying in bed on an air mattress with legs elevated and leaning towards the right side of the bed. Further observations on 10/04/15 at 8:59 A.M., 9:10 A.M., 9:25 A.M. 9:46 A.M., 10:05 A.M., 10:20 A.M., and 10:35 A.M. revealed the resident was lying in bed in the same position as observed at 7:48 A.M until 10:58 A.M. when State tested Nurse Aide (STNA) #49 began providing care to the resident. Interview with STNA #49 on 10/04/15 at 11:35 A.M. verified Resident #37 was on her assignment and she had not provided any morning care including turning and repositioning and toileting until 10:58 A.M. STNA #37 stated she went into the resident's room at the beginning of her shift around 7:00 A.M. and said hello but did not provide any care. The STNA said she had to get other residents on her assignment dressed, to the dining room and feed the residents on her assignment before she would be able to provide care to Resident #37. STNA #49 said the next time she planned to turn and reposition the resident was at 1:30 P.M. Review of Resident #37's skin condition/wound progression note dated 10/05/15 revealed the right heel had increased in measurements from the 09/28/15 measurement to 2.4 cm in length by 2.2 cm in width. Interview with LPN #45 on 10/06/15 at 10:40 A.M. verified Resident #37's September, 2015 TAR's did not have documented evidence the pressure ulcer interventions were completed as ordered. Interview on 10/15/15 at 1:40 P.M. with RN #69 verified Resident #37's right heel unstageable pressure ulcer had an increase in measurements on 10/04/15 and 10/05/15 as documented in the skin progression/wound condition note. 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's skin plan of care (POC) dated 03/29/13 revealed the resident was at risk for skin alteration with interventions including encourage the resident to turn and reposition every two hours and as needed, staff to assist as needed, pressure reducing device for chair and mattress, and skin assessment weekly and as needed. Review of the physician orders [REDACTED].#1 was to receive a weekly skin assessment every Thursday. Review of the five day MDS 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairments, required extensive one person physical assistance with bed mobility, and extensive assistance with two person physical assistance with transfers. The MDS also revealed Resident #1 was at risk for developing pressure ulcer, did not have any current pressure ulcers, had a pressure reducing device for chair and bed and was on a turning and repositioning program for skin and ulcer treatments. Review of Resident #1's Bath and Skin Report sheets completed by the STNAs during showers revealed for the month of September, 2015 there was no documented evidence bath and skin checks were completed after 09/08/15. Review of the TAR for September, 2015 revealed the skin assessments ordered to be completed weekly was only completed on 09/17/15. There was no documented evidence the skin assessments were completed weekly during the month of September. Review of the Skin Condition Report for Resident #1 revealed on 09/24/15 Resident #1 was assessed to have developed an in-facility acquired unstageable pressure ulcer to the left heel and right heel. The left heel unstageable ulcer measured 2.3 centimeters (cm.) in length, 0.8 cm. wide and unable to determine depth due to the wound being covered in slough and/or eschar. The wound was described as not blanchable, no odor or drainage was apparent, and it was covered with 95 percent (%) slough. The right heel unstageable ulcer measured 1.2 cm. in length, 1.3 cm. wide, and unable to determine depth due to the wound being covered in slough and/or eschar. The wound was described as not blanchable, no odor or drainage was apparent, and it was covered with 100% slough. Review of the TAR for Resident #1 revealed there were treatments initiated on 09/24/15 for Resident #1 to cleanse bilateral heels pressure ulcer with Dermal Wound Cleanser (DWC), apply santyl and cover with Allevyn one time per day. Further review of the TAR revealed treatments to the bilateral heels were not completed on 09/29/15 and 09/30/15 as ordered. On 09/25/15 Resident #1's new unstageable pressure ulcers to the right heel and left heel were added to the care plan. The interventions included to observe response to treatment, resident to not wear shoes, treatments to area as ordered, weekly wound updates, and for the resident to wear bilateral prevalon boots (pressure relieving heel protectors). Observation of Resident #1's wound treatment on 10/01/15 at 3:08 P.M. with LPN #305 revealed the resident had treatment dressings on her bilateral heels dated 09/28/15 which was verified by LPN #305 at the time of the observation. LPN #305 then proceeded to take off the left heel bandage and it was noted there was slight drainage on the bandage. LPN #305 measured the left heel wound at 2.3 cm. in length, 2.0 cm. wide and 0.1 cm. depth and described the left heel wound as covered in 100% slough with yellow drainage, and noted there was an odor to the wound. LPN #305 then proceeded to take off the right heel dressing and measured the wound as 1.6 cm. in length, 1.4 cm. wide, and 0.1 cm.in depth. The LPN described the right wound as covered in 100% slough, painful to touch, redness around the wound and drainage with no odor. Interview with LPN #305 on 10/01/15 at 4:00 P.M. verified the two wounds on the bilateral heels did increase in size from the previous week's measurements. LPN #305 verified the treatments were not completed on 09/29/15 and 09/30/15 as the dressings were dated 09/28/15. Interview on 10/02/15 at 1:20 P.M. with DON #78 verified the last bath and skin report sheet completed for Resident #1 in the month of September, 2015 was on 09/08/15. 3. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #46's skin plan of care dated 09/26/14 revealed the resident was at risk for alteration in skin with interventions including a pressure relieving mattress to the bed, float heels in the bed and check and change every two hours. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #46's cognition was severely impaired, the resident was total dependence with two person physical assistance with bed mobility, transferring, bathing and toileting and total dependence with one person physical assistance with personal hygiene. The MDS also revealed Resident #46 was at risk for developing pressure ulcers. The MDS indicated skin and ulcer treatments that were in place were pressure reducing device for chair and bed, turning and repositioning program, nutrition or hydration intervention, and application of non-surgical dressings. Review of the TAR for September, 2015 revealed there was an order to apply a wound treatment [MEDICATION NAME] cream one percent to the plantar and outer foot (the treatment did not specify what foot or both) then cover with [MEDICATION NAME] gauze daily. There was no documented evidence this was completed on nine days in September, 2015. This was verified with LPN #45 on 10/06/15 at 10:40 A.M. Review of the TAR for September, 2015 documented a treatment order dated 09/24/15 to the left fifth toe one time per day every three days. There was no documented evidence the treatment was completed on 09/27/15 and 09/30/15. This finding was confirmed with LPN #45 on 10/06/15 at 10:40 A.M. Review of the skin condition/wound progression note revealed the resident had a venous ulcer to the left heel acquired on 07/28/15 measuring 3.4 centimeters (cm.) in length and 3.0 cm. wide. On 09/22/15, the venous ulcer was noted to be an open lesion. On 09/24/15, the open lesion was noted to be a pressure ulcer on the left outer aspect of the fifth metatarsal (toe) that was not present upon admission measuring 2.0 cm. in length and 1.0 cm wide. The wound was described as an evolving deep tissue injury with a centralized area of black eschar measuring 1.0 cm in length and 1.0 cm. wide. On 09/28/15 the wound measured 2.0 cm. in length and 1.8 cm. wide. On 10/04/15, the wound increased further to 4.2 cm. in length and 3.2 cm. wide. Review of the skin plan of care for the deep tissue injury on the outer aspect of the fifth left metatarsal initiated 09/25/15 revealed interventions included to turn and reposition every two hours and as needed. On 10/03/15 interventions were updated to include pressure relieving boots to bilateral feet. Review of Resident #46's skin condition/wound progression note dated 10/04/15, revealed the left outer aspect of the fifth metatarsal measurements increased further to 4.2 cm. in length and 3.2 cm. wide. Review of physician orders [REDACTED]. Observation of Resident #46 on 10/01/15 at 4:14 P.M. with STNA #52 revealed the resident was lying on her left side in a geriatric (Geri) chair. Her legs were angled towards her left side arm rest and the left outer leg was lying directly against the metal arm rest with the left outer foot lying directly on the foot rest of the Geri-chair. The resident did not have pressure relieving devices including pressure relief boots in place while in the Geri-chair. Interview with STNA #52 at the time of the observations verified the resident did not have a pressure relieving device in place in the chair, her outer foot was lying directly on the footrest and the resident did not have her pressure relief boots on. The STNA was unaware if a pressure relieving device should be in place or not for the resident. Observation with LPN #47 on 10/02/15 at 3:31 P.M. revealed Resident #46 was lying in her Geri-chair in the lounge area with her heels lying directly against the foot rest without any pressure relieving devices in place. LPN #47 brought the resident to her room and began to complete dressing changes on two wounds. The LPN measured Resident #46 ' s wound on the left outer aspect of the fifth toe revealing an increase in measurements at 3.0 cm. in length and 2.5 cm wide and was described to have 50 percent (%) slough, 25% brown, and 25% granulation, moderate drainage, there was no odor and it was painful to touch. LPN #47 then measured the left heel as 0.2 cm in length and 0.2 cm wide. Interview with LPN #47 on 10/02/15 immediately following the observations verified Resident #46 ' s heels were lying directly on the foot rests of the chair without pressure relieving devices in place. Interview with LPN #45 on 10/06/15 at 10:55 A.M. verified the computerized task list for the STNAs for Resident #46 did not include to turn and reposition the resident every two hours and as needed nor did it include that the resident was to wear pressure relieving boots on both feet. LPN #45 also stated Resident #46 was not on a turn and reposition schedule prior to 09/25/15. Interview with STNA #53 on 10/06/15 at 11:00 A.M. verified his paper assignment sheet did not have any specific type of care including what type of assistance Resident #46 required, whether the resident was continent or incontinent, and any special care details including turning and repositioning or the application of pressure relief boots to the residents bilateral feet. STNA #53 said that he would turn and reposition the resident if she was in bed. STNA #53 said he doesn ' t usually turn or reposition a resident in a Geri-chair. 4. Review of Resident #45's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #45's discharge records from an acute care stay dated 08/25/15 revealed the resident was admitted to the hospital with [REDACTED]. No measurements of the Stage III pressure ulcers were documented on the hospital records. Review of Resident#45's admission observations dated 08/26/15 indicated the resident had no skin issues. Review of the Braden Scale for Predicting Pressure Sore Risk indicated the resident was at a low risk for skin breakdown as evidenced by a score of 16. Review of the resident's skin and wound documentation dated 08/26/15 indicated the resident had an open lesion to the left lower buttocks measuring 1.0 cm by 1.0 cm with a scant amount of drainage present, no description of the drainage was included in the assessment of the open lesion. Review of the resident's skin and wound documentation dated 08/28/15 at 11:09 A.M. indicated the resident had an open lesion to the left inner thigh measuring 2.0 cm by 1.5 cm with a red wound base and a scant amount of red-tinged drainage. The wound was identified as not being present upon admission. Review of the resident's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively impaired, was identified as being dependent on two for transfers and toilet use and required extensive assistance of one with bed mobility. The MDS 3.0 assessment indicated the resident had the current [DIAGNOSES REDACTED]. Slough was identified as being the most severe tissue type present to the pressure ulcers. The resident was also identified as having Moisture Associated Skin Damage (MASD). On 09/12/15, the facility classified the open lesion as Moisture Associated Skin Damage (MASD) with no measurement present. On 09/25/15, during the facility wide skin inspection, the facility classified the MASD to the left lower buttocks as a Stage II (partial thickness loss of dermis) pressure ulcer measuring 21.0 cm by 12.0 cm by 0.1 cm with no apparent drainage. The wound base was documented as having a pink wound base and 100% [MEDICATION NAME] tissue. The assessment indicated the resident had multiple open areas within the 21.0 cm by 12.0 cm measured surface. On 09/28/15 the facility documented the wound as being unchanged and measured 21.0 cm by 12.0 cm by 0.1cm. On 09/25/15 at 11:27 A.M., the facility classified an open lesion on the left inner thigh of Resident #45 as a Stage II pressure ulcer measuring 9.0 cm by 3.2 cm by 0.1 cm with a pink wound base and no drainage. The assessment identified the Stage II pressure ulcer was not present upon admission. Review of the most recent skin and wound assessment dated [DATE] indicated Resident #45 had three separate areas on the left inner thigh measuring 0.6 cm by 0.6 cm, 0.5 cm by 1.3 cm and 1.4 cm by 0.6 cm. The assessment indicated these were not present upon admission. Review of the resident's medical record failed to provide a plan of care for the resident ' s pressure ulcers to the left lower buttock, and the left and right inner thighs. On 09/25/15 at 11:29 A.M. the facility identified Resident #45 had a Stage II pressure ulcer to the right inner thigh measuring 9.9 cm by 0.8 cm by 0.1 cm with a pink wound base and no drainage. On 10/05/15 at 1:15 P.M. the Stage II pressure ulcer to the resident ' s right thigh measured 0.6 cm by 0.6 cm with a pink wound base and a scant amount of bright red drainage. Review of the resident's physician's orders [REDACTED]. Review of the September, 2015 Treatment Administration Record (TAR) revealed the 09/25/15 physician ordered treatment to cleanse the right inner thigh and the left inner thigh with wound cleanser, apply skin prep and cover with a large Allevyn was not completed on five days. On 10/02/15 at 4:20 P.M., interview with DON #78 verified Resident 45 ' s TAR did not contain the current treatment orders for the resident's left lower buttock pressure ulcer and the resident's left inner thigh pressure ulcer was not reflected. Review of the October 2015 TAR revealed the current physician's orders [REDACTED]. On 10/02/15 at 2:20 P.M. observation of Resident #45's pressure ulcers revealed the Stage II pressure ulcer to the left lower buttocks was covered with an Allevyn dated 10/02/15. Observation of the resident's right and left thighs revealed the pressure ulcers were covered with a thick white cream. Observation of the resident's positioning revealed the resident was positioned in supine position with the head of her bed elevated 45 degrees. On 10/04/15 at 8:10 A.M. observation of Resident #45 revealed the resident was positioned on her back with the head of her bed elevated, eating breakfast. On 10/04/15 at 9:15 A.M. observation of Resident #45 revealed the resident remained positioned on her back with the head of her bed elevated. On 10/04/15 at 11:00 A.M. observation of Resident #45 revealed the resident remained positioned on her back with the head of her bed elevated. On 10/04/15 at 11:40 A.M. interview with STNA #44 verified the resident had not been repositioned per the plan of care. Review of the wound and skin documentation dated 10/05/15, completed by the wound certified nurse, RN #69, indicated during the weekly skin sweep Resident #45 was found with a Suspected Deep Tissue Injury (SDTI) to the left great toe measuring 1.2 cm by 1.6 cm. The SDTI was documented to be non-blanchable. A 0.6 cm by 0.6 cm area of 100% eschar tissue was observed at the center of the wound. The facility initiated the treatment of [REDACTED]. 5. Review of Resident #67's medical record revealed an original admission date of [DATE] with a re-admission on 09/21/15 with [DIAGNOSES REDACTED]. Review of the admission/general observation form dated 06/05/15 indicated Resident #67 had no skin problems upon admission. Review of Resident #67's quarterly MDS assessment dated [DATE] indicated the resident had moderately impaired cognitive skills required extensive assistance of two staff with bed mobility, transfers and toileting. He was identified as having an indwelling catheter and was frequently incontinent of bowel. The MDS 3.0 assessment indicated the resident had no skin conditions present. Review of Resident #67's Braden Scale dated 09/29/15 revealed a score of 14 which indicates the resident was at moderate risk for skin breakdown. Review of Resident #67's skin and wound documentation dated 09/25/15 revealed the resident was assessed as having a Stage II pressure ulcer to his penis measuring 0.5 cm in length by 0.5 cm width with 0.1cm depth. The pressure ulcer was not blanchable and had thin red tinged drainage with no odor. The wound was documented as not being present upon admission, was found on 09/24/15 during a wound inspection and was located on the left aspect of the underside of the penis. On 09/25/15 the pressure ulcer was documented as being a Stage I pressure ulcer measuring 0.25 cm in length by 0.25 cm width and the skin was blanchable. On 10/01/15 at 2:50 P.M. observation of RN #50 completing

Based on medical record review, staff, resident and physician interview, review of the pain management program and review of the Controlled Drug Receipt Record and Disposition Form, the facility failed to provide adequate pain management for three residents (Resident #8, #23 and #37). This resulted in Immediate Jeopardy for Resident #23, Resident #37, and Resident #8 who were not administered pain medication in a timely manner. Resident #23 complained of pain on admission and was not administered pain medication for more than 12 hours when his pain level reached a level 10 on a scale of 1 to 10 with 10 being the worst pain. Resident #8 complained of pain, requested an as needed (prn) pain medication and did not receive the requested pain medication for more than 24 hours resulting in uncontrolled pain. Resident #37 requested and displayed non-verbal signs of pain but did not receive pain medication for three hours. This affected three of three residents reviewed for pain. The facility census was 90. The Administrator and Director of Nursing (DON) #78 were notified on 10/05/15 at 11:34 A.M. that Immediate Jeopardy began on 09/29/15 at 10:00 P.M. when Resident #23, who was assessed to be alert and oriented, requested pain medication related to pain to his knees and muscle spasms. The medication was not administered for more than 12 hours after the resident's admission which resulted in the resident experiencing unrelieved pain that he rated a 10 on a scale of one to 10 with 10 being the most severe pain. Resident #23 described the pain as excruciating and reported he did not know if he could make it through the night because of the intensity of the untreated pain. The Immediate Jeopardy continued on 10/02/15 at 10:20 A.M., when Resident #8 complained of pain, requested a prn pain medication and did not receive the requested pain medication for more than 24 hours. Resident #8 reported staff just let him lay in pain. The Immediate Jeopardy continued on 10/02/15 at 3:13 P.M. when Resident #37 grimaced and moaned in pain and requested pain medication. Resident #37 did not receive the requested pain medication for three more hours. The Immediate Jeopardy continued on 10/03/15 at 7:30 P.M. when Resident #23 experienced uncontrolled pain throughout the night and did not receive requested medications until the following day, 12 hours later. The Immediate Jeopardy was removed on 10/14/15 when the facility implemented the following corrective actions: · On 10/04/15 at 10:00 A.M., DON#78 and/or designee began monitoring, to be completed five times a week, for completion of resident pain assessments, timely administration of medication and the effectiveness of the pain medication. DON #78 and/or designee also initiated staff training to nurses including education on controlled medications and the facility's pain management program. · On 10/05/15 at 5:32 P.M., Licensed Practical Nurse (LPN) #48 reassessed Residents #8, #23, #37, #38 and #45 for pain and effectiveness of the physician ordered pain medication. · On 10/06/15 at 7:00 A.M., the facility educated four Registered Nurses and five LPNs on the facility's pain management policy and procedure and ordering controlled medications policy and procedures. Documentation of the nurses inservice was completed, however two nurses were not able to be reached for inservicing and would not be eligible to work until the education was completed. · On 10/06/15 at 4:06 P.M., LPN #48 reassessed those residents who were identified at an increased risk of pain, identified by the facility as Residents #7, #10, #47, #56 and #65. · On 10/06/15 at 4:30 P.M., five residents (Resident #8, #11, #23, #35 and #53) were interviewed by RN #67 for satisfaction of the current physician ordered pain management. · On 10/06/15 at 4:45 P.M., observations of 18 residents (Resident #4, #8, #9, #15, #37, #38, #41, #43, #45, #53, #67, #68, #73, #75, #80, #82, #92, and #98) were made by RN #67 for signs and symptoms of pain or discomfort with no concerns identified. · On 10/06/15 at 10:00 A.M., DON #78 performed a medical record review on Resident #99, who was newly admitted to the facility and Resident #97, who was readmitted to the facility to ensure an initial pain assessment was completed and the residents had valid prescription for narcotic pain medications. · On 10/07/15 at 10:00 A.M., DON #78 performed a medical record review on Resident #100, who was newly admitted to the facility and Resident #79, who was readmitted to the facility to ensure an initial pain assessment was completed and the residents had valid prescription for narcotic pain medications. · On 10/07/15 at 10:15 A.M., observations of 11 residents (Residents #4, #8, #9, #15, #37, #38, #41, #43, #45, #54, #92) were made by RN #67 for signs and symptoms of pain or discomfort. · On 10/07/15 at 4:15 P.M., seven residents (Residents #67, #68, #73, #75, #80, #82, and #98) were interviewed by RN #67 for satisfaction of the current physician ordered pain management. · On 10/12/15 at 3:00 P.M. DON #78 conducted education with four RNs and five LPNs on the new medication administration times. · On 10/13/15 at 8:00 A.M., five residents (Resident ##29, #36, #37, #43 and #82) were observed by RN #78, RN #79 and RN #80 for signs and symptoms of pain and three residents (Residents #30, #38 and #103) were interview for pain control. · On 10/14/15 at 8:00 A.M. RN #99 completed the medication times for all residents residing in the facility to reflect the newly implemented medication times. · On 10/14/15 at 2:00 P.M. RN #69 conducted a medication administration audit for LPN #305. · On 10/14/15 at 2:30 P.M., DON #77 revised and updated the medication audits to specify the frequency of the audit, as well as the number of residents and staff involved in the medication audit. The medication audits will be completed by the DON or designee. Two residents per unit will be monitored five times a week for six weeks. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of implementing on-going monitoring of the corrective measures and implementing an audit system. Findings include: 1. Review of Resident #23's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's discharge records dated 09/29/15 from the acute care hospital stay revealed he was discharged on the following medications: [REDACTED]. Review of a Resident #23's admission observation dated 09/30/15 at 5:06 A.M. revealed the assessment was blank, which included an initial assessment of the resident, an initial pain assessment, and vital signs. Review of Resident #23's electronic Medication Administration Record [REDACTED].M., which was 12 hours after Resident #23 stated he first requested it. On 10/01/15 at 1:30 P.M., observation of the facility's scheduled II through V drugs contained in the EDK revealed, the kit contained 24 tablets of [MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg. On 10/01/15 at 3:25 P.M., interview with DON #78 verified Resident #23 did not receive the prn pain medication as requested on 09/29/15 at 10:00 P.M. DON #78 verified the medication was not administered for 12 hours after the resident request was made. On 10/02/15 at 3:40 P.M. interview with LPN #65 revealed he had spoken with Resident #23 regarding the pain he experienced in his knees. LPN #65 was aware the resident requested his prn pain medication [MEDICATION NAME] 5-325 mg every four hours and preferred two tablets instead of one tablet. On 10/04/15 at 2:30 P.M. interview with Resident #23 revealed he was admitted to the facility on [DATE] at 10:00 P.M. from a local hospital, where he was being treated for [REDACTED]. Resident #23 indicated he had a significant amount of pain and stated he requested pain medication upon his arrival to the facility. The resident stated at the time of the initial request he rated his pain a five on a scale of one to 10 with 10 being the most severe pain. Resident #23 stated he was aware he had an order for [REDACTED]. on 09/30/15. Resident #23 stated by the time he was given the pain medication he rated his pain as a 10 out of 10 on the pain scale. During the interview with Resident #23, he shared he had documented a time line of the care and pain he was experiencing following his admission to the facility. Resident #23 indicated by 1:22 A.M. the pain to his knees and the muscle spasms were excruciating. Resident #23 also reported during the interview he felt like he would not make it through the night. The resident reported by 4:10 A.M. on 09/30/15, RN #88 informed him the discharging hospital had failed to send a prescription for the [MEDICATION NAME] 5-325 mg and she had no idea when he would get the medication. Resident #23 indicated he did not receive the requested pain medication until 09/30/15 at approximately 10:30 A.M. During the interview Resident #23 also expressed concerns with the inability to receive pain medication on 10/03/15. Resident #23 stated he requested the pain medication on 10/03/15 at 7:30 P.M. so he would receive it at 8:00 P.M. The resident stated the nurse informed him he had run out of the prn pain medication and would have to wait until the facility pharmacy delivered the medication. Resident #23 stated he received the requested dose of pain medication at 11:30 P.M. on 10/03/15 at which time his pain was uncontrolled and rated a 10 on a scale of one to 10. The resident stated he felt he had discussed with many facility nurses prior to this incident that if his pain became excruciating, he had difficulty getting it back under control and felt he needed to take the prn pain medication [MEDICATION NAME] every four hours. Review of the progress note dated 10/04/15 at 4:02 A.M. revealed LPN #92 documented Resident #23 was unhappy and angry when he was notified his prn pain medication was not available and would have to wait until the pharmacy delivered the medication to the facility. LPN #92 documented an attempt was made to get an authorization to pull from the Emergency Drug Kit (EDK) but was informed the pharmacy had already dispensed the medication. Review of Resident #23's medical record failed to provide any evidence of LPN #92 contacting the resident ' s physician regarding the resident's pain or non-pharmacological interventions being attempted in an effort to relieve or minimize the resident's pain to his bilateral knees and legs at that time. Review of the progress notes dated 10/04/15 at 11:58 A.M., revealed LPN #46 documented Resident #23 had the option to choose one or two tablets of [MEDICATION NAME] 5-325 mg and more frequently than not requested two tablets in an effort to keep his pain manageable. On 10/04/15 at 3:00 P.M. interview with Licensed Practical Nurse (LPN) #45 revealed the facility had the medication [MEDICATION NAME] 5/325 mg in the EDK and an authorization should have been obtained to sign a dose out of the EDK. LPN #45 said the facility's pharmacy makes a daily delivery between the hours of 10:30 A.M. and 11:00 A.M. LPN #45 said medications can be delivered outside of the routine delivery and should arrive within two hours during pharmacy business hours and four hours after pharmacy business hours. As of 10/08/15 at 4:10 A.M., Registered Nurse (RN) #88 documented the resident ' s admission observation was completed, but upon surveyor review the assessment remained blank. On 10/08/15 at 4:32 A.M., RN #88 documented a general observation of Resident #23, however, the general assessment did not include any type of pain assessment. 2. Review of Resident #8's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of quarterly Resident #8's Minimum Data Set 3.0 (MDS) assessment dated [DATE] indicated the resident was usually able to understand others, usually made himself understood and had no cognitive deficit. Review of the MDS assessment indicated required extensive assistance for activities of daily living (ADL's). Review of the health conditions on the MDS 3.0 assessment revealed Resident #8 experienced occasional moderate pain. Review of Resident #8's monthly physician's orders [REDACTED]. An order dated 06/09/15 indicated the resident was to have a pain assessment daily at 10:00 P.M. Review of Resident #8's plan of care dated 06/09/15 revealed the resident was at risk for pain due to rotator cuff syndrome and [DIAGNOSES REDACTED]. The goal was the resident will not complain of pain greater than one time a day. Interventions included, administer pain medications and monitor the effectiveness, determine the location of pain, type of pain and duration of pain, reassess pain control daily and prn, and update the physician as needed. On 10/01/15 at 9:53 A.M., interview with Resident #8 revealed he felt his daily pain was not controlled. The resident reported he was in pain on a daily basis with a serious headache daily. Resident #8 said he had to ask for his prn pain medication [MEDICATION NAME] 5-325 mg and rated his pain level as a 10 on a scale of one to 10. On 10/02/15 at 10:20 A.M. LPN #48 was observed administering routine medications to Resident #8. During the administration, the resident requested two [MEDICATION NAME] pain medications. LPN #48 told the resident she would have to check on it. Observations made of LPN #48 during the request for the pain medication revealed the LPN did not assess the resident's pain by requesting the location of the pain, intensity of the pain or the duration of the pain. Review of Resident #8's eMAR for October 2015 revealed the resident's last dose of [MEDICATION NAME] was administered on 10/02/15 at 6:12 A.M., at which time the resident verbalized pain at a level of seven out of 10. Interview with LPN #48 on 10/02/15 at 3:40 P.M., verified Resident #8 had not received the requested pain medication from his request of 10:20 A.M. LPN #48 stated she was still checking on his pain medication order. On 10/02/15 at 3:50 P.M., interview with Resident #8 confirmed he did not receive any pain medication as requested at 10:20 A.M. earlier that morning. The resident reported the staff just let me lay in pain. Review of Resident #8's Controlled Drug Receipt Record and Disposition Form indicated the resident received no requested pain medication on 10/02/15. The medication was signed out as administered to the resident on 10/03/15 at 9:50 A.M. a day after the resident had initially requested the medication on 10/02/15 at 10:20 A.M. 3. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of medical record revealed the resident had an unstageable pressure ulcer (blackened in color with necrotic tissue) on the right heel. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #37 had severe cognitive impairment and required total dependence with two person physical assistance with bed mobility and transfers. The MDS revealed Resident #37 was not on a pain management program, there were no as needed pain medications administered and there were non-medication interventions for pain. Review of the most recent pain level assessments revealed on 09/30/15 Resident #37 rated her pain an eight on a scale of one to 10 and on 10/02/15 a one on a scale of one to 10. Review of Resident #37's plan of care for pain dated 07/01/15 revealed the resident was at risk for pain due to [MEDICAL CONDITION] and cervical and lumbar stenosis. The goal was for the resident to not display non-verbal signs and symptoms of pain. Interventions included administer medications per physician orders, observe for signs and symptoms of pain such as moaning, wincing and flinched face, observe pain status each shift, provide non-drug interventions such as repositioning, music for distraction, and turn and reposition every two hours and as needed. Review of the plan of care for Hospice services dated 07/01/15 revealed the resident had a terminal [DIAGNOSES REDACTED]. Interventions included for the Hospice team and nursing staff to collaborate on pain management. Review of the most recent pain control progress note, dated 10/05/15 revealed the pain assessment should not be conducted with Resident #37 as the resident was rarely/never understood. The resident was observed in pain one to two days in the last five days and non-verbal signs and symptoms exhibited were grimacing and moaning. Interventions included administer medications per the physician assistant, nurse practitioner and physician orders [REDACTED]. On 10/02/15 at 3:13 P.M. Resident #37 was observed with LPN #47. As the LPN went to reposition the resident to complete a dressing change to the resident's pressure ulcer, the resident grimaced and moaned. When asked if she wanted a pain medication, the resident nodded and LPN #47 stated that she would let the floor nurse (LPN #48) know and left the resident's room. Upon return to the resident's room, LPN #47 indicated she had told LPN #48 that the resident needed pain medication. Hospice Aide #70 came into the resident's room to provide the resident a bath at that time. Interview with Hospice Aide #70 on 10/02/15 at 4:00 P.M. revealed Resident #37 was provided a bath and the resident never received any pain medication while she was providing care. Hospice Aide #70 stated Resident #37 was not relaxed during the personal care provided and indicated the resident usually enjoyed her baths. Interview with LPN #48 on 10/02/15 at 4:00 P.M. revealed she was unaware if she was Resident #37's nurse and said this was her first day working at the facility. Further interview with LPN #48 on 10/02/15 at 4:15 P.M. revealed she was waiting for the physician orders [REDACTED].#37 because she did not have access to the resident's MAR. Interview with LPN #47 on 10/02/15 at 4:15 P.M. confirmed she told LPN #48 that Resident #37 requested pain medication. At 4:15 P.M. LPN #47 was observed again telling LPN #48 the resident requested pain medication. Interview with LPN #48 along with Registered Nurse (RN) #67 on 10/02/15 at 6:07 P.M. confirmed Resident #37 still had not been administered the pain medication that was requested at 3:13 P.M. and the LPN could not explain why she had not administered it earlier. LPN #48 stated she would do it right then. On 10/02/15 at 6:10 P.M. LPN #48 was observed to enter Resident #37's room with what she identified to be the resident's pain medication. Review of the narcotic count sheet for Resident #37 revealed [MEDICATION NAME] was signed out for the resident on 10/02/15 at 5:00 P.M. However, review of MAR indicated [REDACTED]. Interview with RN #67 on 10/06/15 at 3:03 P.M. confirmed LPN #48 administered the [MEDICATION NAME] at 6:10 P.M. and confirmed [MEDICATION NAME] was not marked as administered on the MAR indicated [REDACTED] Interview on 10/01/15 at 1:40 P.M. with the facility's administrator stated Former Director of Nursing (FDON) #400 resigned on 09/22/15 and was let go on the same day due to performance issues. The administrator stated there was a reason FDON #400 was let go on the day she resigned but she did not elaborate on the issues. Review of the facility's pain management program last revised 02/14 indicated the residents will be monitored for pain on a daily basis. Residents will have a comprehensive pain assessment upon admission, quarterly and or with a significant change in condition. The interdisciplinary team will re-evaluate pain management interventions until pain is managed. For residents who are able to self-report pain, nursing staff should utilize objective pain scales to determine the severity of a resident's pain and effectiveness of the interventions. For residents with cognitive impairment will be assessed for pain through the use of staff observations and interviews, clinical assessment, changes in mood and behaviors, and by monitoring other clinical symptoms which may indicate the presence of pain. This deficiency substantiates Complaint Number OH 664 and Complaint Number OH 948.

Based on record review, review of hospital documentation, and interview the facility failed to ensure Resident #200's indwelling urinary catheter was properly positioned and maintained in a clean and sanitary manner. This resulted in actual harm to Resident #200 when the facility failed to identify the indwelling catheter was encrusted with feces and the catheter tubing was wrapped around his penis preventing urine flow to the straight drain urine collection bag. Additionally, the facility failed to ensure Resident #67's indwelling urinary catheter was properly positioned to prevent the resident from developing a Stage II (partial thickness tissue loss) pressure ulcer. The facility also failed to ensure the use of an indwelling urinary catheter was justified for Resident #45. This affected three residents (Resident #45, #67 and #200) of three residents reviewed for indwelling urinary catheters. The facility identified five residents as having indwelling urinary catheters. The facility census was 90. Findings include: 1. Review of Resident #200's closed medical record revealed he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident had an indwelling urinary catheter. Review of progress notes revealed on 09/06/15 the indwelling catheter was changed and 300 milliliters of bright red urine/blood drained from the foley drainage bag system. The doctor was notified and told the nurse he would be in in 30 minutes. On 09/08/15 the progress note stated the doctor was notified of cloudy bloody urine. The catheter was irrigated and assessed to be clear yellow urine with a small amount of red drainage. Review of the telephone orders revealed an order for [REDACTED]. On 09/15/15 the progress notes revealed Resident #200 was sent to the emergency department of a local hospital as he was awake but was not responding to touch or commands, his gaze was fixed, his extremities were stiff, and his skin was warm and clammy. Interview on 10/01/15 at 1:40 P.M. with the Administrator revealed the facility received a call on 09/18/15 from the social worker at a local hospital regarding the physical condition in which Resident #200 was in when he arrived at the emergency department. The Administrator stated she requested information regarding the resident's condition on 09/18/15. She stated the information received was not detailed. The Administrator stated the social worker alleged concerns with the resident's skin condition and care of his indwelling urinary catheter. The Administrator confirmed Resident #200's medical record revealed no documentation of problems or concerns with his indwelling urinary catheter. The Administrator stated it was not until 09/23/15 when she received a copy of the emergency department notes that the extent of the resident's condition was known to her. Review of the hospital triage nurse's notes revealed Resident #200 indwelling urinary catheter tubing was strapped around his penis and knotted and covered with feces. Review of the emergency department physician's notes dated 09/15/15 revealed Resident #200 had past medical problems including acute [MEDICAL CONDITION] syndrome, [MEDICAL CONDITION], and a multi-drug resistant strain of of bacteria ([MEDICATION NAME]) isolated in his urine. The notes stated the resident had a catheter in place and it was very dirty. The catheter was removed. Several failed attempts were made by the nurses and the emergency department doctor to reinsert an indwelling catheter requiring a urologist to reinsert the indwelling catheter. Review of the Urologist notes, dated 09/15/15 revealed the nurses reported Resident #200's catheter was not draining the tubing appeared kinked resting under his bottom, it was kinked and soiled with feces. When the nurses retracted the foreskin there was a large amount of smegma and pus. Interview of the Director of Nursing on 10/01/15 at 4:31 P.M. revealed she talked with the doctor and he did not come in on 09/04/15 to see the resident as he followed up with the nurse on duty, was told the bleeding had stopped and no treatment was required. 2. Review of Resident #67's medical record revealed an original admission date of [DATE] with the latest re-admission on 09/21/15. The resident had [DIAGNOSES REDACTED]. Review of the resident's skin and wound documentation dated 09/25/15 revealed the resident was assessed as having a Stage II pressure ulcer to his penis measuring 0.5 centimeters (cm) by 0.5 cm by 0.1 cm. The pressure ulcer was not blanchable and had thin red tinged drainage with no odor. The wound was documented as not being present upon admission. The wound was documented as being found on 09/24/15 during a wound inspection and was located on the left aspect of the underside of the penis. On 10/01/15 at 3:05 P.M., interview with Registered Nurse (RN) #50 revealed the resident was admitted back to the facility with a disposable securement device placed at the top of his left thigh near his groin, which cause the indwelling urinary catheter tubing to loop under his penis causing a Stage II pressure ulcer. 3. Review of Resident #45's medical record revealed an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had unclear speech, usually understands others, and usually made herself understood. She had both short and long term memory impairment and her cognitive skills for daily decision making was moderately impaired. She was identified as being dependent on two staff for transfers and toilet use. The MDS 3.0 assessment revealed the resident required extensive assistance of one staff with bed mobility. The resident was identified as having an indwelling urinary catheter and always incontinent of the bowel. Review of the resident's discharge records dated 09/29/15 from an acute care stay revealed an indwelling urinary catheter was inserted for accurate output monitoring. Review of Resident #45's medical record failed to provide a medical reason for the use of the indwelling urinary catheter. On 10/01/15 at 4:20 P.M., interview with Director of Nursing #78 verified the resident had no medical justification for the use of the indwelling urinary catheter. This deficiency substantiates Complaint Number OH 925.

Based on record review, resident interview, staff interview, physician interview, observation and review of facility Cast/Immobilizer - Care of the Resident procedure, the facility failed to ensure complete and thorough skin and neurovascular assessments were completed for one of five residents sampled and reviewed related to pressure ulcers (Resident #60). The facility identified three residents with pressure sores. Harm occurred to Resident #60 when the facility failed to thoroughly monitor the resident's skin integrity while the resident wore a knee immobilizer resulting in the development of a pressure ulcer which was a Stage III at the time it was first observed. Findings include: Record review for Resident #60 revealed she was admitted to the facility on [DATE]. Review of the face sheet admission information (dated as of 10/01/10) revealed [DIAGNOSES REDACTED]. Review of the minimum data set assessment (assessment reference date 09/17/10) revealed the resident had no short- or long-term memory loss, required extensive assistance for bed mobility and transfers, and had a Stage III pressure ulcer (a full thickness of skin is lost, exposing the subcutaneous tissues - presents a deep crater with or without undermining adjacent tissue). Review of nursing Skin Condition notes revealed on 09/17/10, facility Licensed Practical Nurse (LPN) #10 observed a Stage III pressure ulcer, 4.3 centimeters (cm) long by 3.1 cm wide, on Resident #60's right calf. The Skin Condition note further stated the skin at the wound site was non-blanchable with minimal tan and red-tinged drainage, no odor and the surrounding skin tissue was reddened. On 10/25/10 at 1:30 P.M., interview with LPN #10 revealed she found skin redness along the side of the immobilizer upon observation and changing of the resident's knee dressing on 09/17/10, and at that point, the immobilizer was removed and the pressure ulcer was first observed and treatment orders obtained. LPN #10 stated she was not aware of complaints of pain by Resident #60 specific to the site of the pressure ulcer. On 10/25/10 at 11:45 A.M., interview with Resident #60 revealed before the pressure area to her calf was first observed, she wore a brace that was not removed. She stated she had complained of pain to a therapist; however, it was attributed to the fracture and working the leg in therapy. She further stated when the brace (knee immobilizer) did come off, she had the pressure area from the metal rod (of the brace) into her calf. She further stated she had vascular issues and had an appointment scheduled (10/27/10) for a stint placement. On 10/25/10 at 3:20 P.M., interview with the Unit Manager, LPN #30, revealed staff completed a daily dressing change on Resident #60's knee and were monitoring the immobilizer and leg on each shift; however, per Orthopedic Surgeon #15's order of 09/07/10, the knee immobilizer was not removed and the straps were to be tightened as needed. Review of a progress note from Orthopedic Surgeon #15, dated 09/07/10, revealed to leave the knee immobilizer in place and tighten it up as needed, with a return appointment scheduled for 09/29/10. The progress notes further revealed the knee immobilizer was replaced and skin was intact and without breakdown. On 10/27/10 at 10:05 A.M., interview with Resident #60's Primary Care Physician #20 revealed he had spoken with the resident's Orthopedic Surgeon #15, and the surgeon had intended for the knee immobilizer to not be removed by staff (after the resident's appointment with him on 09/07/10) and that removing the immobilizer could be disruptive to healing of the knee, joint and leg (which had been surgically repaired). Review of the nursing notes revealed on 09/12/10, facility LPN #50 thoroughly assessed Resident #60's surgical wound (knee) and leg for circulation and swelling, pain, and adaptive devices used. The note revealed the brace (knee immobilizer) fit without causing redness or rubbing. Review of the Treatment Administration Record for September 2010 revealed the immobilizer and knee dressing was checked twice a day to ensure it was kept clean and dry and that a daily dressing change was completed to the knee surgical site; however, there was no further documentation in the nursing progress notes of assessment of Resident #60's skin condition, circulation, pain or the knee immobilizer until LPN #10's observation of the pressure ulcer to the right calf of 09/17/10. Review of the facility procedure for Cast/Immobilizer - Care of the Resident (dated Rev: June 07) revealed skin around the immobilizer was to be observed every shift for areas which included redness, irritation, drainage, and odor, and skin integrity and skin care assessments and interventions were to be documented. On 10/27/10 at 2:00 P.M., interview with the director of nursing (DON) verified the Treatment Administration Record documented the facility nursing staff had observed the leg immobilizer and changed the knee dressing daily; however, the DON further verified the facility nursing notes were silent to a complete and thorough assessment of Resident #60's skin integrity and neurovascular status. On 10/26/10 at 10:45 A.M., observation of Resident #60's dressing change to her right calf, completed with Unit Manager LPN #30, revealed a Stage IV pressure ulcer (full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone). Resident #60 was seen on 10/26/10 at a scheduled wound clinic appointment, and review of the discharge details revealed the wound measured 8.3 cm long by 2.4 cm wide. The wound progress was documented as improving and revealed the wound had been further debrided (removal of dead tissue) that day in the wound clinic. Facility Registered Nurse #90 provided a written and faxed statement to the director of nursing on 10/28/10 which stated she completed the surgical incision dressing change on Resident #60 on 09/16/10 and the resident complained of general pain in the right leg; however, the leg was not lifted out of the immobilizer due to the physician's orders [REDACTED]. [REDACTED]. On 10/28/10 at 2:45 P.M., interview with the DON revealed Registered Nurse #90 was coming to the facility later that day to complete a late entry nursing note of her faxed statement that she had observed Resident #60's leg and immobilizer on 09/16/10 and noted no redness or skin breakdown.

Based on clinical record review, review of facility fall tracking, and staff interview, the facility failed to provide interventions to prevent repeated falls for two of 19 sampled residents (Residents #81 and #96). Harm occurred to Resident #96 when facility staff failed to provide appropriate fall risk interventions after a resident experienced repeated falls while trying to go to the bathroom. Resident #96 fell and fractured his left hip requiring surgical intervention. Findings include: 1. Review of the closed clinical record for Resident #96 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for Resident #96 completed on 07/13/10 revealed the resident had difficulty with short- and long-term memory and moderately impaired decision-making skills, had impaired vision and usually understood others but may miss some part/intent of message. The assessment indicated Resident #96 required the extensive assist of one to transfer and walk in room. Resident #96 required extensive assist of one with toileting. The resident had poor balance with unsteady gait. The assessment revealed Resident #96 had falls in the past 30 days and in the past 31-180 days but no fractures. The assessment of medications revealed the resident had received antipsychotic medications 7 of 7 days, antianxiety medications 7 of 7 days and antidepressants 7 of 7 days in the assessment period. Review of fall risk assessments dated 05/17/10 and 07/08/10 revealed the resident was a high risk for falls. Review of the plan of care for Resident #96 titled "Care Plan History" with a start date of 11/02/09 revealed the resident had potential for falls due to the resident's impulsiveness, unsteady gait, incontinent and psychoactive medication use. The resident was non-complaint with fall interventions. Interventions included: a. 11/02/09 - One person assist for transfers with wheeled walker, assist resident with toileting as needed, keep call light in reach, educate staff on toileting plan, monitor for adverse effects from psychoactive medication, remind resident not to try to transfer self without assist, restorative program for ambulation and transfers. b. 11/03/09 - Keep resident's wheelchair out of sight until anti-rollbacks become available. c. 11/04/09 - Physical therapy (PT) to work with him on energy conservation for safe transfers. d. 11/11/09 - Offer toileting every 2 hours while awake and at HS. e. 11/16/09 - Toilet every 2-3 hours or ask to toilet at HS if awake. f. 02/05/10 - Therapy screen, evaluate and treat as indicated. g. 04/15/10 - Instruct the resident to wash hands after applying oil to prevent slippage on hand rails and assistive devices. h. 04/20/10 - Offer to toilet at 1:30 to 1:45 daily. i. 06/03/10 - Do not leave unattended in bathroom. j. 06/21/10 - Most frequently used personal items within reach, including wheel chair. k. 07/07/10 - PT and occupational therapy (OT) evaluation. l. 07/08/10 - Intervention to place the resident on the Lighthouse program. Please note- the surveyor was not provided a copy of the Lighthouse program or any specifics regarding what the program included. m. 07/12/10 - Determine if resident would allow staff to apply safety devices, such as helmet or hipsters due to frequent falls, look into elbow pads to prevent skin tears secondary to falls. Review of the Care Plan History for Resident #96 for Urinary Incontinence (dated 08/04/09) revealed interventions included: assist with toileting as needed, encourage use of call light, toilet every 2-3 hours or ask to toilet at HS if awake. Review of the form "Toileting" for Resident #96 revealed the entries from 07/12/10 through 07/23/10 revealed the resident was not offered or taken to the toilet every 2-3 hours. Review of 07/22/10 documentation revealed the resident was assisted to the bathroom at 3:04 P.M. with a positive result. Review of the 07/23/10 documentation revealed an absence of toileting until 4:06 A.M. No other entries were made for the dates of 07/22/10 or 07/23/10. Review of the nursing documentation to include fall history for Resident #96 obtained from the document titled "Progress Notes by Resident" revealed the following documentation: A note dated 01/29/10 at 9:07 A.M. by LPN #22 revealed Resident #96 was found on the floor (fall #1) on his back with his legs crossed and his hands under his head waiting for staff to help him up. A note completed on 01/31/10 at 7:09: A.M. by LPN #23, revealed the nurse heard yelling, upon investigation Resident #96 was found lying on the floor in the bathroom. The resident was encouraged to use call light and ask for help (fall #2). A note on 02/12/10 at 7:41 P.M. by LPN #24 revealed the resident fell when trying to transfer from the toilet to wheelchair (fall #3). Resident #96 was instructed to use call light when transferring. A note on 04/08/10 at 7:50 A.M. revealed on 03/23/10 at 12:30 A.M., the resident was observed (by an aide) sitting on the toilet with skin tear/laceration on both right and left elbows, with blood on the floor when the aide went to answer the call light. The resident stated he was going to use the bathroom but got up to quickly and was dizzy (fall #4). A note on 04/15/10 at 2:00 P.M. by LPN #26 revealed the resident was found on the floor in the bathroom, the left elbow bleeding (fall #5). A note on 05/17/10 12:39 A.M. by LPN #22 revealed Resident #96 was found on the floor at 8:00 A.M. The resident stated he hit his head the night before but didn't tell anybody (fall #6). A note on 05/19/10 by Registered Nurse (RN) #26 revealed a fall on 05/16/10 at 12:54 P.M. (fall #7). A note on 05/25/10 at 12:38 A.M. by LPN #28 revealed Resident #96 was found sitting on the bathroom floor with a skin tear and bleeding on the left elbow, and did not have glasses on. The resident was encouraged to use his call light when he had to go to the bathroom (fall #8). A note on 06/03/10 at 1:14 P.M. by LPN #29 revealed a State-tested nurse aide (STNA) called the nurse to the resident bathroom where the resident was sitting on the floor next to the toilet (fall #9). A note on 06/21/10 at 11:30 A.M. by LPN #29, revealed Resident #96 began yelling for help. The resident was found on the floor and stated he tried to get to his wheelchair to go to the bathroom, and the wheelchair was across the room (fall #10). A note on 07/04/10 at 8:21 A.M. by LPN #31 revealed a decline in restorative program, not meeting goals, unable to ambulate hallway, complaint of feeling tired and weak. Nursing and therapy were made aware. The resident would ambulate to the bathroom, gait unsteady. Review of the fall investigation titled "Interdisciplinary Team Review Form" dated 07/07/10 for Resident #96 revealed the resident went to the bathroom unassisted and was found on the floor. Under the section of Discussion: a suggestion was made to use a helmet, elbow pads and hipster for protection from injury status [REDACTED]. A note on 07/08/10 at 2:24 A.M. by LPN #22 revealed Resident #96 was found on the floor in his bathroom (fall #11). Review of an Interdisciplinary Screen/Data Collection form completed on 07/08/10 by therapy, revealed Resident #96 was found on the floor, lost his balance, and grabbed hand rail. The resident stated he was tired of waiting on call light to be answered. The form was marked that no evaluations were indicated. A note on 07/12/10 at 2:59 P.M. by LPN #26 revealed the STNA reported seeing the resident ambulating to the bathroom, she then came to assist, the resident's leg gave out, and the resident was lowered to the floor. Review of the fall investigation titled "Interdisciplinary Team Review Form" dated 07/12/10 for Resident #96 under Discussion revealed the resident needed frequent checks and cueing as to requesting assistance with transfers, using call light when needed. An increase in STNA checks was required. The staff implemented an increase in checks every one hour which continued for 36 hours then stopped. The fall on 07/12/10 was related to the resident ambulating unassisted to the bathroom. The intervention of the resident required an increase in STNA checks was not added to the plan of care to prevent falls or provide more frequent toileting. Review of the note on 07/23/10 by LPN #32 at 12:15 A.M. (with actual entry on 07/23/10 at 6:12 P.M.) revealed Resident #96 was found on the floor with the roommate attempting to help him off the floor. LPN #32 noticed blood on the floor on the left side of the resident's elbow and left hand with a large skin tear with large amount of bright red drainage. The resident's left side of the forehead had a skin tear draining bright red drainage. LPN #32 observed the resident while on the floor with no lower extremity rotation. The resident stated "I was trying to go to the bathroom and was reaching for the wheelchair and I fell ." The resident reported left leg pain with transfer, starting at the knee and down to the calf. The resident was transferred to bed with two staff assist and reported increased left leg pain (fall #12). Review of a physician's orders [REDACTED]. Review of the x-ray results completed on 07/23/10 revealed the x-ray of femur, knee and tibia and fibula were negative for fracture. The x-ray did not include the left hip. Review of a physician's orders [REDACTED]. Review of the fall investigation titled "Interdisciplinary Team Review Form" dated 07/23/10 revealed the resident was found on the floor after he had been trying to get in his wheel chair and go to the bathroom. The record revealed the resident was admitted to the hospital on [DATE] and returned on 07/28/10 with [DIAGNOSES REDACTED]. Review of the History and Physical record for Resident #96, completed on 07/28/10, upon return to the facility, revealed the resident had returned from the hospital with a [DIAGNOSES REDACTED]. Review of the total falls for Resident #96 revealed 10 of 12 falls were related to the resident trying to take himself to the bathroom unassisted. Review of the facility fall tracking for June 2010 revealed an identified issue of falls on 3-11 shift on the Lavender unit. On 10/25/10, a request was made for fall tracking for July 2010 and was not provided by the facility. Review of room placement for Resident #96 revealed the resident's room was located one room from the end of the hall. The nursing station was located at the beginning of the hall. Review of the medication record for Resident #96 revealed the resident received an antipsychotic medication (Haldol 1 milligram (mg)) and an antianxiety medication (Ativan .25 mg) on 07/22/10 at 8:00 P.M. The required documentation to monitor for drowsiness, dizziness and hangover effect from the medication was not recorded by LPN #33 the evening of 07/22/10. On 10/28/10 at 1:30 P.M., interview with the director of nursing (DON) with review of the plan of care for falls verified Resident #96 had refused the plan of care intervention for therapy evaluations on 07/07/10 and applications of safety devices, such as helmet or hipsters due to frequent falls. The resident also refused elbow pads to prevent skin tears secondary to falls. On 10/28/10 at 1:30 P.M., review of the urinary incontinence plan of care with the DON verified no change was made to the plan of care to prevent the resident from attempting to go to the bathroom without assistance resulting in a fall on 07/23/10 at 12:15 A.M. when Resident #96 fell and fractured the left hip. 2. Review of the admission face sheet for Resident #81 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no short and long-term memory impairment and was independent regarding daily decision-making. Further review of the MDS revealed the resident needed extensive, one person assistance for bed mobility, transfers, walking in her room and in the hallway, dressing and toilet use. Review of the Fall Risk Assessments dated 06/20/10, 08/30/10, 09/18/10, and 10/20/10 revealed the resident was a high fall risk. Review of the plan of care regarding falls dated 06/21/10 stated the goal was not to fall more than two times a month. Review of the Interdisciplinary Team Review Form (fall investigation) dated 06/20/10 revealed Resident #81 fell attempting to go to the bathroom without assistance and the resident suffered a left hip fracture. Review of the Interdisciplinary Team Review Forms dated 08/05/10 revealed the resident fell attempting to go to the bathroom, the resident used her call light but did not wait for help. The facility intervention was to keep the resident's wheelchair outside of the room when the resident was not using the wheelchair. Review of the Interdisciplinary Team Review Form dated 08/30/10 revealed the resident slid out of bed trying to get to her wheelchair. Facility intervention was to educate staff regarding keeping the wheelchair out of the room when not in use. Review of Interdisciplinary Team Review Form dated 09/17/10 revealed the resident fell after she got up out of bed without assistance and did not wait on staff for help. Facility intervention was to educate staff on answering the call light. On 10/28/10 at 8:20 A.M., during interview, Licensed Practical Nurse (LPN) #17 was asked what the intervention was for the 6/20/10 fall when the resident fractured a hip. LPN #17 stated the resident was counseled to use the call light. When asked regarding the 08/30/10 fall, LPN #17 verified the wheelchair was still in the resident's room, and the STNA assigned for that resident was re-educated regarding placing the wheelchair outside of the resident's room. When asked regarding the 09/17/10 fall, LPN #17 stated the STNA was educated regarding answering call lights more quickly but there was no new intervention put in place.

Based on clinical record review, observation, staff interview, and review of a facility policy, the facility failed to provide supervision to prevent a fall for one of 11 sampled residents (Resident #83). The facility failed to provide a safe environment to protect 39 of 55 facility residents from potential injury by preventing access to unlocked chemicals (Residents #41, #42, #44, #45, #47, #48, #49, #50, #53, #54, #55, #57, #58, #59, #60, #61, #62, #66, #67, #68, #69, #70, #71, #72, #73, #74, #76, #77, #79, #81, #82, #83, #84, #85, #86, #87, #88 and #90) who reside on second floor. Findings include: 1. Review of the clinical record for Resident #83 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was documented as obese and weighed 278 pounds on the Minimum Data Set assessment dated [DATE]. Review of the progress notes dated 12/02/10 by Licensed Practical Nurse (LPN) #50 at 7:30 P.M. (actual entry was 12/03/10 at 7:09 P.M.) revealed Resident #83 was sitting on the floor yelling "help me, help me." A report per an unidentified State-tested Nurse Aide (STNA) revealed the resident was being transferred from a wheelchair to bed when her left lower extremity gave in and the resident was lowered to the floor. The progress note on 12/02/10 at 10:00 P.M. by LPN #50 revealed the resident was having pain of the lower extremities and was provided with pain medication. An x-ray was obtained of both lower extremities and hips related to the resident's complaints of pain. The x-rays were negative for fracture. Review of the plan of care for Resident #83 for fall risk dated 04/23/08 revealed the resident was to have two or more persons to assist on transfers using a Hoyer lift or transfer by two or more assist on transfers using EZ stand-Hoyer lift. Review of the fall investigation for Resident #83 completed on 12/03/10 revealed the fall occurred on 12/02/10 at 7:25 P.M. The Summary of Findings revealed a STNA was transferring the resident and the resident's legs gave out. The STNA lowered the resident to the floor. The resident did complain of leg pain. The fall investigation revealed the range of motion was the best to be expected related to the resident's weight. Review of the fall risk assessment completed 12/03/10 revealed a fall risk of 16 which indicated the resident was at high fall risk. This was the only fall risk assessment made available by the facility upon request. Review of the therapy screen completed on 12/03/10 for Resident #83 revealed a notation the STNA tried to transfer the resident by herself from bed to chair. The therapy screen identified the resident required a two-person assist. The resident had decreased cognition and safety awareness. On 12/15/10 at 10:00 A.M., observation revealed Resident #83 was up in a wheelchair. An opportunity to observe a transfer was not available. A Hoyer lift was noted in the hallway. On 12/16/10 at 7:15 A.M., interview with the director of nursing (DON) with review of the plan of care dated 04/23/08 revealed the resident required transfer by two persons or more with use of the EZ stand or Hoyer lift. The DON verified the notes revealed the STNA failed to follow the plan of care during an attempt to transfer Resident #83 by herself, resulting in the fall of Resident #83 and causing pain to the resident. The DON verified the STNA did attempt to transfer Resident #83 by herself. 2. On 12/15/10 at 9:05 A.M., observation of the facility beauty shop located on the second floor revealed the door to the salon was left open and no staff was present. Further observation revealed the beauty shop contained an unidentified substance in a bottle on the countertop. Observation of the contents of the unlocked cupboards revealed solutions identified as harmful and dangerous to children. Observation revealed a dryer was on and plastic capes were draped over the top of the dryer and were very warm to the touch. At 9:07 A.M., Cosmetologist #55 returned to the room and verified she left the door open. There were no residents at the door of the salon during the observation. This was verified by the facility administrator at the time of the observation. Review of the facility policy titled Salon Equipment and Area (dated July 2008) revealed the salon door was to be locked when no one was present. A request was made of names of residents on the second floor who were cognitively impaired and mobile by ambulation or wheelchair. The following residents were listed: Residents #41, #42, #44, #45, #47, #48, #49, #50, #53, #54, #55, #57, #58, #59, #60, #61, #62, #66, #67, #68, #69, #70, #71, #72, #73, #74, #76, #77, #79, #81, #82, #83, #84, #85, #86, #87, #88 and #90. These residents were identified as having potential risk for injury related to unlocked chemicals. This was verified by the DON on 12/16/10 at 7:15 A.M. This is a re-cited deficiency to the annual survey completed on 10/28/10.