Every finding on record at Continuing Healthcare of Shadyside

Based on record review, interview, and policy review, the facility failed to ensure residents received refunds due to the residents within 30 days. This affected two residents (#1 and #2) of three residents reviewed for refunds. The facility census was 80. Findings include:1.Closed record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and osteoporosis. Review of a nursing note dated [DATE] at 8:54 A.M. by Licensed Practical Nurse (LPN) #123 revealed Resident #1 discharged from the facility to an assisted living facility. Review of an invoice dated [DATE] revealed Resident #1 was issued a check for $1565 on [DATE]. 2.Closed record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia. Review of a nursing note dated [DATE] at 10:21 A.M. by LPN #200 revealed Resident #2 expired in the facility. Resident's physician, family and hospice were notified. Review of an invoice dated [DATE] revealed Resident #2's estate was issued a check for $6440 on [DATE]. Interview on [DATE] at 9:15 A.M. with Resident #2's responsible party revealed they had still not received a refund from the facility. Interview on [DATE] at 10:00 A.M. with Receptionist #127 revealed she believed the amount of time a refund should be issued was 90 days. Receptionist #127 revealed she was responsible for petty cash at the facility since there was not an in-house business office and the corporate office was located in Cleveland. Receptionist #127 stated she received a call the day prior ([DATE]) related to Resident #2 because his estate had still not received a refund from the facility and she forwarded the information on to the corporate office. Resident #2's responsible party had indicated she spoke with the corporate staff multiple times with no response. Receptionist #127 stated the responsible party was irate. Receptionist #127 confirmed [DATE] to [DATE] was longer than 90 days and was not a timely issue for a refund for Resident #2.Interview on [DATE] at 1:45 P.M. with Administrator revealed the facility policy stated residents should receive a refund within 90 days. Administrator stated refunds are not processed at the facility so he was not aware of any delays.Follow-up interview on [DATE] at 1:39 P.M. with Administrator confirmed Resident #1 discharged from the facility on [DATE] and was not issued a refund until [DATE] which was greater than 90 days per facility policy and 30 days per regulations, and Resident #2 was admitted to the facility on [DATE] and expired on [DATE] and was not issued a refund until [DATE] which was greater than 90 days per facility policy and 30 days per regulations. Review of an undated policy titled Refund Policy revealed in the event a credit balance has resulted from a private pay payment on a resident account the balance will be refunded based on the following: the account is paid in full by all other entities, refund will be issued by check within 90 business days, and refund will be issued only to the resident, resident's estate or in some cases, the responsible party.This deficiency represents non-compliance investigated under Complaint Number 2797689.

Based on record review and interview, the facility failed to accurately reflect on the facility assessment the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessments and care plans. This had the potential to affect all residents of the facility. The facility census was 83.Findings include:Review of a document titled Facility Assessment Tool, which was updated 02/13/26, revealed the facility would conduct, document, and review a facility wide assessment which included both the resident population and resources the facility needed to care for the residents at least annually. The facility average daily census was 83. The locked memory care unit had a 32 bed capacity, with an average daily census of 28. The facility identified care needs of the memory care unit as activities of daily living (ADL), mobility and fall risk, bowel and bladder, skin integrity, mental health and behavioral, medications, pain management, infection prevention and control, management of medical conditions, therapy, nutrition, and person-centered/directed care: psycho/social/spiritual support. The facility identified it estimated needing 12-14 licensed nursing staff to provide direct care, 20-25 nurse aides, and three nursing personnel (with administrative duties) to provide care for the population of residents at the facility. This was confirmed with Regional Administrator #502 on 03/05/26 at 1:44 P.M.On 03/05/26 at 1:44 P.M., an interview with the Regional Administrator #502 revealed the estimated range of staff needed, which was documented on the Facility Assessment, was incorrect. When she was determining the number of licensed nurses providing direct care, she had included the administrative nurses as well, which included the Director of Nursing, Assistant Director of Nursing, and the Minimal Data Set (MDS) nurse. When she had determined the number of Nurse aides, she had included such individuals as the staff in administrative roles, such as admissions and medical records. She reported she needed to look at how she determined these numbers across all facilities she assisted with.This deficiency represents an incidental finding during the investigation of Master Complaint Number 2746972.

Based on observation, interview and record review, the facility failed to protect residents dignity. This affected one resident (#25) of the memory care unit. The facility census was 83.Findings include:Review of the medical record for Resident #25, revealed an admission date of 08/06/22. Diagnoses included pneumonia; unspecified dementia, anemia; chronic vascular disorder of intestine; gastrointestinal hemorrhage; dysphagia; unspecified psychosis not due to a substance; delusional disorder; transient cerebral ischemic attack; hyperlipidemia; depression; anxiety disorder; unspecified disorder of vestibular function; atherosclerotic heart disease of native coronary artery without angina pectoris; gastro-esophageal reflux; muscle weakness; difficulty in walking not elsewhere classified; and unsteadiness on feet.Review of the most recent Minimum Data Set (MDS) 3.0 assessment for Resident #25, dated 02/11/26, revealed a Brief Interview for Mental Status (BIMS) of 0 on a 0-15 scale. A BIMS score of 0 suggests severe cognitive impairment. The MDS indicated the resident had unclear speech, could sometimes understand others and make himself understood. He had highly impaired vision.Further review of the MDS indicated the resident's ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident was dependent , which meant a helper had to do all of the effort. The resident did none of the effort to complete the activity. He was also dependent with all activities of daily living (ADL), including dressing, bed mobility, bathing/showering, toileting and oral hygiene.Review of a care plan for Resident #25, dated 09/11/25, revealed the resident had a focus of care for Activities of Daily living with a self care performance deficit related to dementia. He required the assistance of two staff to transfer and the amount of assistance he required could vary based on behaviors. On 03/04/26 at 8:55 A.M., an observation of Resident #25 revealed he was sitting alone at a dining table in a wheelchair. He was dressed in a hospital gown, with his back exposed as well as his legs uncovered. He had a full tray with scrambled eggs and ground ham in front of him. He was not feeding himself. This was confirmed by Certified Nurse Aid (CNA) #388 on 03/04/26 at 9:10 A.M.On 03/04/26 at 9:10 A.M., an interview with CNA #388 revealed Resident #25 had to be brought to the dining room because if not he would try to get up in his room. Per CNA #388, there was not enough time or enough people to get the resident dressed before breakfast, so he had to be brought to the dining room in the hospital gown. She reported she knew this was not appropriate dress for the dining room. She then proceeded to leave the dining area without covering the Resident #25 further.On 03/04/26 at 9:40 A.M., an interview with Licensed Practical Nurse #384 revealed she thought it was appropriate for a resident to be in the dining area in a hospital gown. Stated, it is ok for skilled residents to stay in hospital gowns. She did acknowledge Resident #25 could not choose how he was dressed due to his cognitive impairment.On 03/04/26 at 11:55 A.M., an interview with Resident #25's spouse revealed she believed the staff did everything they could considering the ratio of workers to residents. She reported it sometimes took awhile for staff to respond because they were so busy. Review of a facility document titled Dignity, Respect, and Privacy Policy, updated 01/03/26, revealed the facility would provide care to residents while maintaining their dignity and privacy. Residents were to always be treated with respect and cared for in a manner that protected their privacy.This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2746972.

Based on review of medical records, review of facility policies, observation, and interview, the facility failed to maintain the privacy of personal health information for three residents (#7, #42, and #79) of 83 residents residing in the facility. The facility census was 83.Findings include:1.Review of the medical record for Resident #7 revealed admission to the facility on [DATE] for diagnoses including chronic resp failure, chronic lung disease, morbid obesity, diabetes, bipolar disorder (mood disorder), right sided weakness following a stroke, high blood pressure, and poor circulation to legs. Review of the medical record for Resident #42 revealed admission to facility on 11/23/22 for diagnoses including dementia (memory impairment) with mood disturbance, anemia (low blood count), constipation, insomnia (sleep disorder), depression, restless leg syndrome, and difficulty with walking. Observation on 03/04/26 between 9:53 A.M. and 10:30 A.M. revealed the facility's Nurse Practitioner (NP) #500 and registered nurse (RN) #346 in the east hallway near room [ROOM NUMBER] discussing medications with Resident #7. Further observations revealed NP #500 and RN #346 proceeding to the activities room where there were six residents seated at a table playing a dice game. NP #500 approached Resident #42 and began to discuss medical conditions related to her ankle pain and that NP #500 would prescribe new medication. The NP #500 and RN #346 did not ask Resident #42 if she was okay with being assessed at her current location with the other five residents present. There were no observed accommodations made by NP #500 or RN #346 to remove Resident #42 from the table where the other five residents were sitting. Interview on 03/04/26 at 10:40 A.M. with RN #346 revealed verification that RN #346 and NP#500 had assessed Resident #42 in the activities room with other residents present. Review of Resident #42's medical record revealed a general progress note dated 03/04/26 at 10:34 A.M. and authored by RN #346. The progress note revealed that Resident #42 was seen by NP #500 and new orders were received related to c/o pain in legs. Interview on 03/05/26 at 9:22 A.M. with RN #346 revealed that the NP #500 and did not assess Resident #7 on 03/04/26 and that NP #500 was approached by Resident #7 in the hallway asking the NP #500 questions regarding medications that were prescribed by the physician the day prior. Note- there was no evidence NP #500 had directed Resident #7 to a private location to review and discuss her questions about her medications. Review of the facility policy titled Dignity, Respect, and Privacy Policy, updated on 01/03/25 revealed unnecessary individuals shall be asked to leave residents room while care is provided, and the purpose of policy was To provide care to residents while maintaining their dignity and privacy. Residents are to always be treated with respect and cared for in a manner that protects their privacy. Their individual preferences are to be evaluated, and reasonable accommodations made, and care and treatment are to be delivered in a way that always maintains their dignity. 2. On 03/04/26 at 12:28 P.M., observation of the lunch meal revealed Speech Therapist (ST) #503 speaking with Resident #79 in the dining area. There were two visitors and 11 residents, along with two Licensed Practical Nurses (LPN)s in the dining room. ST #503 could be heard asking Resident #79 about his doctor appointment the day prior. When he could not provide the information due to cognitive issues, ST #503 yelled to LPN #384 and asked, how was his appointment yesterday? LPN #384 proceeded to describe the resident's physician appointment loud enough the surveyor could hear from the other side of the room. On 03/04/26 at 12:40 P.M., interview with LPN #384 confirmed ST #503 had requested resident private medical information in the full dining area. She further confirmed she had replied and given a report to the ST regarding the resident's physician appointment the day before. She agreed this was private resident information and should not be shared in a public dining area, regardless of whether or not it was a memory care unit, and acknowledged there were two visitors in addition to the 11 residents and the surveyor present at the time of the interaction. This deficiency represents non-compliance investigated under Complaint Number 2667202.

Based on observation, record review, and interview, the facility failed to have sufficient nursing staff to maintain the highest practicable psychosocial well-being of each resident when a resident was brought to the dining room in a hospital gown which was opened in the back or to assist the resident with breakfast in a reasonable time. This affected one resident (#25) of six residents residing on the memory care unit. The facility census was 83.Findings include:Review of the medical record for Resident #25, revealed an admission date of 08/06/22. Diagnoses included pneumonia; unspecified dementia, anemia; chronic vascular disorder of intestine; gastrointestinal hemorrhage; dysphagia; unspecified psychosis not due to a substance; delusional disorder; transient cerebral ischemic attack; hyperlipidemia; depression; anxiety disorder; unspecified disorder of vestibular function; atherosclerotic heart disease of native coronary artery without angina pectoris; gastro-esophageal reflux; muscle weakness; difficulty in walking not elsewhere classified; and unsteadiness on feet.Review of the most recent Minimum Data Set (MDS) 3.0 assessment for Resident #25, dated 02/11/26, revealed a Brief Interview for Mental Status (BIMS) of 0 on a 0-15 scale. A BIMS score of 0 suggests severe cognitive impairment. The MDS indicated the resident had unclear speech, could sometimes understand others and make himself understood. He had highly impaired vision.Further review of the MDS indicated the resident's ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident was dependent , which meant a helper had to do all of the effort. The resident did none of the effort to complete the activity. He was also dependent with all activities of daily living (ADL), including dressing, bed mobility, bathing/showering, toileting and oral hygiene.The MDS revealed the resident was on a mechanically altered diet which required a change in texture of food or liquids. There were no days during the MDS evaluation period when the resident received any restorative nursing programs for eating and/or swallowing.Review of a care plan for Resident #25, dated 09/11/25, revealed an intervention for fall risk related to a history of falls. Interventions included eating meals in all purpose room as he would allow (05/27/24) and when awake bring to all purpose room for closer monitoring (08/10/25).Review of a progress note for Resident #25, dated 02/05/26 at 4:48 P.M., revealed the resident was admitted to [NAME] Memorial Hospital with a diagnosis of pneumonia.Review of a History and Physical for Resident #25, completed by NP #500, dated 03/03/26, revealed a new diagnosis of dysphagia was added. Plan for this diagnosis was to monitor therapy and effectiveness.Review of a Speech Therapy note for Resident #25, dated 03/03/26, revealed the resident's diet was upgraded from pureed to mechanical soft diet with thin liquids. He was to be up in a chair for meals. The resident was to be assisted with intake. On 03/04/26 from 8:55 A.M. until 9:23 A.M., an observation of the dining area of the memory care unit revealed four residents sitting at dining tables with trays in front of them. Two residents were sitting away from the tables in wheelchairs, and one resident was wandering around the dining area, talking to herself. There was no staff present or interacting with the residents.On 03/04/26 at 8:55 A.M., an observation of Resident #25 revealed he was sitting alone at a dining table in a wheelchair. He was dressed in a hospital gown, with his back exposed as well as his legs uncovered. He had a full tray with scrambled eggs and ground ham in front of him. He was not feeding himself. This was confirmed by Certified Nurse Aide (CNA) #388 on 03/04/26 at 9:10 A.M.On 03/04/26 at 9:10 A.M., an interview with CNA #388 revealed Resident #25 had to be brought to the dining room because if not he would try to get up in his room. Per CNA #388 there was not enough time or enough people to get the resident dressed before breakfast, so he had to be brought to the dining room in the hospital gown. She reported she knew this was not appropriate dress for the dining room. She then proceeded to leave the dining area.On 03/04/26 at 9:23 A.M., an observation revealed CNA #306 arrived to the dining room. She stood beside Resident #25 and fed him a couple bites of breakfast without re-heating the food, and then sat and fed the resident the remainder of his breakfast. This was confirmed immediately with CNA #306.On 03/04/26 at 9:35 A.M., an interview with CNA #306 revealed she assisted with residents eating on the memory care unit once she completed other duties on a different unit. She thought the resident sometimes fed himself, but she did not know why he had not been fed. She thought breakfast trays arrived at 8:00 A.M.On 03/04/26 at 9:40 A.M., an interview with Licensed Practical Nurse (LPN) #384 revealed breakfast arrived on the memory care unit at a few minutes before 8:00 A.M. Nurses helped feed residents when they could, however morning was a very busy time with medication pass. She thought it was appropriate for a resident to be in the dining area in a hospital gown. LPN #384 stated, it is ok for skilled residents to stay in hospital gowns. She did acknowledge Resident #25 could not choose what he wore due to his cognitive impairment.On 03/04/26 at 11:55 A.M., an interview with Resident #25's spouse revealed she believed the staff did everything the could considering the ratio of workers to residents. She reported it sometimes took awhile for staff to respond because they were so busy. She would come and feed the resident lunch every day, however he always needed assistance with eating since his hospitalization in January (2026) for pneumonia. His food texture had changed because the hospital told her aspirating his food had caused his pneumonia. They pulled hunks out of his lungs with a tube. She indicated for some time the resident had not had use of his right arm and hand. He was left handed and had forgot how to use silverware, so with the new diet of ground food, he required feeding assistance with all meals.Review of a facility document titled Dignity, Respect, and Privacy Policy, updated 01/03/26, revealed the facility would provide care to residents while maintaining their dignity and privacy. Residents were to always be treated with respect and cared for in a manner that protected their privacy.This deficiency represents non-compliance investigated under Master Complaint Number 2746972.

Based on observation, interview and policy review, the facility failed to maintain an environment free from risk of infection by allowing a dog to be at the lunch table with residents eating their meal. This affected two residents (#77, #65) sitting together in the memory care dining area at lunchtime. The facility census was 83.Findings include:On 03/04/26 at 12:00 P.M., observation of the dining area of the memory care unit revealed a small table with Resident #77 and Resident #65 seated. Each resident had a visitor also sitting at the table. The visitor for Resident #77 was holding a small dog, who would lay it's head on the table. When the lunch tray for Resident #77 arrived, the visitor holding the dog did not wash her hands and continued holding the dog, while feeding Resident #77 her lunch. This was confirmed by Licensed Practical Nurse (LPN) #384 on 03/04/26 at 1:00 P.M.On 03/04/26 at 1:00 P.M., an interview with LPN #384 confirmed the visitor for Resident #77 was holding the dog and feeding the resident. She confirmed the visitor had been there prior to lunch and had not done hand hygiene or put the dog down at any point.On 03/04/26 at 1:15 P.M., an interview with the Director of Nursing (DON) confirmed it would be an infection control issue to have a dog at the table while residents were eating. It also would be against the facility infection control policy to be holding a dog and feeding a resident, especially if the visitor did not wash their hands.Review of a facility document titled Infection Control Prevention Policy, updated 01/11/25, revealed it was the policy of the facility to provide resident care in a safe environment that promoted health and reduced the risk of acquiring infections. This policy was confirmed by the Director of Nursing on 03/04/26 at 1:15 P.M. This deficiency represents an incidental finding of non-compliance during the investigation of Master Complaint Number 2746972.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, facility policy review and interview, the facility failed to provide a timely assessment and necessary and timely treatment for Resident 3181 following an unwitnessed fall with injury. This affected one resident (#181) of two residents reviewed for accident hazards. Actual harm occurred on 02/07/25 at 7:30 P.M. when Certified Nursing Assistant (CNA) observed Resident #181 on the floor in front of her wheelchair. The CNA notified Registered Nurse (RN) #109 of the resident having an unwitnessed fall; however, the RN failed to assess and provide needed treatment to the resident thereby delaying necessary treatment including transfer to the hospital. Following the incident, the resident complained of pain to her hip and had a decrease in mobility. However, the resident was not transferred to the emergency room until 02/09/25 at which time she was admitted for treatment of an acute right hip fracture. Findings include: Review of the closed medical record for Resident #181 revealed the resident was admitted to the facility on [DATE] for a five-day hospice respite stay. Resident #181 was readmitted to the facility on [DATE] receiving hospice services. The resident was discharged from the facility on 02/09/25 to the hospital and then discharged (from the hospital) to home. Resident #181 had diagnoses including senile degeneration of the brain, chronic obstructive pulmonary disease, dementia, Alzheimer's disease, malignant neoplasm of the bronchus or lung and repeated falls. Review of the resident's Admission Packet dated 02/07/25 revealed the resident was oriented to self only, was confused, with short term memory loss with mild cognitive impairment. The resident was ambulatory and had scratches noted to right iliac crest with multiple falls within the last six months. The resident had no limitations in range of motion. Review of the facility's incident and accident investigation report dated 02/07/25 at 7:30 P.M. revealed Resident #181 had a fall in the hallway from her wheelchair. Review of the baseline care plan dated 02/08/25 revealed Resident #181 was at risk for elopement/wandering related to dementia, at risk for falls and potential injury related to history, and received psychoactive medication which was required due to alteration in mood and behavior related to anxiety and wandering without purpose. Interventions included commonly used articles within easy reach, maintain clear pathways, monitor for side effects of psychotropic medications, and a room close to nurses' station. Review of the medical record revealed a progress note on 02/07/25 at 3:30 P.M. that identified Hospice was contacted to confirm the resident's orders for respite admission. The orders were confirmed. There was nothing noted on this date in the medical record regarding an unwitnessed fall or an assessment of the resident for falls or injury. Review of the medical record revealed a progress note on 02/08/25 at 12:50 A.M. that identified the resident was administered Lorazepam 0.5 milligrams (orally) for anxiety, restlessness. Review of hospice visit note by Hospice Registered Nurse (RN) #102 on 02/09/25 at 5:57 P.M. revealed Resident #181 had facial grimacing and was unable to be consoled with touch and verbal communication. Facial pain scale denoted 8 out of 10 on a 1 to 10 pain scale. RN #109 administered Morphine (for moderate to severe pain), with little effect. RN #109 reported that Resident #181 normally walked with a shuffled gait and held onto the walls, rails or furniture, throughout the day. On 02/09/25, Resident #181 had not ambulated. RN #109 denied Resident #181 had any falls. Resident #181's daughter reported Resident #181 had several falls at home prior to being admitted (to the facility on [DATE]) but had no signs of injury. An assessment completed by Hospice RN #102 revealed Resident #181's left leg was notably longer than the right leg, RN #109 verified the findings during the 02/09/25 visit. New orders were received for Resident #181's bilateral hips, pelvis, and lumbar spine to be x-rayed. Review of the medical record revealed the next progress note dated 02/09/25 at 7:55 P.M. indicated the resident was administered Morphine sulfate 20 mg/5ml, liquid by mouth one ml for pain rated 9-10 or shortness of breath. There was no comprehensive assessment of the resident that identified what complaints of pain the resident was experiencing or the condition of the resident. Review of Resident #181's medication administration record (MAR) reflected the resident received Morphine Sulfate oral solution 20mg/5ml, one ml on 02/09/25 at 7:55 P.M. for a pain rating of nine (9). It was documented as effective. Review of the medical record revealed the next progress note dated 02/09/25 at 8:19 P.M. identified Morphine sulfate 20 mg/5 ml, every 1 hour as needed for pain 9-10 or shortness of breath. The PRN administration was identified as effective and the follow up pain scale was four (4). There was no comprehensive assessment of the resident that identified what complaints of pain the resident was experiencing or the condition of the resident. Review of Resident #181's medication administration record (MAR) reflected the resident received Morphine Sulfate oral solution 20mg/5ml, 0.75 ml by mouth on 02/09/25 at 9:19 P.M. for a pain rating of seven (7). It was documented as U unknown for effectiveness. Review of a progress note dated 02/09/25 at 11:22 P.M. revealed Resident #181's daughter came in to visit and asked if her mother had been in bed all day. The nurse explained that since Resident #181 had arrived, she would be active, get tired, and then go to her bed and rest. The daughter pointed out to the nurse that the resident was indicating that she was having pain when her right leg was moved. The progress note indicated that the Hospice Nurse also came in and assessment was collaborative. Morphine Sulfate liquid was given hourly as needed for pain. A call was placed to the resident's physician for orders for mobile x-rays stat. The x-rays were completed and identified a right hip fracture. The physician was notified of the x-ray results and ordered the resident to be transferred to the hospital for evaluation related to fracture of the right hip. The resident was transferred to the hospital (on 02/09/25) at 10:45 P.M. Review of the Emergency Department (ED) provider note dated 02/09/25 at 11:17 P.M. revealed Resident #181 presented to ED today by ambulance from the facility to be evaluated for right hip pain. The x-ray showed a minimally displaced and minimally angulated fracture of the distal femoral neck area. An orthopedic consultation was ordered, and Resident #181 was admitted to the hospital. Active hospital diagnoses include hip fracture, right distal femoral neck, acute hypoxia- patient required oxygen for desaturation likely related with sedation, Stage IV metastatic adenocarcinoma of the right lung to mediastinum, chronic obstructive pulmonary disease, presenile dementia, anxiety and depression. Review of the resident's facility medical record revealed a progress note titled General Note dated 02/10/25 at 11:54 A.M. indicating Resident #181 presented with new onset of pain on 02/09/25 to right lower extremity. As needed Morphine was given. The floor RN assessed the resident and provider was notified of clinical findings with orders given for hip x-ray. X-ray performed same day with findings of acute right hip fracture at the intertrochanteric region. The medical provider was notified of the findings with order to send to the ED that evening for evaluation and continued treatment. The resident's daughter was aware of the findings. The resident was admitted to the hospital for orthopedic management. Upon facility investigation, the resident had a fall on 02/07/25, found sitting in the hallway in from of room [ROOM NUMBER]. The note included the resident continued to ambulate that night per baseline with no reports of pain present until 02/09/25. The facility was to assess root cause of the fall and implement fall intervention pending the resident's return to the facility. Review of a hand written statement from CNA #152 dated 02/09/25 (from the incident dated 02/07/25) revealed Resident #181 was sitting in her wheelchair outside of room [ROOM NUMBER] when CNA #152 came on shift at 7:00 P.M. Around the time of the incident, the CNA was assisting another resident and RN #109 was standing at the nurse's cart. When CNA #152 came around the corner she saw Resident #181 was sitting on the floor next to her wheelchair. The CNA informed the nurse (RN #109) that the resident was on the floor and it was unwitnessed. CNA #152 walked back to the resident and the nurse never came to assess the resident. So, CNA #152 then helped the resident up off of the floor and back into her wheelchair and pushed her into the day room. Review of a handwritten statement from RN #109 dated 02/09/25 for an incident dated 02/09/25 (note- this date is in error and should reflect the incident date 02/07/25) revealed she didn't remember seeing a resident on the floor Friday (02/07/25). RN #109's statement identified that she was not aware of Resident #181 being on the floor Friday (02/07/25). Review of a typed statement dated 02/11/25 at 2:50 P.M. by the Administrator revealed he had called and spoken with Resident #181's daughter regarding the resident being transferred to the emergency roiagnom on [DATE]. The daughter stated the resident had been admitted to the hospital on 02/09/25 with a diagnosis of right hip fracture. Review of a document titled personal witness statement, revealed a hand written statement signed by the Director of Nursing (DON) dated 02/18/25 that identified the DON had spoken with CNA #152 and made her aware if a situation where a resident was on the floor and the nurse was not assessing them, the CNA should make another nurse on the floor aware or call the DON personally. The CNA was not to pick the resident up without being properly assessed. The CNA said she understood. The CNA stated she had helped her (Resident #181) off the floor only because the resident was already attempting to get up herself. The CNA did not want the resident to cause potential further injury. Interview on 04/16/25 at 2:50 P.M. with Regional Clinical RN #198 revealed the facility completed an investigation and determined Resident #181 had a fall on the evening of 02/07/25' however, there was no documentation of the fall in the resident's medical record or of a resident assessment being completed. Per Regional Clinical RN #198, CNA #152 had notified RN #109 that Resident #181 was sitting on the floor next to her wheelchair and the fall had been unwitnessed. Regional Clinical RN #198 verified that Resident #181 was not assessed by the nurse and the resident was assisted back into wheelchair by CNA #152. Interview on 04/17/25 at 6:29 A.M. with CNA #152 revealed around 7:30 P.M. (on 02/07/25) Resident #181 was sitting back by room [ROOM NUMBER] and attempted to ambulate multiple times. CNA #152 assisted Resident #181 back into her wheelchair and CNA #152 went to assist another resident. When CNA #152 came back out, Resident #181 was observed sitting on the floor in front of the wheelchair. CNA #152 told RN #109 that Resident #181 was on the floor. CNA #152 stated she waited with Resident #181 for at least five minutes and the nurse did not come to assess Resident #181. Prior to the fall on 02/07/25, the resident was ambulating on the unit, with no signs of pain observed. Review of the Fall Policy dated 02/2018 revealed the facility was to assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. Section Two: Assessments and Notification, appropriate medical care would be provided as needed, including calling for emergency transport to the emergency room if needed. The physician would be notified of the fall and outcome. The resident representative would be notified of a fall. The DON/Designee would be notified of each fall. The deficiency was corrected on 02/10/25 after the facility implemented the following corrective actions: On 02/09/25 Resident #181 was assessed by nursing staff, x-rays completed on this date, and the resident was transferred to the hospital for care and treatment including surgical correction of a fractured hip. On 02/10/25 the Director of Nursing (DON)/designee completed audits of all current residents in the facility for pain and new skin alterations to ensure no incidents had occurred to cause any of the same. There were no negative findings upon assessment of all residents. On 02/10/25 the DON completed all staff education regarding the facility Fall policy to ensure staff know what to do when a resident was seen on the floor. The DON ensured that 100% of all staff were educated. On 02/10/25 the DON completed all nurses education on the facility Fall policy and proper assessment, fall investigation, provider and family notification, and documentation of falls. The DON ensured that 100% of all staff were educated. On 02/10/25 an Ad Hoc QAPI meeting was conducted with the Medical Director, Executive Director, DON, Assistant DON, and RN Unit Manager. The meeting was convened to thoroughly review the Self-Imposed Action Plan developed in response to the incident involving Resident #181 on 02/07/25. Key areas discussed included analysis of the circumstances surrounding the fall, review of current safety protocols and identification of potential gaps, proposed modifications to existing procedures to enhance resident safety, and assignment of responsibilities for implementing the Action Plan. Beginning on 02/10/25 the DON/designee completed audits 3-4 times per week of of 5-10 random residents for four (4) weeks for new onsets of pain and new skin alterations and if any falls occurred to ensure a note was entered into the resident electronic health record (EHR), immediate interventions were put into place, care plan updated, and fall follow-up was accurate. During the survey timeframe of 04/14/25 through 04/22/25 surveyor review of facility education records, completed audits, and resident record reviews revealed the facility corrective action steps were completed. This deficiency represents non-compliance investigated under Complaint Number OH00162774.

Based on medical record review and interview, the facility failed to ensure Resident #8's bedroom furniture was maintained in a safe manner to prevent the resident from sustaining an injury when her foot hit the board as she was attempting to sit up. This affected one resident (#8) of two residents reviewed for edema. Actual harm occurred on 05/21/24 when Resident #8 required seven sutures to the top of her right foot as a result of her foot being cut on the footboard of her bed. Following the incident, the facility identified the footboard was in need of repair as it was torn and rough in texture. Findings Include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and type II diabetes. Review of a nursing note dated 05/21/24 at 3:48 A.M. revealed Resident #8 had cut her right foot on her footboard. Resident #8 reported she was trying to sit up and used her foot to push. The footboard was torn on the left side of the bed. A Certified Nursing Assistant (CNA) applied pressure to the wound which was four centimeters (cm) by 0.5 cm with an unknown depth. A Registered Nurse (RN) came to see the wound and was unsuccessful at approximating the wound. The wound stopped bleeding, a dry dressing was applied and Resident #8 was transferred to the hospital. Review of a nursing note dated 05/21/24 at 7:30 A.M. revealed Resident #8 returned from the hospital with seven sutures on top of her right foot. Resident #8's family and the physician were notified. Review of an interdisciplinary team note dated 05/21/24 at 11:44 A.M. and authored by Licensed Practical Nurse (LPN) #195 revealed Resident #8 received a skin laceration to her right foot while trying to swing her legs around to the side of the bed so she could sit up. Resident #8 bumped her foot on the footboard causing the laceration and was sent to the emergency department where she received six sutures. The maintenance department smoothed out the rough edges on the footboard and it was then padded with a pool noodle. Interview on 04/16/25 at 5:04 P.M. with Maintenance Technician (MT) #132 revealed he sanded Resident #8's footboard after she cut her foot on it. MT #132 verified there was a rough patch on the foot board. There was no evidence provided to ensure the facility had a system in place to provide for the ongoing maintenance and timely repairs of resident equipment to prevent resident injury. Interview on 04/16/25 at 5:06 P.M. with LPN #195 verified Resident #8 cut her foot (on 05/21/24) at approximately 3:00 A.M. The LPN revealed Resident #8 had a lot of swelling in her legs, so her skin was fragile. The LPN recalled Resident #8's wound looked like a clean cut and was not jagged. LPN #195 stated Resident #8 had a new bed with a different footboard now. Interview on 04/17/25 at 9:44 A.M. with Resident #8 revealed she recalled the incident where she had to get sutures on her right foot. The resident reported the injury had been caused from the foot board of her bed. The resident indicated she had been able to feel when her foot was sliced, but was not able to visualize the appearance of the footboard to determine why the injury occurred.

Based on record review, hospital record review and interview, the facility failed to provide adequate and timely respiratory care and treatment for Resident #2, related to a decline in the resident's respiratory status and need for oxygen use. This affected one resident (#2) of one resident reviewed for edema. Actual harm occurred beginning on 03/10/25 when the facility failed to adequately and timely treat respiratory complications exhibited by Resident #2 which included shortness of breath, abnormal lung sounds and decreased oxygen saturation. On 03/11/25 staff had increased the resident's oxygen to seven liters (the resident had an order for oxygen at one to five liters at that time) with no additional intervention noted. On 03/14/25 at 11:45 P.M. Resident #2 was transferred to the hospital and admitted for a six day hospitalization for treatment of acute respiratory failure with hypoxia, acute exacerbation of chronic obstructive pulmonary disease (COPD), and pneumonia requiring intravenous antibiotics. Findings Include: Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, non-displaced fracture of lateral malleolus of left fibula, subsequent encounter for closed fracture with routine healing, aphasia, pneumonia, morbid obesity, anemia, hemorrhoids, reduced mobility, allergic rhinitis, weakness, COVID-19, chronic obstructive pulmonary disorder (COPD), asthma, anemia, hypertension (HTN) , hyperlipidemia, gastrointestinal reflux disease (GERD), seizures, diaphragmatic hernia. Review of Resident #2's care plan dated 08/09/24 revealed the resident had COPD. Goals included the resident would display optimal breathing patterns daily through review date. Interventions include giving aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Head of bed elevated to prevent shortness of breath. Identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, perfumes, etc. Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for signs and symptoms (s/sx) of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath (SOB) at rest, cyanosis, somnolence. Monitor/document for anxiety. Offer support, encourage resident to vent frustrations and fears. Reassure. Give as needed (PRN) medications for anxiety as ordered. Monitor/document/report PRN any s/sx of respiratory infection: fever, chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (dyspnea), increased coughing and wheezing. Record review of the Minimum Data Set (MDS) assessment completed 02/14/25 revealed a Brief Interview For Mental Status (BIMS) score of 00 indicating the resident had cognitive impairment. The MDS did not reflect the resident utilized oxygen. Review of a progress note dated 03/08/25 at 8:56 P.M. and authored by Licensed Practical Nurse (LPN) #180 revealed the resident presented with a productive cough and redness noted to face. Vital signs included blood pressure (BP) 122/74, temperature 99.8 Fahrenheit (F), heart rate (HR) 95, respiratory rate 18 and oxygen saturation (Sp02) 90% on room air (RA). The resident was noted to have swelling to left side of face. An order was received from Nurse Practitioner (NP) #999 to transfer resident to the emergency room (ER) for evaluation. Review of a progress note dated 03/08/25 at 11:58 P.M. and authored by Licensed Practical Nurse (LPN) #195 revealed on 03/08/25 at 11:17 P.M. the resident's temperature was 99.5 Fahrenheit (F), lung sounds were congested and the resident had nasal congestion. Oxygen saturation was 93% on room air. The resident had complaints of feeling chilled. The LPN notified Nurse Practitioner (NP) #888 who ordered a chest x-ray (CXR) and Tamiflu. Record review revealed a chest x-ray completed 03/08/25 with findings of bibasilar atelectasis on Resident #2. Record review revealed an order obtained on 03/09/25 from NP #999 for oxygen at 1-5 liters per minute (LPM) via nasal cannula (N/C). May titrate. May remove for care, treatment and activities as needed every shift. This order was discontinued on 03/18/25. Review of a progress note dated 03/09/25 at 12:33 P.M. and authored by LPN #180 revealed this nurse called the hospital for an update on the resident. The resident tested positive for Influenza A. The resident would be discharging back to the facility when transportation was available. A progress note dated 03/10/25 at 10:21 A.M. by LPN #160 revealed the resident had labored breathing with a pulse ox of 79% with the resident wearing three liters of oxygen. The oxygen was increased to five liters with no change in pulse ox reading. High flow concentrator obtained, resident placed on seven liters of oxygen with a saturation of 95%. The note indicated NP #999 was aware of all, care on going at this time. A progress note dated 03/11/25 at 00:00 A.M. by NP #999 revealed the resident was seen to assess comfort and dyspnea (shortness of breath). The note revealed the resident had been sent out on Saturday (03/08/25) for dyspnea and diagnosed with Influenza A. O2 saturation was 91% with O2 flow rate of seven liters. Respiratory status noted the resident had scattered rhonchi. The resident had influenza due to identified novel influenza A virus with other respiratory manifestations. The plan was to continue Tamiflu through 03/14/25. No other treatments or orders were provided at that time. Record review revealed no documented evidence of assessment or monitoring from 03/12/25 through 03/13/25 of Resident #2's respiratory or neurological status. Record review revealed no documentation of Resident #2's plan of care reflecting use of oxygen. Record review revealed a progress note dated 03/14/25 at 11:58 P.M. and authored by LPN #180 that indicated Resident #2 presented with (new) onset shortness of breath (SOB) and chest pain. Vital signs include blood pressure (BP) 146/74, heart rate (HR) 75, respiratory rate (RR) 22, oxygen saturation 92% on seven liters (L). The resident was noted to have two plus pitting edema to right lower extremity (RLE). Respirations were abnormal and included inspiratory and expiratory wheezing and rhonchi noted bilaterally. The nurse called 911 at 11:35 P.M. The resident was transferred out of facility at 11:45 P.M. to the hospital via stretcher and two attendants. Report was called to the hospital at 11:50 P.M. Record review revealed a progress note dated 03/15/25 at 4:25 A.M. authored by LPN #180 that indicated the hospital was called to get a report on the resident's status. The facility was informed the resident was being admitted to the hospital with a diagnosis of hypoxia. Record review revealed a progress note dated 03/19/25 at 1:47 P.M. authored by LPN #206 which indicated the resident was admitted to the hospital with a diagnosis of pneumonia. Review of the March 2025 medication administration record (MAR) treatment administration record (TAR) for Resident #2 revealed documentation of oxygen in use and on resident from 03/10/25 through 03/14/25 on day and night shift over the ordered 1-5 LPM. Documentation revealed five days oxygen was administered to Resident #2 at seven liters per minute via nasal cannula. Record review revealed no new orders or documentation of new orders being implemented for assessments, interventions, or medications by NP #999 on 03/10/25 or 03/11/25 for Resident #2 following the identification of labored breathing, scattered rhonchi, increased swelling, and increased oxygen demand. Review of hospital documentation for Resident #2 revealed the resident was admitted for acute respiratory failure with hypoxia, acute exacerbation of COPD, and pneumonia. Resident #2 was prescribed Vancomycin and Zosyn while hospitalized from 03/14/25 through 03/19/25. Interview on 04/16/25 at 6:51 A.M. with LPN #180 revealed she did not work for a few days prior to Resident #2 being transferred to the hospital (on 03/14/25). She said when she got to the facility on this date and went in to see Resident #2 she realized something was not right and began to assess the resident and then subsequently had her transferred out of the facility (to the hospital) for more treatment. Interview on 04/16/25 at 8:58 A.M. with LPN #160 revealed staff were concerned about Resident #2's status on 03/11/25 as the resident was having ongoing issues. The LPN stated she saw Resident #2 that day and knew something wasn't right with the resident; the resident was having labored breathing. LPN #160 revealed she called NP #999 who instructed her to keep Resident #2 at the facility as long as her oxygen level stayed up. LPN #160 revealed she was unsure if NP #999 came in that day but believed she did; however, no new orders were provided. LPN #160 stated she continually went into the room to check on Resident #2 and looped the CNA staff in as well.

Based on medical record review, interview, and policy review the facility failed to ensure antibiotics usage met criteria. This affected four residents (#7, #28, #51, and #54) of four residents reviewed for antibiotic use. Findings include: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, heart failure, and liver disease. On 04/05/25 the resident reported having pain in upper left side ribcage area. The physician was notified and ordered a chest x-ray. The x-ray result indicated an increase in left basilar infiltrates (from previous x-ray completed 01/14/25) and pleural effusion was noted. On 04/07/25 the physician was notified of x-ray results and ordered Omnicef (antibiotic) 300 milligrams (mg) twice daily for seven days as well as DuoNeb four times daily for seven days. The physician was aware the resident didn't meet McGeer's criteria and no new orders given. There was no documented evidence of why the resident needed Omnicef when she didn't meet the criteria. Review of Resident #51's medication administration record (MAR) dated 04/2025 revealed the resident was ordered and received Omnicef 300 mg from 04/07/25 to 04/14/25 for pneumonia. Review of McGeer's Criteria for Infection Surveillance Checklist dated 04/07/25 revealed Resident #51 did not meet any criteria to receive an antibiotic for pneumonia. Interview on 04/16/25 at 11:55 A.M. with Infection Preventionist (IP) #161 confirmed there was no documented evidence Resident #51 met criteria for antibiotic treatment due to the x-ray did not show pneumonia and the resident had respiratory symptoms. The IP confirmed the physician did not provide an explanation why the antibiotic was warranted. 2. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Resident #28's progress note dated 04/12/25 revealed the resident returned back to facility after the hospital re-inserted a foley catheter. Per the nurse the resident had some minor bleeding and a few clots, however after irrigating the foley the urine was pale yellow. The resident will return with new orders for Bactrim twice daily for seven days for a urinary tract infection. Review of the infection control log dated 04/2025 revealed no evidence the resident was listed on the infection control log nor was there McGeer papers completed for the resident. Review of Resident #28's medication administration record dated 04/2025 revealed the resident had started the Bactrim on 04/12/25 and continued to receive the medication twice daily as of 04/16/25. Interview on 04/16/25 at 12:44 P.M., with IP #165 confirmed Resident #28 did not have McGeer criteria completed nor was the resident list on the infection control log. Interview on 04/16/25 at 1:21 P.M., with the Director of Nursing (DON) and Registered Nurse (RN) #301 confirmed Resident #28 did not meet criteria for antibiotic treatment due to the urine growing less than 10,000 mixed flora. The DON confirmed that the IP nurse didn't notify the physician until today the resident did not meet criteria. 3. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, and anxiety. Review of Resident #7's progress note dated 04/03/25 revealed the physician reviewed urine results and a culture was not completed. New order to obtain another urine with reflex and then to start Keflex 500 mg three times a day for five days. Orders placed in chart and urine collected without complications. Review of Resident #7's progress note dated 04/04/25 revealed the Nurse Practitioner visited and reviewed urine results and wanted Keflex continued until sensitivity was available. Review of Resident #7's MAR dated 04/2025 revealed the resident received Keflex for five days (04/03/25 to 04/08/25). Review of McGeer's Criteria for Infection Surveillance Checklist dated 04/03/25 revealed the form was not completed. Interview on 04/16/25 at 2:14 P.M., with IP #165 confirmed Resident #7 did not meet criteria for antibiotic treatment due to there was no culture performed with either urine collected. The IP nurse confirmed there was no evidence the physician was notified there was no culture with the second urine that was collected on 04/03/25. Review of the facility policy titled Antibiotic Stewardship dated 09/25/24 revealed the facility has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. The Centers for Disease Control (CDC) has reported that antibiotic resistance was one of the major threats of human health, especially because some bacteria have developed resistance to all known classes of antibodies. According to the CDC, improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance as national priority. Diseases caused by these bacteria and increasing in long-term care facilities and contributing to higher rates of morbidity and mortality. The IP would be responsible for infection surveillance and MSRO tracking, The IP would collect and review data as such. The IP would collect and review data such as whether appropriate tests such as cultures would obtain before ordering antibiotics. 47985 4. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including dementia, ileus, and dysphagia. Review of a nursing note dated 01/25/25 at 4:06 P.M. revealed Resident #54 was having behaviors including opening doors and being combative towards an aide. A call was placed to a medical provider and awaiting further instructions. Review of a nursing note dated 01/25/25 at 8:26 P.M. revealed Resident #54 was in the emergency room and had no significant behaviors. Resident #54 would be treated for a urinary tract infection (UTI) and sent back to the facility. Review of a nursing note dated 01/25/25 at 7:58 P.M. revealed Resident #54 readmitted to the facility with a new order for Keflex (antibiotic) 250 mg by mouth four times a day for seven days. Family and provider were updated. Review of a urinalysis completed on 01/25/25 at the hospital revealed Resident #54's urine had no significant growth over 48 hours. Review of McGeer's Criteria for Infection Surveillance Checklist dated 01/26/25 revealed Resident #54 did not meet any criteria to receive an antibiotic for a UTI. Review of a nursing note dated 01/28/25 at 8:18 A.M. by Director of Nursing (DON) revealed Resident #54 was started on antibiotics in the emergency room for a UTI but he did not meet McGeer's criteria for an antibiotic. The DON made the medical provider aware who gave an order to continue the medication related to change in condition, agitation and increased confusion. Review of a policy titled Antibiotic Stewardship dated 12/01/23 revealed it is the facility's policy to implement an antibiotic stewardship program which will promote the appropriate use of antibiotics while optimizing the treatment of infections at the same time reducing the possible adverse events associated with antibiotic use.

Based on medical record review and interview the facility failed to notify the resident representative of an unwitnessed fall that resulted in the resident's injury. This affected one resident (#181) of four residents reviewed for accidents. The facility census was 75. Findings include: Review of the medical record for Resident #181 revealed the resident was admitted on [DATE] on hospice services with a facility discharge date of [DATE]. The resident's diagnoses included senile degeneration of the brain, chronic obstructive pulmonary disease, dementia, Alzheimer's disease, malignant neoplasm of the bronchus or lung and repeated falls. Review of the baseline care plan dated 02/08/25 revealed Resident #181 was at risk for elopement/wandering related to dementia, at risk for falls and potential injury related to history, psychoactive medication required due to alteration in mood and behavior related to anxiety and wandering without purpose. Interventions included to have commonly used articles within easy reach, maintain clear pathways, monitor for side effects of psychotropic medications, room close to nurses' station. Review of facility investigation dated 02/10/25 revealed Resident #181 was found on the floor on 02/07/25 at 7:30 P.M. Review of Resident #181's medical record revealed no documented evidence the resident had fallen on 02/07/25, nor was there documented evidence the resident's representative or physician was notified of the fall. Interview on 04/17/25 at 11:33 A.M. with Regional Clinical RN #198 confirmed Resident #181 had fallen on 02/07/25, however the fall was not documented in the medical record nor was the responsible party or physician notified until 02/10/25 after the resident was hospitalized on [DATE]. Review of the facility Fall policy (dated 02/2018) revealed the facility was to assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. Section Two identified Assessments and Notification revealed appropriate medical care will be provided as needed, including calling for emergency transport to the emergency room if needed. The physician will be notified of the fall and outcome. The resident representative will be notified of a fall. The DON/Designee will be notified of each fall. This deficiency represents non-compliance investigated under Complaint Number OH00162774.

Based on observation, medical record review, review of operational manual, observation, and interview the facility failed to ensure a pressure relieving air mattress was accurately set per the resident's weight and maintained per the manufacturer's guidelines. This affected one resident (#34) of four residents reviewed for pressure ulcers. Findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including suspected deep tissue injury (SDTI) (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. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue), peripheral vascular disease, anemia, chronic kidney disease, vascular dementia, hemiplegia, protein-calorie malnutrition, and diabetes. Review of Resident #34's Minimum Data Set (MDS) dated [DATE] revealed the resident was at risk for pressure injury and had one unstageable pressure ulcer. Review of Resident #34's impaired skin integrity plan of care dated 03/18/25 and revised 04/14/25 revealed the resident had a pressure injury to the coccyx/bilateral buttocks region. Interventions included an air mattress with a pump for comfort and wound. Review of Resident #34's wound assessment revealed the resident had developed a SDTI on his coccyx 03/18/25 that measured 10 centimeter (cm) by seven cm by unable to determine (UTD). A pressure reduction mattress per facility protocol was in place. Review of Resident #34's weight dated 04/04/25 revealed the resident weighed 174.5 pounds. Review of Resident #34's treatment administration record (TAR) and orders dated March 2025 and April 2025 revealed staff were signing off the air mattress was checked every shift for function and no issues noted. Observation on 04/14/25 at 10:24 A.M., of Resident #34 revealed the pressure relieving air mattress weight setting was set on eight (441-500 pounds) and the service light was on. The label on the bed indicated a resident weight between 163-244 pounds should be set on three and eight was for a resident weighing 441-500 pounds. Observation on 04/15/25 at 8:20 A.M., revealed the pressure relieving air mattress was set on eight (441-500 pounds) and the light was on to service the mattress. Observation on 04/15/25 at 9:56 A.M., with the Assistant Director of Nursing (ADON)/wound nurse (WN) #195 confirmed the pressure relieving air mattress was set on eight and according to the weight plate the setting should have been set on three for a resident weighing between 163-244 pounds. ADON/WN reported she was not sure why the service light was on, and she would have to investigate that due to the mattress being rented from a company. The facility usually sets the mattress for residents' comfort, and she would have to look at the manufacturer's guidelines for the weight as well. Observation and interview on 04/15/25 at 2:32 P.M of Resident #34 with Certified Nursing Assistant (CNA) #110 revealed the CNA confirmed the resident's last weight was 174.5 pounds and the mattress was set on 441-500 pounds (eight), and it should have been set on three since the resident weighed between 163-244 pounds per the label on the bed. The CNA #110 confirmed the service light was on. Review of Prius 3-1 alternating anti-decubitus system manufacturer's manual (undated) revealed the mattress provided alternating therapy to prevent and treat pressure ulcers. When the mattress was fully inflated, set the dial in accordance with the patient's size and weight. P3 was for a weight of 163-244 and P8 was for weight of 441-500 pounds. The service light indicated service was required after 8760 hours of use. Interview on 04/15/25 at 10:37 A.M. and 3:21 P.M., with ADON/WN #195 revealed the company was going to come and replace the mattress. The ADON confirmed the facility was not aware the comfort setting was referencing the resident weight. The ADON confirmed the setting should have been on three not an eight according to the manual. The ADON reported the company reported the service light didn't indicate the mattress was not functioning properly it was just a warning the mattress needed service after so many hours of use. The company confirmed they were not tracking the service light, and it was the facility's responsibility to notify them when the service light was activated. The ADON confirmed the service light was activated and staff did not report the service light was activated nor was the facility aware the staff need to notify the company when the light was activated.

Based on observation, medical record review, interview, and policy review the facility failed to ensure dialysis dietary recommendation to administer protein snack at night was implemented and failed to ensure meal intakes were adequately monitored and documented. This affected two residents (#44 and #51) of three residents reviewed for nutrition. Findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with end stage renal disease, protein-calorie malnutrition, heart failure, diabetes, and liver disease. Review of Resident #51's dialysis plan of care dated 02/21/25 and revised 03/20/25 revealed the resident dialysis days were Monday, Wednesday, and Friday at 10:30 A.M. There was no evidence to provide a protein snack at night. Review of Resident #51's plan of care for compromised nutritional status dated 02/21/25 revealed to offer increased protein in the diet. There was no evidence to offer a protein snack at night. Review of dialysis nutrition note dated 03/24/25 (re-faxed 04/16/25) revealed the Dialysis Dietician (DD) #303 had faxed the dietary note to the facility originally on 03/24/25. The DD #303 had recommended high-protein snacks at night. The resident's albumin was 3.2 and goal range was greater than 4.0. The DD #303 indicated the resident's albumin may be low if she was not eating enough protein. Review of the facility's dietary notes dated 03/26/25 and 04/16/25 revealed no evidence of a protein snack at night. Review of Resident #51's orders dated 03/2025 and 04/2025 revealed no evidence of an order for high-protein snack at night. Review of the resident supplement orders list dated 04/17/25 revealed no evidence Resident#51 was receiving a supplement at night. Interview on 04/16/25 at 1:06 P.M., via phone with the DD #303 revealed she had recently started faxing over her assessments to the facility's dietician in the last month. Prior, they had spoken on the phone monthly. DD #303 reported the facility's dietician had reached out to her today per the surveyor's request for dietary notes and she had to remind the facility's dietician that she had faxed her recommendation over last month. The facility's dietician reported to DD#303 she had misplaced them. The Dialysis Dietician reported she did not have access to the resident medical record at the time of the phone interview, however she had made some adjustments in the resident diet due to her labs. Interview on 04/17/25 at 7:30 A.M. with Dietary Manger (DM) #170 confirmed the kitchen prepares nighttime snacks and there was no resident currently with a special order, such as a high protein snack. The DM reported she usually put peanut butter and jelly sandwiches, ham or chicken salad sandwiches, chips, cookies, pudding, or leftover snacks (cakes/pies) on the snack cart. The dietary staff or floor staff would help distribute the snacks around 6:30 P.M. to 6:45 P.M. nightly. Interview on 04/17/25 at 7:40 A.M., with Resident #51 revealed she doesn't receive a snack at night unless she asks for one. She has never received a protein snack at night from the facility, however occasionally she will not eat the one the dialysis center gives her, a protein bar, and she will bring it back to the facility for a snack. Interview on 04/17/25 at 7:55 A.M., with the Director of Nursing (DON) confirmed Resident #51 was not ordered a protein snack at night per the dialysis dietician recommendation. The DON reported the facility's dietician was contracted and was not in the facility full time, however the number on the fax cover sheet was the facility's fax number the dialysis dietician had faxed to on 03/24/25. 51519 2. Record review revealed Resident #44 was admitted to the facility 07/19/23 with diagnoses including dementia, anemia, HLD, HTN, depression, protein - calorie malnutrition, anxiety, overactive bladder, cognitive communication deficit, difficulty walking, weakness, dorsalgia, gastroesophageal reflux disease (GERD), major depressive disorder. Review of a quarterly minimum data set (MDS) completed 02/22/25, section C revealed a brief interview for mental status (BIMS) score of 00 indicating cognitive impairment. Section D revealed the resident was feeling down, depressed, or hopeless, and had a poor appetite or overeating for a total severity score of 06 and often feels socially isolated. Section GG functional abilities revealed for eating the resident's had the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Resident #44 required set up or clean up assistance. Review of care plan completed 09/02/21, revised 02/04/25 revealed resident #44 was at nutrition/hydration risk due to diagnoses of left hip fracture with surgical repair, urinary tract infection, diabetic therapeutic diet, body mass index (BMI) low, history of edema, diuretic use, psychoactive medication use, non-significant weight loss. Resident desired to eat meals in room, malnutrition, poor intakes/appetite, refused alternate foods/fluids, dementia, and tube feedings declined. Goals included Resident #44 will consume more than 75% of most meals, resident will maintain weight without unplanned significant weight changes. Interventions included to assess and report signs of edema to Medical Director, assess for signs and symptoms of aspiration, assist with meals as needed, encourage compliance with diet guide lines, ,encourage resident to dine in dining room as is appropriate, encourage resident to make healthful diet choices, honor food preferences as able, administer medications as ordered, monitor blood glucose levels per order and PRN, monitor consistency of diet served, monitor for signs and symptoms of dehydration, monitor labs as ordered, obtain food preferences, offer meal alternate if resident refuses meal, oral care as needed, occupational therapy referral as needed, provide assistance with meals and snacks as necessary, provide diet as ordered, provide supplements as ordered, registered dietician referral as needed, speech therapy referral as needed, weights as ordered. Review of Resident weights revealed the following: 04/14/25 Resident #44 weighed 80.0 pounds (Lbs) 04/07/25 78.0 Lbs, 03/31/25 81.0 Lbs, 03/24/25 81.0 Lbs, 03/24/25 81.0 Lbs, 03/11/25 76.0 Lbs, 03/03/25 80.0 Lbs, 02/24/25 80.0 Lbs, 02/17/25 80.0 Lbs, 02/10/25 77.0 Lbs, 02/03/25 80.0 Lbs, 01/27/25 77.0 Lbs, 01/20/25 79.0 Lbs, 01/13/25 78.0 Lbs, and 01/06/25 75.0 Lbs. Record review for the task of what percentage of the meal was eaten, revealed no documentation for any meal on 03/20/25, 03/22/25, 03/27/25 (Resident #44 was out of the facility for lunch and breakfast meals and returned to the facility on [DATE] at 3:44 P.M.) , 03/30/25, 04/04/25, 04/05/25, 04/12/25, 04/15/25. Record review for the task of what percentage of the meal was eaten for Resident #44 revealed 57 documented meals in the past 30 days (03/18/25 through 04/16/25) Resident #44 consumed 25% of one meal, 25-50% of five meals, 51-75% of 31 meals, and 76-100% of 20 meals. Interview on 04/16/25 at 8:20 A.M. with Certified Nursing Assistant (CNA) #184 revealed Resident #44's appetite can fluctuate day by day. CNA #184 stated Resident #44 really likes sweets, she snacks with activities when she goes. CNA #184 stated she is not sure if Resident #44 receives a snack at bedtime because she does not work night shift but the cart typically goes around 6:45 P.M. to 7:00 P.M CNA #184 stated for each meal they are to document how much the residents eat and drink. They used the computer to document intakes for every meal and if there was any meals they receive outside of the scheduled meals. CNA #184 stated if a resident refused a meal they were to document it as refused, if the resident was out of the facility they were to document resident not available, and if they set up the residents tray and they ate nothing but do not refuse it is a 0% intake. Observation on 04/16/25 at 8:38 A.M. revealed Resident #44 eating cream of wheat with two 3/4 cup of orange juice, 1/2 cup of vanilla ice cream, 8 fluid ounces of water, 2 scrambled eggs, and 2 slices of bacon. Resident #44 was sitting up, tray was set up by staff, and the resident was feeding herself. At this time, 25% of meal consumed.

Based on medical record review, interview, and policy review the facility failed to ensure dialysis orders to hold medications were clarified and implemented. This affected one resident (#51) of one resident reviewed for dialysis. Findings included: Medical record review revealed Resident #51 was admitted to the facility on [DATE] with end stage renal disease, protein-calorie malnutrition, heart failure, diabetes, and liver disease. The resident was hospitalized from 02/10/25 to 02/20/25. Review of Resident #51's dialysis plan of care dated 02/21/25 and revised 03/20/25 revealed the resident dialysis days were Monday, Wednesday, and Friday at 10:30 A.M. There was no evidence to hold medication on dialysis days. Review of Resident #51's orders dated 02/08/25 to 04/16/25 revealed no evidence to hold medication on dialysis days. Review of Resident #51's medication administration record (MAR) dated 02/08/25 to 04/16/25 revealed in February (2025) staff held A.M. medication on dialysis three of four days, in March (2025) 11 out of 13 dialysis days, and six out of seven dialysis days in April (2025) without a physician order. Further review of April (2025) MAR revealed the resident's A.M. medication included: Allegra 180 milligrams (mg) in the morning for allergies, Aspirin 81 mg in the morning for clot prevention, Budesonide 9 mg in the morning for colitis, Cardizem (blood pressure) 180 mg in the morning, Miralax in the morning for constipation, Singular 10 mg in the morning for allergies, Omeprazole (proton-pump inhibitor) 40 mg in the morning, Vitamin B-12 (supplement) injection once every Monday, Colace (stool softener) 100 mg twice daily, Lactulose 30 milliliters (ml) twice a day for constipation, Prostat (supplement) 30 ml twice daily, Senna Plus twice daily for constipation, Calcium Acetate 667 three times daily before meals, and Levoalbuterol nebulizer three times daily. Interview on 04/16/25 at 8:42 A.M. and 12:42 P.M. with the Director of Nursing (DON) revealed the resident was discharged home on 01/28/25 and was readmitted on [DATE]. The resident had an order from a previous admission to hold medications on dialysis days. The DON confirmed in February, March, and April (2025) staff continued to hold all A.M. medication without a physician order on dialysis days. The DON reported she had updated the resident physician and dialysis of the medication errors. Interview on 04/16/25 at 1:21 P.M. interview with the DON revealed dialysis sent over a new order and dialysis only wanted the resident blood pressure medication to be held on dialysis days not all A.M. medications. Review of the facility policy titled Dialysis dated 01/01/25 revealed to coordinate with dialysis center and provider regarding medication administration times.

Based on medical record review and interview the facility failed to ensure medications were reconciled correctly on admission. This affected one resident (#181) of one resident reviewed for psych/opioid medication review. The census was 75. Findings include: Review of the closed medical record review for Resident #181 revealed the resident was admitted on [DATE] under hospice services and discharged to the hospital on 02/09/25. The resident's diagnoses include senile degeneration of the brain, chronic obstructive pulmonary disease, dementia, Alzheimer's disease, malignant neoplasm of the bronchus or lung and repeated falls. Review of the baseline care plan dated 02/08/25 revealed Resident #181 was at risk of injury related to smoking, at risk for elopement/wandering related to dementia, at risk for falls and potential injury related to history, psychoactive medication required due to alteration in mood and behavior related to anxiety and wandering without purpose. Intervention included to have commonly used articles within easy reach, maintain clear pathways, monitor for side effects of psychotropic medications, room close to nurses' station. Review of Resident #181's hospice medication list dated 01/24/25 revealed Resident #181 was receiving Lorazepam Oral Tablet 0.5 milligram (MG) give 1 tablet by mouth every four hours for anxiety and/or restlessness. Morphine Sulfate Oral Solution 20 milligrams (MG)/5 milliliters (ML) give 0.25 ml by mouth every 1 hours as needed for pain 1-3 or shortness of breath, Morphine Sulfate Oral Solution 20 MG/5ML give 0.5 ml by mouth every 1 hours as needed for pain 4-6 or shortness of breath for 14 Days, Morphine Sulfate Oral Solution 20 MG/5ML give 0.75 ml by mouth every 1 hours as needed for pain 7-8 or shortness of breath, Morphine Sulfate Oral Solution 20 MG/5ML give 1 ml by mouth every 1 hours as needed for pain 9-10 or shortness of breath. Review of a progress note dated 02/07/25 at 11:55 PM revealed RN #109 contacted hospice to confirm Resident #181's medication orders on admission. Review of physician orders dated 02/07/25 revealed Lorazepam Oral Tablet 0.5 milligram (MG) give 1 tablet by mouth four times a day for anxiety/restlessness (not every four hours per hospice order). Review of the Medication Administration Record (MAR) for February 2025 revealed Lorazepam Oral Tablet 0.5 milligram (MG) give 1 tablet was administered four times a day. Further review of the February 2025 MAR revealed 0.75 milliliter (ml) of Morphine Sulfate Oral Solution 20 milligram (MG)/5 milliliter (ML) was administrated on 02/09/25 at 7:55 P.M. and 1.0 milliter (ml) administrated at 9:19 P.M. Review of the Narcotic count sheet (undated) revealed the Morphine Sulfate Oral Solution 20 MG/5ML 0.5 milliter (ml) was administered at 5:30 P.M. and 6:40 P.M. which did not match the MAR. Interview on 04/17/25 at 2:10 P.M. with Regional Clinical RN #198 confirmed the Ativan order was not correctly entered on admission due to the hospice order was for Ativan 0.5 mg every four hours and staff entered it as four times a day. RN #198 also confirmed the Morphine Sulfate Oral Solution 20 MG/5ML administered on 02/09/25 was not accurately documented on the narcotic count sheet.

Based on observation, interview, facility document review and facility policy review the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when caring for COVID-19 positive residents, performed hand hygiene and disposed of sharps appropriately, and failed to ensure the disinfectant wipes outside of COVID-19 isolation rooms was not expired. Staff not wearing the appropriate PPE and the expired disinfectant wipes had the potential to affect all 56 residents residing in the facility who had not tested positive for COVID-19. The hand hygiene concern affected Resident #233 and the improper disposal of sharps had the potential to affect all residents residing in the facility. The facility census was 69. Findings included: 1. Observation on [DATE] at 9:00 A.M. upon entrance into the facility revealed signage on the entrance door reading Please be aware that (Facility Name) is currently in Outbreak due to Positive staff/residents which informed those who enter the building that the facility was in an active state of COVID-19 outbreak. Review of the facility order listing report, dated [DATE], revealed there were 13 Residents (#2, #8, #11, #12, #15, #22, #29, #62, #66, #72, #74, #223, #236) in the facility which were positive for the COVID-19. Observation on [DATE] at 8:54 A.M. of State tested Nurse Aide (STNA) #491 standing in the open doorway of Resident #8 and #74's shared room who were on COVID isolation due to testing positive for the COVID-19 virus. She had an isolation gown on and a surgical mask. She had her regular eyeglasses on but no goggles or a face shield and she was not wearing gloves. She received a tray from STNA #427. Interview on [DATE] at 8:56 A.M. with STNA #491, after she exited Resident #8 and #74's room, verified while in the room she was wearing an isolation gown and surgical mask as her PPE. She verified she was not wearing a N-95 mask and should have been, she verified she was wearing her vision glasses but no appropriate eye protection (face shield or protective goggles) and should have been , and she verified she was not wearing any gloves and should have been. She reported she usually worked in the memory care unit, and she was not used to wearing PPE when caring for residents who had tested positive for COVID-19. This surveyor did not observe STNA #491 enter any other resident rooms after exiting Resident #8 and #74's room. STNA #427 donned (put on) the appropriate PPE to enter the next isolation room. Interview on [DATE] at 9:30 A.M. with Regional RN #490 verified STNA #491 had been sent home from work due to her potential exposure to COVID-19 secondary to not wearing the appropriate PPE while in the room with residents who had tested positive for COVID-19 . Interview on [DATE] at 12:27 P.M. with STNA #427 verified she was handing breakfast trays to STNA #491. STNA #427 verified since STNA #491 was not wearing the appropriate PPE to care for residents who had tested positive for COVID-19, she donned the appropriate PPE and went into the next isolation room and had STNA #491 stay in the hallway and hand her trays. She reported STNA #491 was then sent home. Review of the facility policy titled Infection Control Prevention Program, revised ,d+[DATE], revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Residents have the right to reside in a safe environment that promotes health and reduces the risk of acquiring infections. Further review revealed the goals of the facility infection prevention program are to reduce the spread of infectious disease within the facility, decrease the risk of infections within the facility through standard and transmission-based precautions, and monitor for occurrence of infection and implement appropriate control measures. Review of the Post Public Health Emergency (PHE) Guidance, dated ,d+[DATE], revealed when entering a transmission-based isolation room appropriate PPE is required (mask, protective eyewear, gloves, gown). 2. Observation on [DATE] at 1:45 P.M. of Licensed Practical Nurse (LPN) #492 administering an intravenous antibiotic to Resident #233. She donned (put on) the appropriate PPE due to the resident being on COVID-19 isolation. LPN #492 entered the room and disconnected and discarded the intravenous antibiotic bag which had been administered earlier in the day from the intravenous tubing. LPN #492 then doffed (removed) her gloves and donned new gloves. She did not perform any hand hygiene between doffing of the old and donning of the new gloves. LPN #492 then proceeded to connect the intravenous tubing to the antibiotic bag being administered. Interview on [DATE] at 2:00 P.M. with LPN #492 verified she did not perform hand hygiene between doffing and donning of gloves and should have. Review of the facility policy titled, Hand Hygiene, undated, revealed hands should be washed for at least twenty (20) seconds using soapy and water under the following conditions: L. before putting on gloves and M. after removing gloves. 3. Observation on [DATE] at 8:10 A.M. of the Dispatch Hospital Cleaner Disinfectant Towels with Bleach outside of Resident #15 and #66's room in the bottom drawer of the isolation cart. These were the disinfectant wipes to be used for cleaning protective eyewear after exiting a room with COVID-19 positive residents. Observation of the container revealed the Dispatch Hospital Cleaner Disinfectant Towels with Bleach had expired on [DATE] and even though it had bleach in it, Coronavirus was not listed as one of the viruses the disinfectant killed. Review of documentation from the internet revealed the Dispatch Hospital Cleaner Disinfectant Towels with Bleach did kill the Coronavirus. Interview on [DATE] at 8:13 A.M. with Regional RN #490 verified the wipes were expired. An assessment of all isolation carts by the Regional RN #490 revealed the Dispatch disinfectant wipes outside of Resident #22's and Resident #72's rooms were also expired. Regional RN #490 revealed the facility was pulling all the disinfectant towels from the isolation carts and will only use disposable face shields. Telephone interview on [DATE] at 9:17 A.M. with customer service personnel for the manufacturer of Dispatch disinfectant wipes revealed the Dispatch Hospital Cleaner Disinfectant Towels with Bleach did not have an extended shelf life beyond the expiration date and the efficacy could not be guaranteed for any pathogen, including COVID-19, beyond the expiration date. 4. Observation on [DATE] at 11:05 A.M. of LPN #456 obtaining a finger stick blood sugar (FSBS) from Resident #44. LPN #456 gathered her supplies which included two lancets (a needle device to prick the finger for a drop of blood for FSBS testing), performed hand hygiene, donned gloves and informed the resident what would be happening. She obtained the FSBS, and the reading was 343. LPN #456 informed Resident #44 she would return with his insulin to cover his elevated blood sugar. She exited the room and placed the used lancet and unused lancet in the trash can connected to the medication cart. Interview on [DATE] at 11:14 A.M. with LPN #456 verified she discarded one used lancet and one unused lancet in the trash can connected to the medication cart. She verified that was not appropriate disposal of a lancet, especially one which had been used and had blood on it. Review of the facility policy titled, Sharps Disposal, revised ,d+[DATE], revealed the facility shall discard contaminated sharps into designated containers. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. Further review revealed contaminated sharps will be discarded into containers that are: closable, puncture resistant, leakproof on sides and bottom, labeled or color-coded in accordance with our established labeling system, and impermeable and capable of maintain impermeability through final waste disposal.

Based on record review, review of liability notices, and staff interview, the facility failed to ensure a resident received appropriate notice prior to the end of their Medicare (MCR) Part A services and residents that opted to receive those services continued to receive them while MCR was billed for an official decision on payment. This affected two residents (#1 and #48) of three residents reviewed for liability notices. Findings include: 1. A review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. She was readmitted to the facility on [DATE]. Her diagnoses included end stage renal disease, dependence on renal dialysis, dementia with a mood disturbance, congestive heart failure and chronic obstructive pulmonary disease. Her diagnoses list was updated n 05/01/23 to reflect she had a below the knee amputation of the right leg. A review of Resident #1's Notice of MCR Non-Coverage (NOMNC) revealed her skilled services ended on 05/24/23. The resident received the notice on 05/22/23 providing her with at least a 48 hour notice as required. In addition to the NOMNC, the resident received a skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) that informed her beginning on 05/24/23 she may have to start paying out of pocket for her care, if she did not have any other insurance that may cover those costs. The care specified was occupational therapy, physical therapy, speech therapy, and nursing care. The reason MCR was indicated that they may not pay was due to the resident meeting her maximum potential. The estimated cost of those services was $200.00. The resident chose option 1 on the SNFABN indicating she wanted to continue to receive the care above and wanted MCR to be billed for an official decision on payment. She acknowledged that if MCR did not pay, she would be responsible for paying for those services, but could appeal to MCR by following the directions on the Medicare Summary Notice (MSN). Resident #1's medical record was absent for any evidence of her to continue to receive the care that she elected to continue to receive pending a MCR decision on payment. Findings were verified by Registered Nurse (RN) #488. On 09/21/23 at 9:16 A.M., an interview with RN #488 revealed she could not find any evidence of Resident #1 continuing to receive her skilled service, after 05/24/23, as elected by the resident pending a MCR decision. She suspected the form may have been marked incorrectly by the staff member completing it. 2. A review of Resident #48's medical record revealed she was originally admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE]. Her diagnoses included unspecified dementia with agitation and atrial fibrillation. Her diagnoses list was updated on 04/20/23 to include the diagnoses of an atrioventricular block- second degree, syncope and collapse, and placement of a cardiac pacemaker. A review of Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. Her cognition was assessed as being severely impaired. A review of Resident #48's NOMNC revealed her last covered day for MCR Part A services was on 07/13/23. The resident was informed of her last covered day of MCR Part A services on 07/13/23 (day of her last covered day) and was not provided a 48 hour notice as required. The resident signed the NOMNC acknowledging her skilled service would end on 07/13/23, despite her cognition being severely impaired. The notice was not signed by her resident representative (daughter). A review of Resident #48's SNFABN revealed the facility provided a SNFABN for an end of service beginning on 05/11/23. They did not provide a SNFABN for her end of service on 07/13/23. There was no evidence provided of a SNFABN being provided to the resident when her skilled service ended on 07/13/23. On 09/16/23 at 9:16 A.M., an interview with RN #488 confirmed Resident #48 was not given timely notice of her MCR Part A services ending on 07/13/23. She acknowledged the resident/ resident representative should have received at least a 48 hour notice before her skilled service ended. The facility denied they had a policy specific to liability notices. They contacted the regional office who told them they just followed Centers for Medicare and Medicaid Services (CMS) regulations.

Based on resident record review, interview, and facility policy review, the facility failed to ensure residents who were being transferred to the local emergency room for care received a copy of the bed hold notice. This affected two residents (#24 and #66) of two residents reviewed for hospitalization . The facility census was 69. Findings included: 1. Review of Resident #24's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, stage three, acute and chronic combined systolic and diastolic heart failure, neuromuscular dysfunction of the bladder, weakness, and essential hypertension. Review of Resident #24's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/25/23, revealed she was cognitively intact and had active diseases of chronic kidney disease, stage three and heart failure. Review of Resident #24's progress note dated, 08/01/23 at 1:30 P.M., revealed her daughter was called and updated on her mother being sent to the emergency room for evaluation of increasing edema to her legs and blistering skin to left lower limb with an open wound to her left medial lower leg draining a large amount of clear fluid. Review of Resident #24's medical record revealed no documentation to support the facility provided the resident and/or the resident's representative information regarding the facility policy for bed hold on 08/01/23. Interview on 09/20/23 at 10:47 A.M. with Business Office Manager (BOM) #447 verified there was no bed hold notice for Resident #24 due to her stay being covered by insurance. BOM #447 revealed she was not aware that residents with pay sources other than Medicaid were to be offered a bed hold notice. 2. Review of Resident #66's medical record revealed she was admitted to the facility on [DATE] with diagnoses including encephalopathy, malignant melanoma of skin, urinary tract infection, and morbid obesity. Review of Resident #66's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/21/23, revealed she was cognitively intact and had a multidrug resistant organism (MDRO). Review of Resident #66's progress note, dated 07/05/23, revealed she was transferred from the facility on 07/05/23 via emergency medical services to a local emergency room . Review of Resident #66's medical record revealed no documentation to support the facility provided the resident and/or the resident's representative information regarding the facility policy for bed hold on 07/05/23. Interview on 09/20/23 at 10:47 A.M. with BOM #447 verified there was no bed hold notice for Resident #66 due to her being skilled care. BOM #447 revealed she was not aware that residents with pay sources other than Medicaid were to be offered a bed hold notice. Review of the facility policy titled, Notice of Bed Hold Policy, dated 02/18, revealed the document must be signed by the patient upon discharge to the hospital or therapeutic leave. Further review revealed the top section was to be completed upon admission and the bottom section was to be completed if the resident leaves the center for a hospitalization or therapeutic leave to reflect the resident's decision to hold or not hold the resident's bed, subsequent to any State required bed hold period.

Based on medical record review and staff interview, the facility failed to ensure all resident Pre-Admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected three residents (#44, Resident #9, and Resident #15) of three residents reviewed for PASARR documents. The census was 69. Findings Include: 1. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, osteomyelitis, major depressive disorder, bipolar disorder, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively intact, and had diagnoses of dementia, depression and bipolar disorder. Review of Resident #44's PASARR document, dated 10/27/22, revealed under Section E, there were no diagnoses listed. Review of the resident's diagnoses list revealed bipolar disorder and major depressive disorder were added on 01/24/20. During interview on 09/20/23 at 8:37 A.M., Regional Registered Nurse (RN) #488 confirmed the resident's PASARR document did not indicate any mood disorders and should have been updated with the diagnoses of depression and bipolar disorder. 45440 2. Review of Resident #9's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (entered 09/26/23), anxiety disorder (entered 09/26/18), other psychotic disorder not due to a substance of known physiological condition (entered 05/29/15), and dysthymic disorder (entered 05/29/15). Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/26/23, revealed she was rarely/never understood, and had short-term and long-term memory problems. Further review revealed she had active diagnoses of anxiety disorder, depression, and psychotic disorder. Review of Resident #9's most recent PASARR, dated 12/13/07, revealed under Section D: Indications of Serious Mental Illness, the boxes beside mood disorder, panic or other severe anxiety disorder, and personality disorder were marked with an X. Interview on 09/19/23 at 7:48 A.M. with Social Services Designee #452 verified Resident #9's most recent PASARR was not accurate and up to date. She verified the PASARR had documented Resident #9 had a personality disorder when none was noted in her medical record and the PASARR did not have documented a psychotic disorder, which was an active diagnosis. She verified Resident #9 could be eligible for mental health services if the PASARR was completed accurately. 3. Review of Resident #15's medical record revealed she was admitted to the facility on [DATE] with diagnoses including bipolar disorder, current episode depressed (entered 07/18/23), major depressive disorder, recurrent, moderate (entered 08/11/22), generalized anxiety disorder (entered 08/11/22), and post-traumatic stress disorder (PTSD) (entered 08/11/22). Review of Resident #15's annual Minimum Data Set (MDS) 3.0 assessment, dated 07/21/23, revealed she was cognitively intact. Further review revealed her active diagnoses included anxiety disorder, depression, and PTSD. Review of Resident #15's psychiatric progress note, dated 05/16/23, revealed mental health diagnoses of bipolar, panic disorder, general anxiety disorder and PTSD. There was no diagnosis of psychosis. Review of Resident #15's psychiatric progress note, dated 08/08/23, revealed mental health diagnoses of bipolar, panic disorder, general anxiety disorder and PTSD. There was no diagnosis of psychosis. Review of Resident #15's most recent PASARR, dated 07/28/23, revealed under Section E: Indications of Serious Mental Illness, the boxes beside mood disorder, panic or other severe anxiety disorder and other psychotic disorder marked with an X. Interview on 09/19/23 at 7:55 A.M. with Social Services Designee #452 verified Resident #15's most recent PASARR was not accurate and up to date. She verified the PASARR revealed a psychosis disorder and there was none documented in the diagnoses. She verified Resident #15 could be eligible for mental health services if the PASARR was completed accurately. Interview on 09/19/23 at 8:17 A.M. with Regional Registered Nurse (RN) #488 revealed she coded Resident #15's PASARR with a psychosis diagnosis due to her diagnosis of PTSD. She presented this surveyor with a website which revealed PTSD was a psychiatric condition. RN #488 verified that PTSD was a psychiatric condition but fell under an anxiety disorder and not a psychosis disorder.

Based on record review, observation, and staff interview, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with the removal of unwanted facial hair. This affected one resident (#48) of three residents reviewed for activities of daily living (ADL's). Findings include: A review of Resident #48's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, dementia with agitation, depression, anxiety disorder, difficulty walking, weakness, and abnormalities of gait and mobility. A review of Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She was not known to have rejected any care during the seven days of the assessment period. She required an extensive assist of one for transfers and personal hygiene and was totally dependent on one for bathing. A review of Resident #48's care plans revealed she had a care plan in place for being at risk for a decline in ADL function related to an alteration in ADL performance/participation related to impaired mobility, impaired balance, decreased range of motion to her right elbow, and dementia. Her goal was for the resident's needs to be met with regard to ADL's. Her interventions included encouraging her participation while performing ADL's, staff to anticipate her needs and assist as needed, and to try to make her ADL routine consistent to foster recognition of necessary tasks. A review of Resident #48's bathing activity documented under the task tab of the electronic health record revealed she had been receiving bed baths as her bathing activity. The last bed bath was documented as having been received on 09/19/23. She required an extensive assist with the physical assist of one for personal hygiene which included shaving. On 09/18/23 at 1:54 P.M., an observation of Resident #48 noted her to have a few long, white hairs on her chin. Follow up observations on 09/19/23 at 10:18 A.M. revealed the resident continued to have a few long, white hairs on her chin that had not been removed. On 09/19/23 at 1:05 P.M., an interview with State tested Nursing Assistant (STNA) #404 revealed Resident #48 required an extensive assist of one for personal hygiene. She was asked what the facility staff did for female residents who was noted to have facial hair. She stated they would use a straight razor to shave it. She reported the resident was compliant with the removal of unwanted facial hair when that was needed. She was asked to check Resident #48 to see if she had any facial hair that needed to be removed. She confirmed the resident had several long white hairs on her chin and they had been growing a little while to get to the length they were. She asked the resident if she wanted her to shave the long hairs she had on her chin. The resident replied that would be fine with her.

Based on record review, interview, and policy review, the facility failed to ensure Resident #28 was provided prompt and necessary medical treatment following an unwitnessed fall with serious injury. Actual Harm occurred on 05/02/23 when Resident #28, who was severely cognitively impaired, did not receive timely treatment and services following a fall. The resident complained of pain (initially beginning on 05/02/23 at 12:00 P.M.) and continued to complain of pain in the right hip throughout 05/03/23. The resident had limited weight bearing and a decrease in range of motion (ROM) to the right lower extremity (RLE). The resident was not transferred to the hospital until 05/03/23 at 4:04 P.M. where he was treated for a fractured right femur. This affected one resident (#28) of three residents reviewed for falls. Findings include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, difficulty in walking, convulsions, hearing loss, tricuspid valve disorder, major depressive disorder, and anxiety. The resident resided in the secured dementia care unit. Review of the plan of care, dated 06/27/22, revealed Resident #28 was at risk for falls related to dementia, difficulty walking, hypertension, advanced age, and medications. Interventions included to ensure the call light was within reach and to encourage the resident to use it for assistance, and to encourage and assist as needed to reapply appropriate footwear. Further review of the plan of care, dated 07/11/22, revealed the resident had pain related to generalized discomfort. Interventions included to evaluate the effectiveness of pain interventions, to review for compliance, alleviation of symptoms, and to notify the physician if interventions were unsuccessful or if current complaint is a significant change from resident's past experience. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/25/23, revealed the resident had severely impaired cognition with no behaviors or rejection of care. The resident required extensive, one-person physical assistance for bed mobility, and supervision of one-person for walking in his room, transfers, dressing, personal hygiene, and toileting. The assessment indicated there were no falls since admission or the prior assessment. Review of a nursing progress note, authored by Licensed Practical Nurse (LPN) #195, dated 05/02/23 at 10:20 A.M., revealed staff reported they heard a loud sound and entered the room and observed the resident standing from the floor with his briefcase full of art supplies which had tipped over and spilled on the floor. Both arms were bleeding and the resident rubbed the right side of his head. Nurse Practitioner (NP) #300 was in the facility and assessed the resident. The resident denied pain and moved all extremities. There were skin tears noted to the right elbow and the left arm, steri-strips were applied. The resident was able to bear his own weight and neurological checks were within normal limits. The resident stated he got out of bed to walk over to the dresser, and became dizzy after standing up, and lost his balance. Orthostatic blood pressure monitoring was ordered for three days. Review of a nursing progress note, dated 05/02/23 at 12:00 P.M., revealed the resident complained of right hip discomfort. The DON and NP were notified and an order was received for an x-ray of the right hip and pelvis. Review of a nursing progress note, dated 05/02/23 at 2:31 P.M., revealed resident was wincing and yelling out while moving in bed. The resident stated he was not in enough pain to do something about it quite yet. The note indicated staff would continue to monitor. Review of the nursing progress note, dated 05/02/23 at 3:45 P.M., revealed staff reported the resident yelled out and when entering the room, resident was sitting on the floor, on the left side of his floor. The resident was wearing gripper socks and the call light was within reach. The note indicated the resident was moving all extremities without difficulty. Blood pressure was 146/80, temperature 98.1, pulse 76, and respirations were 22. The resident was assisted to a wheelchair for safety and brought out of the room to the dayroom for closer monitoring. The DON updated the NP and the resident's wife. Neurological checks were completed. The note also reflected an x-ray of the right hip/pelvis was negative earlier today. Review of a facility Fall Investigation, dated 05/02/23 at 3:45 P.M., revealed staff heard yelling and entered the room and found Resident #28 sitting on the floor beside the left side of bed. The resident stated he was getting out of bed from taking a nap and his legs gave out and he sat on floor. The fall investigation indicated the risk factors were impaired cognition, gait disturbance, functional loss, and unassisted transfer. The fall investigation indicated the resident refused his medications and the staff's last involvement with the resident was at 3:00 P.M. when an x-ray was obtained and at 3:15 P.M. when the resident used a urinal. A weekly review by the falls committee/administration, dated 05/03/23, indicated the cause was accurately identified. Further review of the fall investigation revealed that it did not include the name/names of the staff who observed the resident on the floor following the fall. Review of the nursing progress note, dated 05/02/23 at 4:41 P.M., revealed Resident #28 complained of right hip pain and received Tylenol 650 milligrams (mg). Review of a nursing progress note, dated 05/03/23 at 2:31 A.M., revealed the resident complained of pain in the right hip and stated, it only hurts when I move it and would not move the right leg without assistance. Review of a nursing progress note, dated 05/03/23 at 3:03 A.M., revealed the resident refused to have blood drawn for labs. Review of a nursing progress note, dated 05/03/23 at 8:21 A.M. revealed the resident refused medications, despite education and encouragement with multiple attempts. Review of a nursing progress note, dated 05/03/23 at 8:31 A.M., revealed the resident was lying in bed with the head of bed elevated to approximately 45 degrees. The resident was overheard talking to himself in the room stating at 9:00 o'clock, the doctor is going to fix my hip. Pain medication offered and refused. Encouragement and education provided. Resident stated he cannot get up due to the amount of pain in his right hip. Review of a nursing progress note, dated 05/03/23 at 8:35 A.M., revealed the resident refused to move from his current position to obtain orthostatic blood pressure (BP). BP obtained from a sitting position and was 156/64. Review of nursing progress note, dated 05/03/23, at 10:17 A.M., revealed yesterday (05/02/23), about one hour after second fall, the resident verbalized that he needed to use the bathroom to urinate and pointed that he wanted to go to the bathroom. The resident stood with two assist and used handrail to pull himself up in bathroom, however, before he could sit down on toilet, he was incontinent of urine. Peri-care was provided and the resident was assisted back to wheelchair and brought up to the day room to be closely monitored as he tried to stand up unassisted several times. Call light was within reach and urinal was provided as transferring to the toilet was difficult due to the weakness of legs. Today, the resident was still having pain to the right hip and staff reported the resident would not get out of bed due to pain, however, he was refusing Tylenol. The DON updated medical provider and received an order to repeat the x-ray of the right hip and obtain an x-ray of the left hip. Review of an Occupational Therapy (OT) evaluation and plan of treatment assessment, dated 05/03/23 at 11:23 A.M., revealed the resident resided in the dementia unit with two recent falls within 24 to 48-hour period with injuries of a skin tear and a head contusion. X-rays thus far had been negative of the pelvic and right hip. OT provided a wheelchair after the first fall. After the second fall, the resident was lying next to his bed and after the first fall, he was near the dresser. At the end of the evaluation and treatment, therapy recommended doing another x-ray as the resident was having pain and was non-weight bearing during transfers and mobility. The DON stated they were ordering more x-rays. Review of a Physical Therapy (PT) evaluation and plan of treatment assessment, dated 05/03/23 at 2:22 P.M., revealed the reason for referral due to new onset of decrease in functional mobility, decrease in strength, resident resides in the dementia unit, with two recent falls within 24 to 48-hour period. Right hip pain, skin tear to upper extremities, and head contusion. Pelvic and right hip x-rays both negative. Nursing reported additional x-rays were being ordered due to second fall and resident continuing to complain of pain and limited right, lower extremity weight bearing. Review of a nursing progress note, dated 05/03/23 at 3:07 P.M., revealed the resident had pain located in the right hip and was refusing to move, stating that he was in too much pain. Pain medication was offered numerous times, but the resident refused. Review of a nursing progress note, dated 05/03/23 at 3:48 P.M., revealed x-ray results received and order received from NP to send the resident to the emergency room . Review of a nursing progress note, dated 05/03/23 at 4:07 P.M., revealed 911 in facility and exited with the resident via stretcher at 4:04 P.M. Review of the x-ray report, dated 05/03/23, revealed the resident had limited ROM for positioning. The result revealed an acute fracture through the proximal right femur. Review of an Emergency Department After Visit Summary, dated 05/03/23, revealed the diagnosis was an accidental fall resulting in a closed, displaced subtrochanteric fracture of the right femur, leukocytosis, and hyponatremia. The resident was referred to orthopedics for a visit as soon as possible, or within three days. The resident was to remain non-weight bearing for the next several months. Hydrocodone-Acetaminophen 5-325 mg was ordered for severe pain. During interview on 05/24/23 at 1:34 P.M., OT #34 revealed she walked into Resident #28's room and there were four to five other staff members present. Resident #28 was lying flat on his back, near his bed. OT #34 suggested placing a pillow under the resident's head for support. The resident was assisted up from the floor and placed into a wheelchair. OT #34 stated that she anticipated the resident would be sent to the emergency room and suspected a fracture because he was yelling out and appeared to be in excruciating pain and was completely non-weight bearing on the right leg. During interview on 05/24/23 at 1:57 P.M., NP #300 revealed she was not notified of Resident #28's ongoing hip pain, refusal of medications and lab work, or his decreased range of motion following his second fall on 05/02/23. NP #300 stated she was not notified of the resident's continued complaints of right hip pain until 05/03/22, and at that time ordered another x-ray. During interview on 05/24/23 at 2:24 P.M., LPN #206 revealed she was Resident #28's nurse on 05/02/23. LPN #206 stated she heard someone call for the nurse and she responded and observed Resident #28 sitting next to his bed and she helped him up and placed him back into the bed. LPN #206 revealed she obtained vital signs and neurological checks which were within normal limits. LPN #206 confirmed the resident complained of pain, however, she didn't do a gait assessment or range of motion assessment because the first x-ray was still pending. LPN #206 confirmed that she did not notify the physician or NP of Resident #28's second fall because she assumed the DON did so. During interview on 05/24/23 at 5:10 P.M., LPN/CCC #195 confirmed she did not witness either of Resident #28's falls on 05/02/23, however, she completed the fall investigation and nursing progress notes regarding both falls. During interview on 05/24/23 at 5:15 P.M., the DON confirmed the NP should have been notified of the resident's continued complaints of pain and decreased range of motion following the second fall on 05/02/23. The DON confirmed she was informed of the resident's complaints of pain and decreased range of motion during morning report on 05/03/23 and notified NP #300, who then ordered another pelvic and hip x-ray for Resident #28. Review of the facility's policy titled, Fall Policy, revision date of 04/20/21, revealed it was the policy of the facility to assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. Assessment for fall risk would be updated quarterly or as needed. A fall assessment would be completed by a nurse as soon as possible after a fall with findings documented in the medical record. Appropriate medical care would be provided as needed, including emergency transport to the emergency room if indicated. This deficiency represents non-compliance investigated under Complaint Number OH00142701.

Based on observation, record review, staff interview, facility self reported incident review, and policy review, the facility failed to ensure Resident #39 was free from abuse by Resident #32, a resident with a known history of aggressive behaviors. This affected one resident (#39) of one residents reviewed for abuse. Actual Physical and Psychosocial Harm occurred, applying the reasonable person concept, on 02/06/23 to Resident #39, a resident with impaired cognition, when Resident #32 pinned Resident #39 by her wrists against the wall. Resident #39 was screaming for help and was found with a skin tear, reddened cheeks, and wrists. Findings include: Review of Resident #39's medical record revealed an admission on 05/24/22 with diagnoses including unspecified dementia, Alzheimer's disease, essential hypertension, and hyperlipidemia. Review of Resident #39's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/31/22, revealed her cognition was severely impaired and she was not known to have any behaviors during the seven-day assessment period. Review of Resident #39's January 2023 Medication Administration Record (MAR) revealed she had presented with behaviors of delusions, yelling out and being demanding on 01/04/23, 01/06/23, 01/11/23, 01/17/23, 01/25/23, 01/28/23, and 01/29/23. Review of her February 2023 MAR, prior to the incident on 02/06/23, revealed she had not presented with any behaviors. A review of Resident #39's care plans revealed she had a care plan in place for behaviors and cognitive decline. Interventions included assisting the resident to develop more appropriate methods of coping and interacting and encourage the resident to express feelings appropriately. The facility was also to monitor behavior episodes and attempt to determine underlying cause considering location, time of day, persons involved, and situations. Review of Resident #39's progress notes dated 01/16/23 to 02/06/23 revealed she only presented with agitation on 02/05/23 toward staff regarding wanting extra Tylenol for pain. Review of Resident #39's progress note, dated 02/06/23 at 8:02 P.M., revealed Licensed Practical Nurse (LPN) #204 was called to Resident #39's room and upon arrival, Resident #39 was sitting on her toilet. Resident #39's lower arms, wrists, and hands were reddened. She had a reddened area to the left side of her face. She also had a very small area to the back of her hand that had a scant amount of blood on it. State tested Nurse Aides (STNA)s #203 and #207 were present in the room and reported they had heard Resident #39 yelling for help and when they arrived to the room, Resident #32 was holding Resident #39 up against her bathroom door by her wrists. Resident #39 stated Resident #32 was squeezing her wrists and arms and scratched her. Review of Resident #32's medical record revealed an initial admission on 08/04/22 and a readmission on 02/20/23 with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, major depressive disorder, anxiety disorder, hallucinations, and unspecified psychosis not due to a substance of known physiological condition. Review of Resident #32's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/30/22, revealed he was rarely or never understood, had a short-term and long-term memory problem, and was severely impaired for cognitive skills for daily decision making. Resident #32's cognition was severely impaired, and he was not known to have any behaviors during the seven-day assessment period. Review of Resident #32's physician orders revealed an order on 01/12/23 for Zyprexa (a second generation antipsychotic) 5 milligrams by mouth two times a day for hallucinations and an order on 01/17/23 to decrease his Xanax (an antianxiety medication) from 0.25 milligrams by mouth four times a day to three times a day for a gradual dose reduction. Review of Resident #32's January 2023 MAR revealed he had presented with behaviors of anxiety, pacing, paranoia, hallucinations and agitation on 01/05/23, 01/06/23, 01/10/23, 01/11/23, 01/13/23, and 01/14/23. The behaviors were not assessed after 01/17/23. Review of his February 2023 MAR prior to the incident on 02/06/23 revealed the behaviors were not assessed. Review of Resident #32's care plans revealed he did not have a care plan for any behaviors other than wondering. Review of Resident #32's progress note, dated 01/11/23 at 1:47 P.M., revealed Resident #32 was walking down hallway toward another resident. The other resident was yelling down hall and Resident #32 became agitated. While attempting to redirect Resident #32 he proceeded to punch the nurse in the back repeatedly. The nurse removed other residents out of the hallway. A State tested Nursing Assistant (STNA) took Resident #32 to the restroom to redirect him. Review of Resident #32's progress note, dated 01/26/23 at 4:12 P.M., revealed he was sitting in a chair in the facility dining room and his right foot boot was halfway off and sideways. A STNA approached him and attempted to fix his boot when he leaned forward and swung at her. The STNA removed herself immediately from Resident #32. A nurse then approached the resident to inform him of his boot being on improperly and to attempt to fix it. Resident #32 leaned forward and verbalized to the nurse f*** it. The nurse was able to remove the boot in order to keep the resident safe when ambulating and was able to apply it after eating supper. Review of Resident #32's progress note, dated 01/28/23 at 12:11 P.M., revealed he was walking around the unit and swatted another resident's head. The other resident stated he only made light contact and Resident #32 was redirected by staff immediately. The other resident stated she was not injured and on inspection of her scalp there were no visible or palpable injuries. An intervention at that time was to place Resident #32 on 15 minutes checks for the shift. Review of Resident #32's progress note, dated 01/29/23 at 8:08 P.M., revealed he was very aggressive with staff. He was pulling his fist back during care. He scratched a STNA during care and redirection was effective for only a short period of time. Review of Resident #32's progress note, dated 01/31/23 at 8:47 A.M., revealed he was up pacing throughout the memory care unit. He was approaching doors and trying to open them. When the staff were attempting to redirect him, he was becoming combative and hitting staff. Review of Resident #32's progress note, dated 02/01/23 at 1:11 P.M., revealed an STNA was assisting the resident to the central bath to provide care and toileting. Resident #32 became agitated and combative and begun hitting the STNA. He then grabbed both of her wrists in an attempt to hold her hands back. Another STNA entered the area and Resident #32 calmed down. The second STNA assisted Resident #32 out of the bathroom. Review of Resident #32's progress note, dated 02/06/23 at 7:23 P.M., revealed a STNA reported to this nurse that while they were assisting another resident, they heard Resident #39 yelling for help from her room. When they entered the room (of Resident #39), Resident #32 had a hold of Resident #39's wrists. Resident #39's back was up against her bathroom door and Resident #32 was holding her hands against the door. Resident #32 was removed from Resident #39's room immediately. Observation on 03/07/23 at 3:55 P.M. revealed Resident #32 ambulating into the room across the hall from his room. There was one female resident lying in her bed. She did not communicate with Resident #32. He walked approximately ten feet into the room and then turned around and walked back out of the room and down the hallway. A review of facility self-reported incident (SRI), tracking number 231796 revealed an initial SRI was submitted on 02/06/23 for an allegation of physical abuse. The alleged perpetrator was Resident #32 and the resident/victim was not identified. No witnesses were identified in the SRI. The date of discovery was 02/06/23 and the brief description of the allegation/suspicion was the STNAs heard yelling from Resident #39's room. When the STNAs entered the room, she found Resident #32 holding Resident #39 against the door by her wrists. The initial source of the allegation was staff. Resident #39 was not able to provide meaningful information. Her diagnoses included dementia with behavioral disturbances, Alzheimer's, anxiety and depression. Resident #32 was not able to provide meaningful information. His diagnoses included Alzheimer's, dementia with behavioral disturbances, and cognitive communication deficit. The narrative summary of the incident revealed STNAs heard yelling coming from Resident #39's room. Upon entering the room, Resident #32 was noted to be standing in front of resident facing Resident #39 against door. Resident #32 was redirected out of the room. Resident #39 did state that Resident #32 hit her but was unable to state how he hit her or with what he may have hit her with. Resident #39 noted to have slightly reddened wrists, small skin tear to right hand and redness on cheeks. Resident #39 was slightly agitated immediately after Resident #32 was redirected out of the room. Resident #39 was calm within 15 minutes of incident and had no recall at that time. The facility unsubstantiated the allegation of physical abuse stating the evidence was inconclusive and abuse was not suspected. The facility indicated as a result of their investigation they did the following: Out of an abundance of caution, Resident #32 was placed under close supervision until medication changes were completed. New orders for routine Tylenol for Resident #32 as well as labs including a urinalysis were obtained. Resident #32 had a recent attempt for gradual dose reduction for medications for mood/behavior which failed and did receive orders to adjust medication dose post incident. Physician and families were notified of the incident and outcomes. No further incidents related to other residents have been reported. The facility's investigation file included a SRI Form for an initial report and two witness statements completed by STNA #203 and STNA #207. The facility investigation also contained a Resident -to- Resident assessment, dated 02/06/23 at 9:00 A.M., which revealed Resident #39 stated Resident #32 was squeezing her wrists and arms and scratched her. The investigation contained a Resident-to-Resident assessment, dated 02/06/23 at 9:00 A.M., which revealed Resident #32 was not able to give a description of the incident and he had a predisposing situation factor of being a wanderer. The investigation file did not contain any skin assessments for the other residents on the memory care unit who did not have the cognition for interview. Review of census documentation for the memory care unit, dated 02/07/23, revealed 19 residents resided in the memory care unit. Review of the skin assessment documentation dated 02/06/23 to 02/07/23 revealed only eight residents on the unit had skin assessments completed. A personal witness statement from STNA #203, dated 02/06/23 at 9:00 A.M., revealed she and STNA #207 heard screaming coming from one of the rooms down the hall. They ran down to see where it was coming from, and it was Resident #39. When they entered Resident #39's room, Resident #32 had Resident #39 pinned against the wall with her arms up and in Resident #32's hands. Resident #32 was squeezing Resident #39's wrists while she was screaming for help. The STNAs were able to redirect Resident #32 out of Resident #39's room. Resident #39 was extremely shaken up. A personal witness statement from STNA #207, dated 02/06/23 at 9:00 A.M., revealed she heard Resident #39 scream and she ran down to see what was wrong. She went through the cracked door to find Resident #32 holding Resident #39 against the door by her wrists. Interview on 03/07/23 at 2:55 P.M. with the Director of Nursing (DON) and Regional Registered Nurse (RN) #205 revealed they did not substantiate the abuse regarding SRI #231796 because they did not know what Resident #39 was doing prior to the incident that may have provoked Resident #32. The DON and Regional RN #205 did verify that without knowing what Resident #39 was doing prior to the incident, Resident #32 was discovered in the process of abusive behavior in Resident #39's room when the STNAs walked into the room. Both the DON and Regional RN #205 verified that no skin sweeps were completed on the remaining residents in the memory care unit to confirm no additional abuse had occurred to them since they were not interviewable due to cognition level. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/22, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Further review of the policy revealed the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy further revealed the definition of willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This deficiency is cited as an incidental finding to Complaint Number OH00140612.

Based on observation, record review and staff interview the facility failed to implement timely interventions to prevent the development of avoidable pressure ulcers for Resident #33 and Resident #21 and failed to ensure ordered/planned treatments and pressure reduction devices (heel protection) were in place. Actual Harm occurred on 08/05/21 when Resident #33, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/05/21 Resident #33 was identified to have an avoidable suspected deep tissue injury (SDTI), (a localized area of persistent deep red, maroon, or purple discoloration that does not turn white when pressure was applied, or (ii) a separation revealing a dark wound bed or blood-filled blister) to the left heel that was 100% purple and measured 3.8 centimeters (cm) in length by four cm width. The resident was also assessed to have SDTI pressure ulcer to the right heel that measured four cm by 4.5 cm described to be a 100% purple mushy blood blister. There was no evidence of adequate interventions being implemented to prevent the development of these pressure ulcers. During the survey, the resident was observed without pressure ulcer prevention measures in place and without a treatment to the left heel. Actual Harm occurred on 08/13/21 when Resident #21, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence pressure reducing/relieving interventions were initiated to reduce pressure to the resident's heels until after the pressure ulcer developed. In addition, observations made during the survey revealed pressure ulcer prevention measures were not in place. This affected two residents (#21 and #33) of three residents reviewed for pressure ulcers. The facility identified seven residents with pressure ulcers three of whom developed the pressure ulcers in the facility. Findings include: 1. Review of Resident #33's medical record revealed a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided in the facility Memory Care Unit. A plan of care, dated 03/05/20 revealed the resident was at risk for skin breakdown due to impaired mobility, advanced age and dementia. Resident #33 sustained a fall and fractured her right femur 07/06/21. The resident was hospitalized and readmitted to the facility on [DATE]. There was no evidence of any pressure ulcers to the resident's heels at the time of re-admission. The plan of care related to risk for skin breakdown was updated on 07/14/21 and included the resident had a surgical wound, a dressing in place to the right hip, incontinence and pain. Interventions dated 07/19/21 included to turn and reposition for comfort and surgical wound and use pillows to position self in bed. There was no plan to reduce pressure to the resident's heels at that time. A 07/19/21 Braden Scale Pressure Ulcer Risk assessment revealed the resident was at moderate risk for skin breakdown due to sensory limitations, mobility issues, activity limitations, inadequate nutrition and friction and shear concerns. Review of a 07/21/21 significant change Minimum Data Set (MDS) 3.0 revealed the resident was severely impaired for daily decision making and required extensive assistance from two staff for bed mobility and transfers. A progress note, dated 07/26/21 revealed the resident's heels were soft and mushy. The note indicated the heels were padded and protected and to be floated with pillows. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change every three days and as needed for protection. On 08/05/21 Resident #33 was assessed to have a SDTI pressure ulcer to the left heel measuring 3.8 centimeters (cm) in length by four cm width. The pressure ulcer was assessed to be 100% purple and a mushy blood blister. A pressure ulcer assessment also identified a pressure ulcer to the right heel (also first identified on 08/05/21) was also present and measured four cm by 4.5 cm, was assessed to be a suspected deep tissue injury and described to be a 100% purple mushy blood blister. On 08/05/21 following the identification of the SDTI pressure ulcers an order was obtained to cleanse bilateral heels with normal saline, apply Silicone foam and change every three days and as needed and apply heel lift boots to feet in bed. On 08/16/21 a new order was obtained to cleanse bilateral heel wounds with normal saline, apply [MEDICATION(S)] and cover with dry dressing daily and as needed. An air mattress was also ordered at that time. On 09/06/21 a pressure ulcer assessment revealed the right heel measured two cm in length by two cm width with no depth noted. The ulcer was described as dark purple and mushy with the edges flaking off. A pressure ulcer to the left heel was assessed to measure two cm in length by one cm width and noted as a partial thickness open area that was pink and moist. The assessment revealed the area was a blood blister that had reabsorbed with the outer later flaked off. On 09/07/21 at 2:50 P.M. Resident #33 was observed in bed without any type of heel lift boots to the bilateral heels. Only the resident's left foot was observed elevated on a pillow. On 09/12/21 at 12:31 A.M. Resident #33 was observed in bed without any type of heel lift boots in place. The resident's left foot was hanging off the bed without any type of dressing in place. A dressing was observed sitting on the resident's over bed table. On 09/12/21 at 12:35 A.M. interview with State tested Nursing Assistant (STNA) #87 and STNA #101 revealed they arrived to work at 11:00 P.M. and worked on the Memory Care Unit where Resident #33 resided. During the interview, neither STNA indicated they had noticed the resident's left heel dressing was off and denied being told in report the resident's pressure ulcer dressing was off. Both STNAs denied attempting to apply the resident's heel lift boots. The STNAs indicated they know what the resident's orders were because they were on a Kardex hanging on the inside door of the resident's closet. Interview with Licensed Practical Nurse (LPN) #71 at this time also verified the resident's pressure ulcer dressing was off and the resident was not wearing the heel lift boots as ordered for pressure prevention. On 09/12/21 at 1:05 A.M. observation of the resident's posted Kardex guidelines revealed it was dated 05/10/21. There was no information for the heel lift boots or to elevate the resident's heels on a pillow included on the Kardex. On 09/12/21 at 1:08 A.M. interview with STNA #87 with the Administrator present verified the Kardex did not include information for staff to know to elevate the resident's heels in bed and to apply heel lift boots. Review of the facility undated Pressure Ulcer Prevention and Risk Identification policy revealed interventions would be implemented as indicated by the physician and as determined by the Interdisciplinary Team. 2. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A plan of care, dated 06/28/19 revealed the resident was at moderate risk for impaired skin integrity related to impaired mobility, [CONDITION(S)], incontinence episodes and weight loss. On 07/10/19 interventions were added which included a pressure reduction mattress to bed and cushion to chair. On 04/25/20 an intervention was added to encourage (resident) to float heels in bed as will allow. Review of the quarterly 07/23/21 MDS 3.0 assessment revealed the resident was severely impaired for daily decision making and required extensive assistance from two staff for bed mobility and transfers. On 08/13/21 Resident #21 was assessed to have a deep tissue injury (DTI) pressure ulcer to the right heel measuring 4.1 cm in length by four cm width. The area was described as being a purple leaking DTI with a one cm round dark center with a small amount of bloody drainage. The area was cleansed and Medi-honey was applied and dressing. The note indicated heel booties in place. On 08/13/21 following the development of the DTI, new interventions were initiated for heel (protectors) booties when in bed. Cleanse wound to right heal with normal saline once daily and apply Medi-honey to wound bed, cover with ABD and Kling every day shift. On 08/14/21 a house protein supplement was ordered. A 08/14/21 Braden Scale Pressure Ulcer Risk assessment revealed the resident was at moderate risk for skin breakdown due to sensory limitations, mobility issues, activity limitations, inadequate nutrition and friction and shear concerns. On 08/14/21 the treatment was changed and a new order was obtained to cleanse right heel wound with normal saline, apply [MEDICATION(S)] and dry dressing daily and as needed. On 09/06/21 the pressure ulcer to the right heel was assessed to be unstageable (full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black). The pressure ulcer measured 1.5 cm in length by 1.6 cm width and was described to be full thickness (tissue loss) wound with 90% black eschar and 10% granulation tissue. On 09/12/21 at 12:05 A.M. Resident #21 was observed in bed with her heels directly on the mattress. The resident was not wearing any type of heel (protectors) booties at that time. There was no pillow at the foot of the bed or evidence staff had elevated the resident's heels prior to the observation. On 09/12/21 at 12:22 A.M. observation with the Administrator verified Resident #21 had been assisted to bed and staff had not applied heel (protectors) booties or elevated the resident's heels to reduce pressure to the right heel that had an unstageable pressure ulcer present. The resident had a visible dressing on her right heel. On 09/12/21 at 12:50 A.M. interview with STNA #90 and STNA #103 revealed they had been working Resident #21's hall since 7:00 P.M. STNA #103 revealed it was her first week employed and she did not know Resident #21 had a pressure ulcer and needed her heels elevated when in bed or needed to have heel boots on. STNA #90 verified she knew the resident had a pressure ulcer and was to have heel boots on. STNA #90 indicated there was a Kardex inside the closet door of the resident's room that would tell staff what care the resident needed. Observation of the Kardex with STNA #90 revealed the Kardex was dated 06/23/21. Noted on the Kardex was to encourage resident to float heels in bed. The Kardex did not include the heel (protector) booties that were added as an intervention on 08/13/21 following the identification of the SDTI. This deficiency substantiates Complaint Number OH 314.

Based on medical record review, staff interviews, review of a facility Self-Reported Incident (SRI), review of witness statements, and review of the facility policies and procedures for abuse, behavior management and restraints, the facility failed to ensure one (Resident #49) cognitively impaired resident with mental health [DIAGNOSES REDACTED]. This resulted in Immediate Jeopardy when the staff heightened and provoked Resident #49's behaviors of hitting, cursing, yelling, and resisting return into the facility as they carried the resident against her will from the front porch into her room when the resident was not in imminent danger, and requested to stay outside during a time of anxiety and agitation. Actual harm occurred when the resident's behaviors escalated, she became increasingly upset during the incident, and received bruising to her wrists and forearms. This affected one (Resident #49) of three residents reviewed for abuse. The facility census was 70 residents. On 06/20/19 at 2:45 P.M, the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO) #402, and Quality Assurance Nurse #405 were notified Immediate Jeopardy began on 05/18/19 at 6:50 P.M. when STNA #300, STNA #305, STNA #310, and RN #400 carried Resident #49 against her will from the front porch to her room when the resident was not in imminent danger, and requested to stay outside during a time of anxiety and agitation. As a result of the incident, when the resident's behaviors escalated, she became increasingly emotionally and physically upset, and received bruising to her wrists and forearms. The Immediate Jeopardy was removed on 05/22/19 when the facility implemented the following corrective actions: · On 05/20/19 at approximately 1:30 P.M., the Administrator submitted a facility SRI and began an investigation. · On 05/20/19, STNA #300, STNA #305, STNA #310, and RN #400 were suspended pending the investigation. · On 05/20/19, Licensed Practical Nurse (LPN) #364 assessed Resident #49 for injury and Physician #800 was notified of the bruising with no new orders. · On 05/20/19 at 2:00 P.M., RDO #402 re-educated the Administrator and DON regarding the abuse policy which included a thorough investigation and timely reporting of any type of alleged abuse, as well as suspending any alleged perpetrator to ensure resident safety. · On 05/20/19, the DON and Administrator educated all staff regarding Resident #49 and necessary de-escalation techniques such as re-direction, validation, leaving her alone if she becomes upset, and one staff member to remain with her until re-direction or diversion back into the facility is successful. This training also included at no time was it appropriate for any staff to put their hands on the resident to bring her back in the facility without her permission. · On 05/20/19 at 2:30 P.M., RDO #402 re-educated all department managers (RN #323, #326, #363, Dietary Manager #316, Director of Rehabilitation #600, Social Service Designee #318, Admission Director #362, Marketing Director/Nurse Liaison #700, Business Office Manager #340, Housekeeping and Laundry Supervisor #317, Human Resource Manager #368, Central Supply Coordinator #352, LPN #364, Medical Records #356, Maintenance Director #701, and Dietitian #401) on the abuse policy including suspension of involved staff and immediately informing the DON and/or the Administrator. · On 05/20/19, an AD H[NAME] Quality Assurance (QA) meeting was held and an auditing staff questionnaire was developed to interview staff regarding any knowledge of abuse incidents, procedures for reporting abuse, and transferring residents against their will. A resident questionnaire was also developed regarding any knowledge of abuse incidents, reporting of abuse to staff, and if staff treat them with dignity and respect. · On 05/20/19, the AD H[NAME] QA meeting determined additional staff training on de-escalation procedures/crisis management was needed. The Administrator, DON, and department managers conducted this training with all facility staff either in person or by phone on 05/20/19 and 05/21/19. New hires will be educated during orientation on the abuse policy with emphasis on not physically restraining residents or making them do something they don't want to do, along with de-escalation techniques. · On 05/20/19, the Administrator, DON, and RN #326 educated all facility staff on staff response to catastrophic reactions and resident combative and aggressive behavior, as well as removing and suspending alleged staff perpetrators pending investigation results. · On 05/20/19 through 05/21/19, all staff were interviewed using the staff questionnaire with no negative findings other than staff heard about, or was witness to, the incident on 05/18/19. Any concerns with these findings were investigated by the Administrator and no new findings were identified. · On 05/20/19 through 05/21/19, all resident questionnaires were initiated and completed with all negative responses investigated by the Aministrator with no additional abuse allegations discovered. · On 05/20/19, Resident #49's care plan was reviewed by the DON. However, no new interventions were added until 06/25/19, which included contact guard assistance with ambulation, involvement in specific activities of choice, offering snacks, using de-escalation techniques, and monitoring for hitting, kicking, or cursing. · On 05/20/19, the DON, Assistant Director of Nursing and Unit Manager reviewed all residents for wandering/elopement risk and combative behaviors. Ten residents (Residents #09, #22, #24, #37, #38, #49, #54, #60, #67 and #172) were identified at risk and their care plans were updated by 05/22/19. · On 05/21/19, Psychiatrist #500 attended a facility re-education regarding de-escalation/crisis management provided by the Administrator and DON. · On 05/21/19, Psychiatrist #500 and QA Nurse #405 reviewed Resident #49's plan of care, and Psychiatrist #500 ordered for the resident to be evaluated at a hospital for medication adjustments. · On 05/22/19, STNA #300 and #305 received verbal warnings, RN #400 received a written warning, and STNA #310 was terminated from employment. · On 05/22/19, Resident #49 was hospitalized for [REDACTED]. She remained hospitalized until 06/13/19. · On 05/29/19, weekly audits of one or two residents began using the QA/Safety Quality Assurance/Performance Improvement questionnaire asking Do you feel that you have been abused or neglected in this facility? Has anyone made you do anything against your wishes? These audits are completed by the Administrator, DON, or department managers, and will be ongoing until the next QA meeting scheduled for 07/25/19. · On 06/18/19, Psychiatrist #500 evaluated Resident #49 for medication management and continued [MEDICATION NAME] (anti-anxiety medication) twice a day. · On 06/24/19 through 06/26/19, 59 of 72 facility staff were educated regarding the difference between a catastrophic reaction and catastrophic event, with this concern being identified through the QA process and staff confusing the two situations. The remaining staff will be trained upon their return to work. · On 06/25/19 and 06/26/19, 71 of 72 facility staff were educated regarding Resident #49's plan of care for wandering behaviors. Laundry Staff #353 will be educated when they return to work on 06/27/19. Although the Immediate Jeopardy was removed on 05/22/19, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of monitoring facility staff response to resident behaviors to ensure compliance and determine if further action is required. Findings include: Review of Resident #49's medical record revealed the resident was [AGE] years of age, and was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care for at risk for wandering related to impaired cognition and exit seeking plan of care, completed by the DON (initiated on 02/09/19 and revised 05/21/19), revealed interventions included involving the resident in activities of choice, provide diversional actives of interest as needed, and re-direct as needed. Review of the plan of care for the resident's potential to cause harm to self and others related to physically combative, verbally aggressive behaviors and difficulty de-escalating behaviors, completed by RN #326 (initiated 03/21/19 and revised 06/14/19), revealed interventions including allowing the resident personal space; maintaining consistent schedule with daily routine; provide clear, simple directions; visual supervision if wandering or pacing; provide reorientation to the situation; provide verbal feedback regarding her behavior; and notify the physician if the resident posed a potential threat to self or others. Review of the elopement risk assessment completed by LPN #705, dated 04/06/19, revealed the resident was at high risk of elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/01/19, revealed the resident had severe cognitive impairment for daily decision making; required supervision with bed mobility, transfers, ambulation, and dressing; required limited assistance of one staff member with toilet use and personal hygiene; wandered daily; and was not short tempered or easily annoyed during the assessment period. Review of the behavior narrative progress note written by LPN #337 on 05/18/19 at 7:40 P.M. revealed at approximately 6:55 P.M., Resident #49 was sitting on the porch with three staff members present. The resident rose and attempted to walk toward the parking lot when the STNAs attempted to redirect the resident into the building. The resident became physically aggressive towards the staff and hit STNA #305 in the stomach. STNA #305 offered food and drinks as a diversion but the resident stated, I don't want anything from you sons of (expletive). The STNA attempted to take the resident's hand to assist her back into the building but the resident hit and kicked staff. Staff (later identified as STNA #300 and STNA #305) put the resident's hands into theirs and extra support at the elbows. As the resident continued to be physically combative, an un-identified staff member stated, just grab her legs and the four staff members (STNA #300, STNA #305, STNA #310, and RN #400) carried the resident into the facility and continued to carry her to her room and laid her on the bed. The staff then left the immediate area after removing the resident's roommate (Resident #25) from the room for safety. Resident #49 got up from the bed and walked to the front entrance with three STNAs (STNA #300, STNA #310, and STNA #313) preventing the resident from exiting the facility. STNA #310 was holding Resident #49's hands and the nurse (LPN #337) directed the STNA to remove her hands from the resident and for all other staff to disperse from the resident's area. The resident then walked to the common sitting area and STNA #305 accompanied the resident until calm. Review of the health status progress note completed by LPN #337 on 05/18/19 at 8:55 P.M. revealed the DON was notified of the incident. Review of the skin progress note (late entry) completed by LPN #364 on 05/20/19 at 3:10 P.M. documented the resident had bruising to the following areas: right wrist measuring 6.2 centimeters (cm) x 8.0 cm; right lower arm 8.0 cm x 8.0 cm; right antecubital 2 cm x 1 cm; left wrist 3.4 cm x 3 cm; left lower arm 3 cm x 3 cm; also a skin tear behind the right knee measuring 1.2 cm x 1.0 cm with a 1.0 cm round bruised area surrounding. No skin flap to the area and the area was dried pink with dried blood. Review of the facility SRI completed by the Administrator on 05/20/19 revealed the DON was made aware of the incident on 05/18/19 regarding Resident #49 not wanting to come back into the facility prior to a predicted thunderstorm. The SRI identified STNA #300, STNA #305, STNA #310 and RN #400 as the alleged perpetrators. Further review of the SRI revealed the resident was outside at the front of the building. The resident had exited the facility, the door alarm sounded, and staff reacted appropriately and accompanied the resident outside. The resident was insistent on going home and finding her mom and dad. Staff (STNA #300, #305, #310, and RN #400) intervened appropriately and tried to redirect the resident without success. The resident continued to be insistent on finding her mom and dad, walking toward the state route and adjacent railroad tracks that were located extremely close to the facility. The resident was redirected back to the facility by STNA #300, #305, #310 and RN #400 and then proceeded to sit in a chair outside of the facility still insisting she was going to see her parents. Again, staff members (STNA #300, #305, #310 and RN #400) tried to redirect the resident back into the facility but were unsuccessful. Out of an abundance of caution and for safety of the resident, staff members (STNA #300, #305, #310, and RN #400) escorted the resident back into the facility and one-on-one supervision by STNA #305 was provided. The resident continued to pace and return to the front door. STNA #310 was located at the front door to monitor for any attempts to exit the building but the resident became combative with STNA #310, trying to hit and kick her. STNA #310 blocked the resident from hitting her. Staff continued to provide one-on-one supervision until the resident calmed and was able to be redirected. There were no further incidents after the occurrence. The facility unsubstantiated the allegation of physical abuse referencing the evidence indicated abuse, neglect or misappropriation did not occur. Review of an undated statement from LPN #337 revealed on 05/18/19 Resident #49 exited the front door of the facility accompanied by staff. The resident attempted to walk toward the parking lot, but staff redirected the resident and she sat down on the porch. Three staff members (STNA #300, #310 and RN #400) were present. The resident rose and started to turn toward the parking lot. STNA #305 approached the resident with food and drink as a diversion, however, the resident did not want the items. STNA #300 and #305 took the resident by the hands and placed their hand under her elbows for support. The resident became further agitated and began hitting and kicking staff, striking STNA #305 in the stomach. An unidentified staff member said, Just grab her legs, and RN #400, STNA #300, STNA #305, and STNA #310 proceeded to carry the resident through the front door, up the front of the east wing and placed the resident in her room for safety. The resident walked again to the front entrance and STNAs #300, #310 and #313 prevented the resident from exiting. STNA #310 held the resident's fists and LPN #337 instructed STNA #310 three times to remove her hands from the resident. STNA #310 became verbally abusive toward the nurse in front of staff and a visitor before releasing the resident and returning to her assignment. LPN #337 accompanied the resident to the main living area and STNA #305 stayed with the resident until she calmed. Review of STNA #300's statement dated 05/20/19 revealed the resident went out of the building onto the front porch. STNA #300 and RN #400 were the first staff to go out and stop the resident. The resident started hitting and kicking RN #400. The staff attempted to calm the resident, but the resident continued to yell and hit both staff. STNA #305 and STNA #310 then came out. STNA #305 stated the last time the resident was acting like this, she had to be assisted back into the building. The resident started again to yell and hit and was trying to leave the front porch. The resident was then assisted by four staff (STNA #300, #305, #310, and RN #400) back into the building and to the resident's room. STNA #300 went back to his assignment. He looked down the hall and saw the resident walking back to the front door. He ran and stood in front of the door, holding it shut so the resident was unable to exit. Resident #49 started hitting STNA #300's arm. STNA #310 entered the situation and tried to calm the resident but the resident began hitting STNA #310. STNA #310 held the resident's arms down. LPN #337 came over and took over the situation. Review of STNA #305's statement dated 05/20/19 revealed when she got to work, the resident was on the front porch with RN #400 and STNAs #300 and #310. At that time, STNA #305 went out to offer the resident coffee and something to eat. The resident stated she did not want anything, and the resident proceeded to get up and walk toward the road. STNA #300 and STNA #305 reached for the resident's hands to try and gently walk with the resident, who was kicking and swinging the whole time. STNA #305 was unable to remember who said to gently pick up the resident's legs, if it was the nurse or an aide. The staff gently and carefully guided the resident through the front door. Review of RN #400's undated statement revealed on 05/18/19 at approximately 6:50 P.M. she was walking down the hallway to put oxygen away when she saw the resident going toward the door. She yelled for the resident to stop but the resident continued through the door. The resident sat on a bench. At the same time, STNA #300 and RN #400 tried to encourage the resident to go inside but the resident was trying to find her mom and dad. The staff tried to explain to the resident her parents were not there but offered the resident the telephone to call her parents, but the resident began cursing at the staff and telling them to go away. The resident was offered food and fluid but refused and punched STNA #305 in the abdomen. At this time for resident safety, the resident was gently picked up by STNA #300, STNA #305, STNA #310, and RN #400 and carefully guided through the door. On 06/19/19 at 10:14 A.M., interview with RN #400 revealed she witnessed Resident #49 exit through the front door and yelled for staff assistance. RN #400 said she was outside with the resident for 30 minutes and the resident was hitting and cursing at the staff outside. RN #400 verified the resident never left the canopied porch but she and three STNAs (STNAs #300, #305, and #310) carried the resident into the building. RN #400 stated the bruising on the resident's arms was probably from her hitting the staff. On 06/19/19 at 1:15 P.M., interview with LPN #337 revealed she was working on 05/18/19 and witnessed the four staff bring the resident into the building. The resident was squirming, trying to get out of the hold of the staff members. They carried her to her room and left. Resident #49 left her room and headed to the front door. Aides were standing at the front door and STNA #310 grabbed the resident's fists to keep her from hitting the staff. LPN #337 approached the situation and told the aides to remove themselves from the situation because there were too many people around the resident. LPN #337 said she had to tell STNA #310 at least three times to let go of Resident #49's fists. There were residents and visitors in the living room area and that would have been in the vicinity to hear the commotion. Further interview verified the resident should not be physically restrained by carrying her into the building and holding her fists, which increased Resident #49's agitation and made her more upset. LPN #337 stated she notified the DON of the incident and the DON said she would make some calls and then call the LPN back. When the DON called back, she informed LPN #337 she spoke with the Administrator and Quality Assurance Nurse #405. LPN #337 stated she was not directed to send any of the involved staff home. LPN #337 said once the other staff left the area, LPN #337 and STNA #305 remained in the immediate area and Resident #49 calmed and no further incidents occurred for the remainder of her shift. On 06/19/19 at 1:54 P.M., interview with LPN #364 revealed she was the facility wound nurse and, during a routine skin assessment on 05/20/19, identified the multiple bruises to Resident #49's forearms, wrists and the skin tear behind the resident's right knee. LPN #364 said she reported her findings to the DON on 05/20/19 since the bruises were newly identified areas. On 06/19/19 at 2:08 P.M., interview with the DON verified the facility did not investigate the areas to the resident's wrists, forearms, or the skin tear behind her right knee despite the resident being carried into the building and her hands being held a few days prior. The DON said in hindsight, the areas should have been investigated. On 06/19/19 at 3:46 P.M., interview with the Administrator and DON revealed the investigation was not initiated for two days because the management did not feel the incident was abuse because the facility was trying to keep the resident safe by carrying her into the building and blocking the resident from hitting STNA #310. The Administrator said the facility did not find abuse had occurred at the conclusion of the investigation and felt the staff had acted appropriately and did not consider carrying the resident into the building or holding her hands as a physical restraint. When asked why the SRI and investigation did not match, the Administrator was unable to provide an answer. On 06/20/19 at 8:35 A.M., interview with the DON verified she did not feel the incident was abuse but did consider the incident a dignity issue and, after speaking with the Administrator and QA nurse, they felt the incident could be addressed on Monday. The DON said she was not notified the incident was an allegation of abuse until LPN #337 approached her a second time and indicated she had abuse concerns with the incident from 05/18/19. At that time, an investigation was immediately initiated, and statements were obtained. The four staff members (STNAs #300, #305, #310, and RN #400) were suspended after being permitted to work on 05/18/19 and 05/19/19. The DON was unsure if residents were in the immediate area, but a family member was in the area; however, she was unable to identify the family member and the facility did not obtain a statement from the visitor. The DON verified carrying a resident and holding her hands would be a physical restraint and an immediate investigation should have been initiated. She also said that limiting a resident's movement is the definition of a physical restraint and the events that occurred would fit the definition. The DON verified the residents' plan of care for behavior and wandering/elopement was not resident specific and did not indicate how to de-escalate catastrophic reactions related to Resident #49. On 06/20/19 at 9:12 A.M., interview with STNA #300 revealed he was walking in the hall and RN #400 was ahead of him when Resident #49 exited through the front door and the door alarm sounded. STNA #300 and RN #400 followed the resident to the porch, covered with a canopy, where the resident was waiting for her parents to pick her up. They tried to encourage the resident to come back inside but the more they talked, the more agitated the resident was. Resident #49 started to hit the two staff members. RN #400 went into the building. STNA #300 and Resident #49 sat on a bench under the canopy. The resident was still hitting STNA #300's leg and arm but he felt he had the situation under control. STNA #300 denied any weather issues or concerns. He denied impending weather conditions and stated the weather was calm and pleasant at the time of the incident. RN #400 returned to the porch followed by STNA #305 and #310. STNA #305 stated the last time the resident was out on the porch, the staff had to assist her back into the facility. Resident #49 stood from the bench and STNA #300 placed his arm under Resident #49's. STNA #305 placed her arm under the resident's other arm. RN #400 was blocking the resident from leaving the porch. STNA #310 picked up the resident's left leg. STNA #300 stated he told STNA #310 several times to put the resident's leg down, but she refused. RN #400 picked up the resident's other leg and the four staff members started walking. They carried the resident through the first door and STNA #300 told STNA #310 to put the resident down, but STNA #310 said no and continued to walk. The resident was squirming to get loose, but the staff continued through the second door and down the hall to the resident's room. The resident continued to yell and squirm. The staff placed the resident on her bed and left the room. STNA #300 and #310 returned to the other unit when STNA #300 witnessed Resident #49 standing at the front door. STNA #300 went to the front door and stood. The resident was talking about her parents and started hitting STNA #300. STNA #310 approached the situation, told the resident to stop hitting and restrained the resident by holding her by the wrists to keep her from hitting staff. At that time, LPN # 337 approached the situation and told the staff there were too many around the resident and instructed the staff to leave the resident. STNA #300 said the resident never left the porch and never stepped into the parking lot. STNA #300 said the resident's safety was never compromised while she was outside on the porch. STNA #300 said having four staff members outside with the resident did escalate the situation and having people in her personal space made the situation worse than it needed to be. STNA #300 said he did not feel he was appropriately educated regarding catastrophic reactions or resident behaviors related to combativeness and attempts to elope to appropriately respond to the situation. On 06/20/19 at 9:50 A.M., interview with Psychiatrist #450 revealed staff should not place their hands on a resident and physically restrain them and should attempt to de-escalate the situation. If residents are in an unsafe situation, the staff must keep them safe and keep the situation calm but, restraining the resident is not the answer and neither is blocking the resident from hitting staff. Staff should not harm residents and need to work on de-escalating the situation. On 06/20/19 at 4:00 P.M., an additional interview with LPN #337 revealed there were no impending weather issues that would have compromised the resident's safety and the resident never left the facility porch or headed toward the road. On 06/20/19 at 4:09 P.M., an additional interview with RN #400 revealed the resident never left the porch and was not in immediate danger at the time of the incident. Lastly, the RN said she did not instruct the three STNAs at any time to put the resident down once they began to carry the resident into the facility. On 06/20/19 at 4:28 P.M., interview with the resident's power of attorney revealed the facility informed her the resident had to be brought into the facility recently because they could not get her back inside. Further interview revealed the resident loved music and often found it calming. Lastly, the representative said she would be upset if her loved one was mistreated but the facility had never reported her loved one being mistreated or abused. On 06/24/19 at 3:45 P.M., interview with STNA #305 revealed she worked on 05/18/19 and assisted with carrying the resident in from outside. Further interview revealed residents are not to be made to do anything against their will and this was an incident that should not have happened the way it did. Further interview revealed STNA #310 refused to put the resident back on the ground once the staff started to carry the resident into the building. Review of the Behavior Modification Policy and Procedure (undated) revealed problematic behavior will be identified and managed appropriately according to resident specific care plan. Staff will work with the resident, physician, family and Interdisciplinary Team (IDT) to identify appropriate, resident specific interventions that decrease problematic behaviors. The IDT will identify precipitating factors that trigger resident behaviors and these triggers will be care planned. Individual positive behavior interventions will be identified, and care planned. Review of the facility's Abuse, Mistreatment, Neglect, Injuries of Unknown Source and Misappropriation of Resident Property policy (dated (MONTH) 2019) revealed staff would be educated during the orientation process and at least annually and as needed thereafter regarding the facility's policy. Catastrophic reactions were defined as extraordinary reactions of residents to ordinary stimuli, such as the attempt to provide care. The policy indicated the facility would not tolerate abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review of the Physical Restraint Policy (undated) revealed physical restraints will not be utilized until all other options have been exhausted and the physician in collaboration with the IDT has determined that the benefits outweigh the risks. Restraints may not be used for the purposes of discipline or convenience. Restraints will not be initiated without first consulting the administrator/DON or designee. Informed consent will be reviewed and signed by the resident/legal representative, or authorized representative.

Based on record review and interview the facility failed to ensure dietician recommended daily fluid intake was achieved to promote adequate fluid status for Resident #72. Actual harm occurred when the facility failed to ensure Resident #72, with a known history of malnutrition and severe dehydration, received adequate hydration to prevent a hospitalization for dehydration. This affected one (Resident #72) of three residents reviewed for change of condition. Findings include: Review of Resident #72's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE] revealed the resident was alert, oriented and cooperative. The resident required one staff member assistance with bed mobility, dressing and personal hygiene. Further review revealed the resident required two staff member assistance with transfers and ambulation, toilet use and eating. Review of the physician's orders [REDACTED]. In addition, an order was written on 05/18/16 for speech therapy five times a week for four weeks to improve oral skills and decrease the risk of aspirating and to start nectar thickened liquids. On 05/20/16, due to low oral intakes, an order was received for high calorie high protein supplements to the resident's diet as well as Two Cal (dietary supplement) four ounces by mouth twice a day. Review of the nutritional assessment dated [DATE] revealed Resident #72 required assistance with eating and had a fair appetite. The resident's laboratory levels on 05/16/16 (prior to admission) were sodium 142, blood urea nitrogen 48 and creatinine 1.30. The resident was 68 inches tall and weighed 125 pounds. Further review revealed the resident's estimated fluid needs were 1425 milliliters (ml) of fluid per day. Review of the fluid intake documentation from 05/17/16 to 05/24/16 revealed the resident did not consume over 120 ml of fluid daily. Review of the nurse's progress notes dated 05/21/16 at 2:47 P.M. revealed the resident was drowsy and confused. The resident needed verbal cueing to swallow. On 05/22/16 at 10:53 A.M. the resident had a decreased blood pressure of 76/46 without further assessment of the resident's blood pressure documented for the remainder of the day. On 05/23/16 at 5:06 A.M. the nurses progress notes indicated the resident had been heard talking to himself and yelling out throughout the night with agitation at times. Review of the nursing progress notes dated 05/23/16 at 9:12 A.M. revealed the resident's skin was inspected by the wound nurse, Licensed Practical Nurse (LPN) #11. The documentation revealed the resident's skin turgor was greater than three seconds (tenting of the skin with a normal rate of less than three seconds. Skin turgor can be an indicator of poor fluid status) without documentation of physician notification. On 05/23/16 at 9:56 A.M. documentation revealed the resident was lethargic but arousable and confused. Resident #72 had been randomly yelling out. Further review of the nursing progress notes revealed on 05/24/16 at 8:39 A.M. Resident #72 was found in bed at 7:30 A.M. with heavy mouth breathing. The resident's eyes were open and the resident was moaning. Mouth care was provided with a toothette (a sponge on a stick) to moisten the resident's mouth. The resident was unable to swallow or close his mouth. Speech therapy was called and ordered not to give the resident anything by mouth. The resident's temperature was 100.8, pulse 100 (normal 60-90) and oxygen saturation was 90% with oxygen in place. The physician and daughter were updated on the resident's condition. The resident was sent to the emergency room per physician's orders [REDACTED]. On 05/27/16 at 2:40 P.M. interview with LPN #13 revealed symptoms to monitor for when observing for dehydration would include poor skin turgor, dry mouth and an elevated temperature. On 05/27/16 at 4:50 P.M. interview with Registered Nurse (RN) #19 verified the resident had a decline in condition, including decreased oral intake, poor skin turgor, low blood pressure and lethargy without evidence of treatment or physician notification. Further interview verified the resident did not have an adequate oral intake and did not meet the daily dietician recommendation for 1425 ml of fluid daily as noted above. RN #17 indicated the physician should have been notified related to the resident's decline in condition and poor fluid intake as well as episodes of low blood pressure and poor skin turgor. RN #19 verified Resident 72 was admitted to the hospital with [REDACTED]. This deficiency substantiates Complaint Number OH 607.