Every finding on record at Daughters of Miriam Center for Nursing & Rehabilit

Based on interview and record review the facility failed to ensure a resident received his medical records in a timely manner. This affected one resident (Resident #75) our of three residents reviewed for medical record access. The facility census was 152. Findings include: Interview on 03/03/25 at 3:32 P.M. with Resident #75 revealed he requested his medical records and it took a while to receive them. Interview on 03/04/25 at 10:08 A.M. with Designated Social Worker (DSW) #431, with administrator present per her request, revealed Resident #75 provided her with a medical records request form on 02/04/25 and she contacted the case manager and scheduler to see who takes care of the request. DSW #431 couldn't remember what they said. Interview on 03/04/25 at 11:02 A.M. with Administrator verified the medical request form submitted by Resident #75 on 02/04/25 was not submitted to attorneys for approval until 02/24/25. Administrator reported they hired a new medical record staff person, Medical Records #383, who started on 02/03/25 and started her vacation on 02/04/24 and didn't' return until 02/20/25. Interview on 03/05/25 at 1:22 P.M. with Medical Records #383 revealed she returned from vacation on 02/20/25 and spoke with Resident #75 regarding his request for medical records on 02/04/25. Medical Records reported he paid the fee on 02/24/25 and she submitted the request and delivered the records to him on 02/24/25. Review of the medical records form, HIPAA Privacy Authorization Form revealed Resident #75 requested medical records on 02/04/25. Review of the medical records form, Record Request Invoice, dated 02/24/25 revealed cash was received on this date for the medical records. Review of facility policy, Medical Record Request, undated revealed purpose to comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) and to afford our patients the right to inspect and obtain a copy of health information about themselves.

Based on observation, interview, and facility policy, the facility failed to ensure Resident #129 received proper incontinence care. This affected one resident (Resident #129) of three residents reviewed for incontinence. The facility census was 152. Findings include: Review of the medical record for Resident #129 revealed an admitted [DATE]. Diagnosis included but were not limited to COVID-19, dysphagia, cirrhosis of Iver, nontraumatic intracerebral hemorrhage, hemiplegia affecting right dominant side, and sickle-cell disease. Review of the Care Plan dated 12/10/24 revealed Resident #129 had bladder and bowel incontinence. Interventions included offer to toilet resident upon waking, before and after meals, at bedtime and as needed (PRN) and provide peri-care after each episode of incontinence. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #129 had severely impaired cognition. Review of the bladder and bowel section revealed Resident #129 was always incontinent of bladder and bowel. Observation on 03/05/25 at 08:07 A.M. of perineal (peri) care (incontinence care) for Resident #129 revealed Wound Nurse # 581 gathered supplies, provided privacy, washed hands in bathroom and applied gloves. Wound Nurse #581 positioned Resident #129 on her right side and removed her brief. Wound Nurse #581 began to clean her buttocks area first with a warm washcloth with soap and water. When she removed the washcloth there was a small amount of stool on the washcloth after wiping. Wound Nurse #581 got another soapy washcloth and cleansed buttocks, then a rinse wash cloth, and then she patted area dry. Wound Nurse #581 removed the dressing to Resident #129's sacrum for the Wound Nurse Practitioner (NP) #700 to measure a pressure ulcer. After Wound NP #700 measured the pressure area Wound Nurse #581 did the pressure ulcer treatment. After completion of wound treatment Wound Nurse #581 then applied new brief, repositioned resident and ensured call light was in reach. Before leaving the room Wound Nurse #581 removed her gloves and washed her hands. Resident #129's front genital area was not cleansed. Interview on 03/05/25 at 8:24 A.M. with Wound Nurse #581 verified she provided peri-care/incontinence care incorrectly. Wound Nurse #581 reported she forgot to cleanse Resident #129's front genital peri area and she was to provide peri care to the front first then do the buttocks. Interview on 03/05/25 at 8:53 A.M. with Director of Nursing (DON) revealed procedure for peri care is to clean the front peri area first then the buttocks. DON verified Wound Nurse #581 performed peri care incorrectly. Review of facility policy, Perineal Care, dated August 2009, revealed the purpose of the procedure is to provide cleanliness and comfort. For female residents wash perineal area then wash the rectal area thoroughly. This deficiency represents non-compliance investigated under Complaint Number OH00161455.

Based on observation, medical record review, staff interviews, and policy review, the facility failed to secure and store medications appropriately. This affected one resident (Resident #136) out of three residents reviewed for secured medications. The facility census was 152. Findings include: Review of Resident #136 medical record revealed the following medications were due for administration the morning of 03/04/25: Amiodarone Hydrochloric Acid (HCI) 200 milligram (mg) give one by mouth (po) once a day (qd) for heart rate, Jardiance 25 mg give 1 tablet po for diabetes mellitus, Metoprolol Succinate extended release (ER) 24 hour 25 mg, give 1/2 tablet 12.5 mg PO qd for blood pressure, Potassium Chloride ER 20 milliequivalent (MEQ) give 1 tablet po qd for hypokalemia, sodium chloride oral tablet give 1 gram qd po for supplement, Vitamin C 500 mg give 1 tablet qd for anemia, and Acyclovir 400 mg give 1 tablet twice a day (BID) for prevention. Observation and interview on 03/04/25 at 11:52 A.M. with Resident #136 revealed a medicine cup on the overbed tray with 6 1/2 pills in the cup. Resident #136 reported the nurse left the medications there for them to take. Resident#136 verified these were his morning medications. Interview and observation on 03/04/25 at 12:03 P.M. with supervisor LPN #583 confirmed a medicine cup with 6 1/2 medications were left in Resident #136's room on his over the bed tray. LPN #583 verified medications are not to be left in a resident room. LPN #583 confirmed there were 6 1/2 pills in the medicine cup and removed the medicine cup, with medications. Interview on 03/04/25 at 12:15 P.M. with Director of Nursing (DON) verified mediations were not to be left unattended in a residents room. Interview on 03/04/25 at 12:26 P.M. with LPN # 322 verified she left the medications at Resident #136's bedside. LPN #322 confirmed medications were not to be left at bedside. LPN #322 confirmed the medications were his morning medications and there were 6 1/2 pills in the medicine cup. Review of facility policy, Medication Administration, dated 09/14/20 revealed to provide guidance for medication administration and administer medications as ordered and stay with until consumed/refused.

Based on record review, interview, and policy review, the facility failed to ensure Resident #201's medical record accurately reflected confirmation of the resident's death. This affected one resident (Resident #201) out of three resident reviewed for death in the facility. The facility census was 152. Findings include: Review of the medical record for Resident #201 revealed an admitted [DATE] with diagnosis including but not limited to malignant neoplasm of nasopharynx, respiratory failure, severe protein-calorie nutrition, congestive heart failure, history of transient ischemic attack (TIA), adult failure to thrive, tracheostomy status, gastrostomy, and mood affective disorder. Resident #201 expired at the facility on [DATE]. Review of the progress note dated [DATE] at 12:00 A.M. authored by Licensed Practical Nurse (LPN) #579 revealed LPN #579 checked on Resident #210 and was unable to obtain vital signs. Resident #201 did not respond to verbal and tactile stimuli. Nursing supervisor was made aware, family and physician notified. LPN #579 contacted the funeral home where they received the body at 11:50 P.M. Interview on [DATE] at 8:54 A.M. with LPN #579 revealed she found Resident #201 deceased and checked for vital signs, and he didn't have any. LPN #579 reported she informed Nursing Supervisor Registered Nurse (RN) #706 and she came and verified no vital signs. Interview on [DATE] at 9:40 A.M. with Director of Nursing (DON) confirmed Resident #201's medical record did not contain documentation of the RN confirming the resident's death. Review of facility policy, Death of a Resident Documenting, undated, revealed all information pertaining to a resident's death (i.e. date, time of death, the name and title of the individual pronouncing the resident death, etc.) must be recorded on the nurses' noted. Review of the facility policy, Charting/Documenting Policy, undated, revealed the purpose of the guidelines is to ensure complete comprehensive and timely document and timely documentation of the resident's/patient's care, treatment, response to care, signs, symptoms, change of condition as well as the progress of the resident/patient.

Based on observation, record review, facility policy review and interview the facility failed to ensure Resident #146, who was dependent on staff assistance for activities of daily living (ADL), received adequate and proper assistance for dressing, personal hygiene, and incontinence care. This affected one resident (#146) of three residents reviewed for ADL. The facility census was 166. Findings include: Review of Resident #146's medical record revealed an admitted [DATE] and a reentry date of 01/26/24. Resident #146's diagnoses included bradycardia, type two diabetes mellitus, vascular dementia, moderate, with psychotic disturbance, and Alzheimer's disease. Review of Resident #146's care plan dated 01/22/24 included Resident #146 had an activity of daily living (ADL) self-care performance deficit related to urinary tract infection, Alzheimer's disease, bradycardia and incontinence. The goal developed was for Resident #146 to maintain, improve current level of function through the review date. Interventions included Resident #146 required the staff assistance of one person for transfers. Review of Resident #146's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 was rarely, never understood and dependent (on staff) for bathing, toileting hygiene, and putting on and taking off footwear. Resident #146 required substantial to maximal assistance with upper and lower body dressing, for chair, bed-to-chair transfer and sitting to standing. Resident #46 was always incontinent of urine and bowel. Review of Resident #146's care plan dated 11/14/24 included Resident #146 had a urinary tract infection. The goal developed was for Resident #146's urinary tract infection to be resolved without complications by the review date. Interventions included to check Resident #146 at least every two hours for incontinence and wash, rinse and dry soiled areas. Resident #146 had bladder incontinence related to Alzheimer's disease, weakness, impaired mobility. The goal developed was for Resident #146 to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to provide peri-care after each episode of incontinence. Observation on 11/18/24 at 8:03 A.M. of Resident #146 with Certified Nursing Assistant (CNA) #400 revealed Resident #146 was sitting in a wheelchair in the hall of the nursing unit he resided on. Resident #146 was not wearing socks, had one shoe on his bare right foot, no show on his left foot, the shoelaces of the shoe on the right foot were not tied and were dragging on the floor. Resident #146's bare left foot was resting directly on the floor and a Band-Aid could be seen on Resident #146's left toe. Resident #146 had black athletic pants on and was wearing an incontinence brief which was observed to be full of urine with the fullness observed even with the athletic pants covering the incontinence brief. CNA #400 stated the night shift aide told her Resident #146 needed his incontinence brief changed. Resident #146's black athletic pants were covered in what appeared to be dried food and drink stains. CNA #400 confirmed Resident #146's pants were dirty, he did not have socks on, only one shoe, and the shoelaces were dragging on the floor. CNA #400 also confirmed Resident #146's incontinence brief was full of urine and needed changed. CNA #400 pushed Resident #146's wheelchair into the common area shower room and bathroom and attempted to stand him up and transfer him to the toilet, but Resident #146 was unable to assist with the transfer and CNA #400 left the bathroom to find another staff member to assist her. CNA #400 came back to the bathroom with Licensed Practical Nurse (LPN) #401. LPN #401 observed Resident #146 only had one shoe on, and his bare left foot was resting on the bathroom floor, and left the bathroom to find his other shoe before providing incontinence care. LPN #401 entered the bathroom and stated she could not find Resident #146's other shoe, but brought non-skid socks and put them on Resident #146's feet. LPN #401 and CNA #400 transferred Resident #146 to the toilet with great difficulty. Resident #146 was unable to use his legs to assist with the transfer and CNA #400 and LPN #401 had great difficulty transferring him to the toilet. Resident #146's pants were removed and CNA #400 identified and confirmed the entire back of his pants was soaked with urine, and the incontinence brief was soaked with urine. CNA #400 and LPN #401 assisted Resident #146 to stand up and CNA #400 provided incontinence care. CNA #400 washed Resident #146's buttocks and anal area using a wash cloth and when she was finished with the buttocks and anal area she folded the wash cloth and used the same wash cloth to cleanse Resident #146's perineal area. After folding the wash cloth CNA #400 proceeded to wash Resident #146's perineal area, and cleaned Resident #146's penis last with the soiled wash cloth used for the buttock and anal area. CNA #400 picked up a towel, wet one end of the towel with water, and used the end of the towel to rinse Resident #146's buttocks, penis and perineal area and used the dry end to dry his buttocks, penis and perineal area. CNA #400 confirmed she used the same wash cloth and washed Resident #146's buttocks and anal area before she cleaned his perineal area and penis. CNA #400 stated she only had one wash cloth, and she should have washed his perineal area and penis before washing Resident #146's buttocks and anal area. After finishing Resident #146's incontinence care, CNA #400 and LPN #401 assisted Resident #146 back to the wheelchair without wiping the urine off the wheelchair seat cushion with disinfectant cloths. CNA #400 and LPN #401 confirmed the cushion was not wiped with disinfectant cloths and it should have been. CNA #400 and LPN #401 were assisting Resident #146 out of the bathroom and when asked if they helped Resident #146 wash his hands after sitting on the toilet and receiving incontinence care they confirmed they did not help him wash his hands and pushed him back to the sink and assisted him to wash his hands. Further observation revealed Resident #146's fingernails were about a half inch long. LPN #401 confirmed the length of Resident #146's fingernails and stated they should have been trimmed on his shower day. CNA #400 and LPN #401 confirmed they had a difficult time transferring Resident #146 on and off the toilet and CNA #400 stated Resident #146 might need a sit-to-stand or mechanical lift. Interview on 11/18/24 at 10:30 A.M. of the Director of Nursing (DON) confirmed CNA #400 and LPN #401 told her Resident #146's incontinence care was not done properly. The DON confirmed she was notified Resident #146's transfer to the toilet was difficult and stated sometimes Resident #146 could help with transfers more than other times. Review of Resident #146's medical record revealed a care plan revision, dated 11/18/24 indicating Resident #146 required staff assistance of one to two persons for transfers. Resident #146's care plan was revised on 11/19/24 and included Resident #146 required the use of a stand up lift with two staff. Review of the facility policy titled Perineal Care revised 08/2009 included the purposes of the procedure were to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review the resident's care plan to assess for special needs of the resident. After assembling supplies for a male resident wet washcloth and apply soap or skin cleansing agent and wash the perineal area starting with the urethra and working outward, continue to wash the perineal area including the penis, scrotum, and inner thighs. Thoroughly rinse the perineal area in the same order using fresh water and a clean washcloth. Gently dry the perineum using the same sequence. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks, dry area thoroughly. Promptly respond to a resident's request for toileting assistance. Review of the facility policy titled Activities of Daily Living (ADL), Supporting revised 03/2018 included residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination (toileting), dining and communication. A resident's ability to perform ADLs would be measured using clinical tools including the MDS. This deficiency represents non-compliance investigated under Complaint Number OH00159838.

Based on observation, record review, facility policy review and interview, the facility failed to implement adequate and necessary interventions to address Resident #146's constipation through implementation of the facility bowel protocol. This affected one resident (#146) of three residents reviewed for constipation. Findings include: Review of Resident #146's medical record revealed an admitted [DATE] and a reentry date of 01/26/24. Resident #146's diagnoses included bradycardia, type two diabetes mellitus, vascular dementia, moderate, with psychotic disturbance, and Alzheimer's disease. Review of Resident #146's care plan dated 01/22/24 included Resident #146 had an activities of daily living (ADL) self-care performance deficit related to urinary tract infection, Alzheimer's disease, bradycardia and incontinence. The goal developed was for Resident #146 to maintain, improve current level of function through the review date. Interventions included Resident #146 required the staff assistance of one person for toileting. Review of Resident #146's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 was rarely, never understood and dependent (on staff) for bathing, toileting hygiene, and putting on and taking off footwear. Resident #146 required substantial to maximal assistance with upper and lower body dressing, for chair, bed-to-chair transfer and sitting to standing. Resident #46 was always incontinent of urine and bowel. Review of Resident #146's electronic medical record aide charting dated 11/14/24 through 11/18/24 revealed the resident did not have a bowel movement for five days. Review of Resident #146's progress notes dated 11/14/24 through 11/18/24 revealed no evidence the resident had a bowel movement during this time period. The medical record did not contain evidence the resident's bowel sounds, pain, tenderness, and firmness of the abdomen were assessed during this time period. Review of Resident #146's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 11/14/24 through 11/18/24 revealed he regularly received Polyethylene Glycol 3350 powder 17 grams (gm) by mouth one time a day for constipation but he did not receive any other medications or treatment related to not having a bowel movement during these five days. Observation on 11/18/24 at 8:03 A.M. of Resident #146 revealed the resident was sitting in a wheelchair and his incontinence brief was observed to be full and the resident needed to be changed. Certified Nursing Assistant (CNA) #400 and Licensed Practical Nurse (LPN) #401 assisted Resident #146 to the toilet in the common area shower room and bathroom to provide incontinence care. While Resident #146 was on the toilet CNA #400 asked Resident #146 if he needed to have a bowel movement and Resident #146 stated no. There was no bowel movement observed during the incontinence care. Interview on 11/19/24 at 11:03 A.M. with CNA #402 revealed the aides charted bowel movements in a resident's electronic record. CNA #402 stated if a resident had diarrhea or was constipated she reported it to the nurse, and if a resident was on the facility bowel protocol it popped up on her computer screen. CNA #402 reviewed the list of residents on the bowel protocol and revealed Resident #146 was on the list of residents who were on the bowel protocol. CNA #402 stated she was assigned to care for Resident #146 today, and was unaware Resident #146 was on the bowel protocol and did not tell the nurse he was on the bowel protocol. CNA #402 stated even though she did not tell the nurse Resident #146 was on the bowel protocol, the nurses also had the residents who were on the bowel protocol pop up on their computer screen. CNA #402 stated Resident #146 required total assistance with care. Interview on 11/19/24 at 11:10 A.M. with LPN #403 revealed Resident #146 popped up on her computer screen to implement a bowel protocol. LPN #403 stated she did not know before now Resident #146 was on the bowel protocol because she had not looked at residents' on the bowel protocol since she arrived for work at 7:00 A.M. LPN #403 indicated a resident popped up on the clinical alert area on the dashboard of the electronic record when they did not have a bowel movement for three days (six shifts). Interview on 11/19/24 at 11:20 A.M. with Unit Manager (UM) #404 revealed she was the unit manager for the nursing unit Resident #146 resided on and stated Resident #146 was on the bowel protocol list from the weekend. UM #404 stated nurses could check the dashboard in the electronic record to check if any residents were on the bowel protocol. UM #404 stated as a back-up measure for residents on the bowel protocol she usually checked the list every morning and alerted the nurses which residents were on the bowel protocol. UM #404 stated yesterday (11/18/24) she was too busy to check the list and she did not get to the list today. UM #404 indicated on 11/18/24 she told the nurses to check the dashboard for residents on the bowel protocol, but she did not know if the nurses checked the bowel protocol list after she told them to do it. UM #404 confirmed Resident #146 did not have a documented bowel movement for five days. Review of the facility undated policy titled Bowel Protocol revealed nursing staff should maintain a record of bowel evacuation on each resident in POC (electronic record). A bowel elimination protocol was initiated by nursing staff when the resident had no recorded results after six shifts, or per resident's pattern. When the BM record shows no bowel elimination by the third day or six shifts, the 7:00 A.M. to 7:00 P.M. charge nurse initiated the bowel protocol unless contraindicated by resident condition or physician (or the resident had existing orders for constipation); the first step was on the third day or after six shifts, the charge nurse gave resident 30 cubic centimeters (cc's) of Milk of Magnesia in the morning; the second step was if the Milk of Magnesia was ineffective, the second shift nurse may administer Dulcolax Suppository 10 mg rectally, consult with physician or the Nurse Practitioner for Dulcolax tablets; if there were no results from the suppository or oral tablets a Fleets type enema (sodium phosphate) was administered by the nurse; bowel routine may be started at any time, but preferable in the morning. Bowel routine may be recorded on the 24 hour report, clinical record, and verbally communicated to oncoming shifts, in report. Note bowel sounds, pain, tenderness, and firmness of the abdomen. Notify physician if bowel routine was ineffective. This deficiency represents non-compliance investigated under Complaint Number OH00159838. This deficiency is also an example of continued non-compliance from the survey dated 11/08/24.

Based on observation, record review, policy review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program to prevent falls, ensure falls were thoroughly investigated and/or ensure residents were safely transferred. Actual harm occurred on 10/03/24 at approximately 11:40 P.M. when Resident #19, who was cognitively impaired, was at high risk for falls and had a history of fall and required substantial or maximal staff assistance for activities of daily living (ADLs), sustained an unwitnessed fall that resulted in displaced fractures of the right seventh through 12th ribs and a non-displaced sternal fracture. Prior to the fall on 10/03/24, Resident #19 had a care planned intervention for staff to check on her between the hours of 10:00 P.M. and 12:00 A.M., due to a previous fall in the facility. However, there was no evidence in the medical record this intervention was monitored and/or being completed. Resident #19 was transferred to the hospital on 10/04/24 at approximately 1:40 A.M. due to pain and was admitted to the cardiac intensive care unit (ICU). This affected two residents (#19 and #68) of seven residents reviewed for falls. The facility census was 166. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including age-related osteoporosis, presence of left artificial shoulder joint, presence of right artificial hip joint, history of falling, Alzheimer's disease, pleural effusion, chronic pulmonary embolism, non-displaced fracture of the sternal end of the clavicle and multiple fractures of ribs with delayed healing. Review of the fall care plan, initiated 06/25/21, revealed Resident #19 was at risk for falls related to dementia, impaired safety awareness, and a history of falls. Interventions included on 06/25/21 were to ensure resident was wearing appropriate footwear, call light within reach and encourage the resident to use the call light for assistance, and anticipate and meet the resident's needs. Additional interventions initiated included educate resident on putting hands into chair seat before sitting to ensure proper positioning (08/17/22), remind resident to not rush and take her time while ambulating (12/12/22), therapy consult for walker safety and management (05/26/23), remain with resident during duration of toileting and do not leave resident unattended (05/30/23), call before you fall sign placed in room (09/07/23), keep all mail and new paper at bedside or within reach (10/19/23), check resident between 10 P.M. to 12 A.M. to ensure she was sleeping (09/27/24), place bedside commode next to bed (10/05/24), and place resident in Broda chair in common area and a fall mat at bedside (10/28/24). Review of the fall risk assessment, dated 08/09/24, revealed Resident #19 was high risk for falls with a score of 65. The assessment indicated Resident #19 had fallen before, had more than one diagnosis in the chart, utilized crutches or a cane or a walker, had a weak gait, and knew her own limits. Review of a facility fall investigation dated 09/26/24 at 10:54 P.M. and authored by Licensed Practical Nurse (LPN) #799 revealed the resident had an unwitnessed fall in her room. She thought it was morning, was trying to get herself dressed, lost her balance and fell to the floor. She was assessed with no injury. A new intervention was added to check on Resident #19 between 10:00 P.M. and 12:00 A.M. to ensure she was in bed and the care plan was updated. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/24, revealed Resident #19 had severe cognitive impairment, required partial or moderate (staff) assistance for toilet transfers, had experienced one fall with no injury since the prior assessment, and reported no pain or hurting in the five days prior to the assessment. Review of physician orders for October 2024 revealed no orders pertaining to fall interventions. Review of the significant change MDS 3.0 assessment, dated 10/13/24, revealed Resident #19 had severe cognitive impairment and required substantial or maximal (staff) assistance with activities of daily living ADLs. Review of a facility fall investigation dated 10/03/24 at 11:40 P.M. revealed LPN #690 heard Resident #19 screaming for help from her room, and when the nurse walked in the resident was on the bathroom floor and said she hit her back. The nurse did vital sign check and with the assistance of three staff transferred the resident back to bed. The resident started to complaint of right-side pain and cried when we touched her side. The resident was unable to describe what happened. An ice pack was applied, acetaminophen (non-narcotic pain medication) was given, and no injury was observed at the time of the incident. The resident was noted to have a pain level of six out of 10 (ten being severe pain). The resident was oriented to self only and complaining of pain. Predisposing environment factors included a wet floor. It was also noted Resident #19 was confused, ambulating without assistance and was trying to toilet herself. A follow up note dated 10/04/24 revealed the resident was transferred to the local hospital on 10/04/24 around 1:40 A.M. for an evaluation. The nurse called for an update at 6:35 A.M. and found the resident was in the ICU with rib fractures. A new intervention was added for a bedside commode and the care plan was updated. There was no information on this incident report to indicate when Resident #19 had last been checked by staff. Review of a witness statement, dated 10/03/24, written by LPN #690 revealed Resident #19 was observed on the bathroom floor screaming for help, reported hitting her head, and complained of pain to the right side. Vital signs were normal, range of motion was normal, and neurological checks were initiated. There was no information on this statement to indicate when Resident #19 had last been checked by staff. Review of a second witness statement, dated 10/03/24, written by an unknown facility staff member (the signature was partially illegible, and this person was not on the all-staff roster for the facility) indicated they did not witness Resident #19 fall, and no other information was provided. There were no other witness statements included in the facility investigation. Review of the October 2024 Medication Administration Record (MAR), Treatment Administration Record (TAR), progress notes, nurse aide tasks, and resident evaluations revealed there was no documentation that the intervention to check Resident #19 between the hours of 10:00 P.M. and 12:00 A.M. was implemented and monitored. It was noted on the MAR that two tablets of acetaminophen (500 milligram tablets) were administered on 10/03/24 at 11:50 P.M. by LPN #690 (which was after the resident had fell in her room) for a pain level of six out of 10. Review of the facility document titled Medication Admin Audit Report, dated 10/03/24, for Resident #19 revealed on 10/03/24 at 11:10 P.M. CVS nasal spray and sodium chloride granules were administered to Resident #19 by LPN #690. The acetaminophen which had been noted in the MAR as being given on 10/03/24 at 11:50 P.M. was not on the audit report. However, an interview with LPN #690 (noted further down in this deficiency) revealed LPN #690 stated she was being trained by LPN #791 on how to add medication administration documentation into the electronic MAR at that time and did not actually administer any medications to Resident #19 at 11:10 P.M. nor provide any care for her at that time. Review of the progress note, created 10/04/24 at 2:51 A.M. with an effective date of 10/03/24 at 11:40 A.M. (this time was inaccurate in the medical record as it should have been 11:40 P.M.) authored by LPN #791 indicated Resident #19 had an unwitnessed fall, the nurse heard Resident #19 yelling from her room, Resident #19 was observed sitting against the wall on the bathroom floor with pants halfway down and the floor was wet, Resident #19 was assisted back to bed by three staff members, a head to toe assessment was completed, Resident #19 complained of right side pain of six out of 10 with tenderness to touch, an ice pack was applied, Tylenol (acetaminophen) was given, and no other injuries were noted. The note indicated Resident #19 was sent to the hospital at approximately 1:40 A.M. Review of the progress note, created 10/05/24 at 12:54 P.M. with an effective date of 10/03/24 at 11:57 P.M., authored by Unit Manager/LPN (UM/LPN) #789 revealed Resident #19 was screaming for help from her room and observed on the floor of the bathroom claiming she had hit her back. Resident #19 was assisted back to bed by three staff. Resident #19 complained of right-side pain and cried when her side was touched. Ice was applied and Tylenol was given. Resident #19 was sent to the hospital at 1:40 A.M. due to intense pain and crying. The note indicated Resident #19 was admitted to the ICU for rib fractures. Review of the hospital records dated 10/04/24 to 10/05/24 revealed Resident #19 arrived at the emergency room at 2:14 A.M. on 10/04/24 complaining of pain all over the right-side motioning broadly to the right flank extending to the base of the right side of the chest along the rib cage and she believes she fell tonight but could not elaborate. Baseline capacity was oriented to self only. Resident #19 appeared elderly, frail and in no acute distress while sitting up in the bed. The radiology report dated 10/04/24 at 3:48 A.M. concluded Resident #19 had displaced fractures of the right seventh through 12th ribs and a non-displaced sternal fracture. A diagnosis of pulmonary embolism (blood clot in the lung) was also diagnosed . The hospital plan of care recommendations included physical and occupational therapy and anticoagulant medication for treatment, however, the family declined and opted for comfort care with hospice services. Resident #19 was discharged back to the facility on [DATE]. On 10/28/24 at 3:07 P.M., an observation of Resident #19 revealed she was sitting in a reclining geriatric chair by the nurse's station. She was alert but unable to provide any valid responses to any simple or open-ended questions. On 10/31/24 at 11:01 A.M., an interview with Registered Nurse (RN) #661 revealed she was familiar with Resident #19 and stated Resident #19 had several falls in the facility due to ambulating without assistance. On 10/31/24 at 1:55 P.M., an interview with UM/LPN #789 revealed just because things were time stamped a certain time in the medication record did not mean that was when it was administered because the time stamp was just when it was documented in the chart. UM/LPN #789 verified there was a discrepancy between the MAR indicating the acetaminophen was given on 10/03/24 at 11:50 P.M. and the Medication Admin Audit Report. On 11/04/24 at 12:23 P.M., a follow-up interview with UM/LPN #789 revealed the progress note with an effective date of 10/03/24 at 11:40 A.M. was inaccurately documented because the fall incident of Resident #19 occurred on night shift not day shift. He further indicated he did not have a witness statement for LPN #791, who wrote the progress note documenting the incident. UM/LPN #789 also confirmed Resident #19 was not transferred to the hospital until two hours after the fall occurred. On 11/04/24 at 2:27 P.M., an interview with LPN #690 revealed on 10/03/24 she was sitting at the nurse's station, and she heard Resident #19 call for help and upon entering the room Resident #19 was observed on the floor. LPN #690 said they could not send Resident #19 to the hospital until they checked to see if she was on hospice, and it took a while to get in touch with hospice on night shift. LPN #690 said Resident #19 was complaining of pain and was ultimately sent to the hospital due to pain. LPN #690 could not recall when she had last seen Resident #19 prior to the fall on 10/03/24. On 11/04/24 at 2:41 P.M., an interview with LPN #791 revealed on 10/03/24 she was sitting at the nurse's station and heard Resident #19 screaming in her room. Upon entering the room, Resident #19 was observed on the bathroom floor. LPN #791 obtained Resident #19's vital signs and completed a head-to-toe assessment which revealed no bruising or swelling. Resident #19 complained of pain on her right side and LPN #791 administered as needed (PRN) Tylenol (acetaminophen) per physician's orders after the fall occurred. LPN #791 said it was about an hour and a half before Resident #19 was sent to the hospital because they had to determine if Resident #19 was on hospice or not. LPN #791 could not recall when she had last seen Resident #19 prior to the fall on 10/03/24. LPN #791 stated she did not complete a witness statement for the incident, she just wrote a progress note in the chart. On 11/05/24 at 8:11 A.M., an interview with the Director of Nursing (DON) confirmed Resident #19 had a fall on 09/26/24 and a new intervention was added to check on Resident #19 between 10:00 P.M. and 12:00 A.M. The DON verified the fall on 10/03/24 occurred within that 10:00 P.M. to12:00 A.M. time. The DON stated staff would not have documented those checks because it would have been a routine check. However, the DON verified there was no documented evidence this new intervention had been implemented for Resident #19. On 11/05/24 at 9:55 A.M., an interview with UM/LPN #789 revealed LPN #690 had administered medications on 10/03/24 at 11:10 P.M. as indicated by the documentation on the Medication Admin Audit Report. UM/LPN #789 confirmed he had previously stated the time stamps in the charts were not indicative of the time something was administered because the time stamp just reflected when it was documented. UM/LPN #789 confirmed he could not verify exactly when the medication administration occurred so there was no firm evidence Resident #19 had been checked by staff prior to the fall. UM/LPN #789 said the intervention of checking Resident #19 between 10:00 P.M. and 12:00 A.M., which was implemented after a fall on 09/26/24, was not documented in the chart because it was part of the routine two-hour check and changes. UM/LPN #789 also confirmed the progress note, authored by him, was created on 10/05/24 after the interdisciplinary team (IDT) had completed their investigation of the fall and he backdated the note to the time of the incident on 10/03/24. UN/LPN #789 stated again that LPN #791's progress note, dated 10/03/24 at 11:40 A.M., was inaccurately documented because it should have reflected a time of 11:40 P.M. On 11/05/24 at 1:15 P.M., an interview with Nurse Practitioner (NP) #839 revealed she could not confirm when the notifications were made for Resident #19's fall on 10/03/24. NP #839 verified there were no physician's orders in the medical record to send Resident #19 to the hospital on 10/03/24 or 10/04/24 and said residents could not be sent to the hospital without physician's orders. On 11/07/24 at 11:08 A.M., an interview with LPN #690 revealed she did not provide care for Resident #19 at all that evening of 10/03/24 until after the fall. She stated LPN #791 provided all care and services, but it was documented on the medication records under LPN #690's name because LPN #791 was showing her how to document it in the electronic record using LPN #690's log-in access. LPN #690 stated she was not able to verify if LPN #791 actually checked on Resident #19 for any reason prior to the fall that evening. Review of the facility policy titled Fall Protocol, dated 10/15/24, revealed each resident would be assessed for the risk of falling, would receive care and services to minimize the likelihood of falls, and the facility would conduct an in-depth root-cause analysis with each fall and would implement interventions appropriate to the resident and the situation. When any resident experiences a fall, the facility would assess the resident for injuries, complete an incident report, notify the physician, notify the family or Power of Attorney (POA), notify the nursing supervisor, document accordingly, review the resident's care plan, initiate an immediate intervention as indicated to decrease risk of further events, and document all assessments and actions in the progress notes including interventions implemented. The nursing department would review falls and conduct a root-cause analysis to include the following: a) all scheduled staff to write a statement of occurrence, b) the resident's statement of occurrence, c) any risk factors that contributed to the fall, d) identification of any high-risk medications, e) current interventions in place, f) the facility's immediate actions, and g) long term interventions to be implemented. Nursing staff would monitor for effectiveness and appropriateness of all new interventions. 2. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of first lumbar vertebrae, postherpetic polyneuropathy, enterocolitis, hypertensive heart disease with heart failure, type two diabetes mellitus, osteoarthritis, fracture of right lower leg, sciatica, and morbid obesity. Review of the care plan dated 02/07/24 revealed Resident #68 had activities of daily living (ADL) self-care performance deficit related to impaired mobility, hip fracture, pain and weakness and required assistance from two staff for all transfers. Review of the quarterly MDS 3.0 assessment completed on 10/07/24 revealed Resident #68 had intact cognition, had impaired range of motion (ROM) on one side of both her upper and lower extremities, and refused the assessment related to transfer ability. Further review of MDS assessments revealed the previous quarterly MDS completed on 09/16/24 and on 07/18/24 revealed Resident #68 was dependent for chair to bed transfers. Observation on 10/30/24 at 1:35 P.M. revealed a Hoyer lift (a mechanical device used to help transfer residents from one place to another) between Resident #68's wheelchair and bed. At the time of the observation, only one staff member, Certified Nursing Assistant (CNA) #810, was in Resident #68's room and he stated he had just finished putting her back to bed. Interview on 10/30/24 at 1:38 P.M. with CNA #810 confirmed he completed the transfer of Resident #68 from her wheelchair to her bed with a Hoyer lift without a second staff member present. During the interview, STNA #810 also confirmed he had performed one-person Hoyer transfers in the past, but knew two staff were required for all mechanical lift transfers. Interview on 10/30/24 at 1:43 P.M. with Resident #68 confirmed no other facility staff were present at the time she was transferred by STNA #810 with the Hoyer lift from her chair to her bed, and it was not the first time only one staff member was present when the Hoyer lift was used. Interview on 10/31/24 at 11:12 A.M. with Registered Nurse (RN) Unit Coordinator #814 confirmed two staff members were required during all Hoyer transfers. Review of the policy titled Mechanical Lift Usage last revised October 2023 revealed a mechanical lift was to be used with two staff members. This deficiency represents non-compliance investigated under Complaint Numbers OH00158926, OH00158389 and OH00158882.

Based on record review, interview, and review of the facility policy, the facility failed to assess Resident #163's wound and obtain appropriate treatment orders upon re-admission from the hospital and failed to complete pressure ulcer treatments as ordered by the physician or nurse practitioner to prevent a decline in the wound resulting in suspected osteomyelitis (serious bone infection). Actual Harm occurred on 10/02/24 when Resident #163's pressure ulcer progressed from a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) measuring 1.5 centimeters (cm) by 2.0 cm with a depth of 0.1 cm to an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) with suspected osteomyelitis measuring 10.7 cm by 7.0 cm with a depth of 1.0 cm due to the facility's lack of timely assessment/monitoring and implementation of wound care orders following the resident's re-admission from the hospital as well as the facility's failure to ensure wound care was provided as ordered once orders were obtained. This affected one resident (#163) of three residents reviewed for pressure sores. The facility census was 166. Findings include: Review of Resident #163's closed medical record revealed Resident #163 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, diabetes, and moderate malnutrition. The resident was hospitalized from 08/26/24 to 08/30/24 and returned to the facility with a new diagnosis of cerebral infarction and was noted to have a new wound on his buttocks. The resident was transferred to the hospital on 10/06/24 for hypotension and lethargy and did not return to the facility. Review of the care plan dated 08/19/24 noted Resident #163 was at risk for skin breakdown. Care plans for a pressure reducing cushion to the chair, pressure reducing mattress to the bed, and regular repositioning were initiated 08/19/24. Record review of Resident #163's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident exhibited mild or no cognitive impairment and had one Stage III pressure ulcer present on admission. The assessment noted the resident was always incontinent of bowel and bladder and needed substantial (staff) assistance to roll or turn in bed. Pressure reducing devices for bed and chair were noted. A progress note dated 08/30/24 revealed the resident was readmitted to the facility on [DATE] at 7:30 P.M. with an undefined wound on his buttocks. Review of the resident's previous physician orders revealed no specific order for regular turns or limiting wheelchair time. Record review revealed wound care orders were not initiated until 09/02/24. Review of Resident #163's assessments revealed the resident was identified as having a very high risk for pressure ulcer breakdown on 08/31/24. The re-admission skin assessment dated [DATE] identified a wound on the resident's sacrum with no additional information related to the wounds size, source, or other qualities. On 09/04/24 Wound Nurse Practitioner #826 assessed the resident and identified the resident had a Stage III pressure ulcer (to the sacrum) measuring 1.5 cm by 2 cm with a depth of 0.1 cm. A nurse practitioner assessment/note by Wound Nurse Practitioner #826 dated 09/11/24 revealed Resident #163 was not on a low air-loss (LAL) mattress and his wound now measured 3.0 cm by 2.0 cm with a depth of 0.1 cm. The nurse practitioner changed the wound care orders and ordered a LAL mattress at that time. A nutrition therapy note dated 09/13/24 acknowledged Resident #163's pressure ulcer and identified the resident was tolerating Novasource renal supplements. On 09/18/24 facility assessment revealed Resident #163's pressure ulcer was noted to be larger, measuring 7.0 cm by 5.0 cm with a depth of 0.2 cm. There were no new orders on this date. A nurse practitioner (NP) note/assessment by Wound Nurse Practitioner #826 dated 09/25/24 revealed the resident's sacral pressure ulcer measured 8.2 cm by 5.0 cm with a depth of 0.2 cm. The nurse practitioner noted the resident had not been seen last week due to dialysis. The NP changed the resident's dressing orders and ordered a ROHO cushion (a pressure reduction cushion to prevent or treat pressure ulcers). The last nurse practitioner wound assessment by Wound Nurse Practitioner #826 on 10/02/24 identified the resident's pressure ulcer was classified as being unstageable, measuring 10.7 cm by 7.0 cm with a depth of 1.0 cm. The nurse practitioner noted the wound was worse and ordered testing for potential osteomyelitis (serious bone infection) including an x-ray of the sacrum and antibiotics. She also noted educating the resident to limit time in the chair when not at dialysis. The wound nurse practitioner assessments made no indication that the decline of the pressure ulcer was unavoidable. Review of Resident #163's treatment administration record (TAR) revealed no documented evidence of wound care until 09/03/24, four days after readmission. There was no documented evidence of wound care on the afternoon of 09/27/24 and 10/04/24. Wound care was documented as not completed due to the resident sleeping on the morning of 09/26/24. Wound care was documented as not completed due to the resident having appointments on the morning of 09/04/24, 09/20/24, 09/27/24, and 10/04/24. Review of the progress notes on these days revealed no clear documentation of appointments except on 09/04/24 and 09/20/24 when it was noted the resident was at dialysis. A LAL mattress was ordered starting 09/12/24 and documented as in place every shift until his discharge. Review of Resident #163's care plans in place as of the resident's discharge on 10/06/24 revealed no noted behavior of refusals of care. Review of Resident #163's progress notes dated 08/16/24 through 10/06/24 revealed noncompliance with pressure sore care was only documented on 10/02/24 (four days before discharge), when it was noted that education was provided, but the resident remained noncompliant with positioning and cushion use. However, this had not been care planned nor were there any additional nursing progress notes to reflect any non-compliance. Record review of an x-ray of Resident #163's sacrum completed 10/04/24 revealed it identified an area concerning osteomyelitis with a recommendation for further evaluation. Interview with Unit Manager #816 on 10/30/24 at 11:33 A.M. revealed she recalled Resident #163 was often noncompliant with repositioning and dressing changes. Interview with Wound Nurse Practitioner #826 at 4:28 P.M. on 10/30/24 revealed she ordered a work-up for suspicion of osteomyelitis in Resident #163's wound, however he was hospitalized before she learned the results. She stated she had concerns with the resident's wound care not being completed as ordered and recalled events where his wound dressings were not changed for multiple days despite orders. She noted she sometimes had to make orders for wound care twice daily at the facility just to make sure residents get them at least daily due to care being skipped. Interview with the Director of Nursing (DON) on 10/31/24 at 9:06 A.M. verified Resident #163's wound declined in the facility and there were multiple missed treatments with no documentation indicating the decline was unavoidable and no documentation of refusals of care beyond one note. Record review of the facility's undated pressure ulcer prevention policy revealed residents were to be assessed for risks and educational needs, and interventions for at-risk residents to be put in place. Pressure sore risk assessments were to be done on admission, quarterly, and with significant changes. The policy noted interventions available for use but did not clarify any specifics for how they should be initiated or tracked. This deficiency represents noncompliance investigated under OH00158683 and OH00158550.

Based on medical record review, review of witness statements, review of facility incident investigation, review of the medical examiner report, review of the police report, and review of the facility policy, the facility failed to ensure timely injury identification and physician notification and treatment following a fall with fracture for Resident #162. Actual Harm occurred on [DATE] 4:30 P.M. when the facility failed to obtain timely and appropriate imaging (x-ray) for Resident #162 following a fall with injury resulting in a delay in treatment. Following the fall, the resident complained of increased pain, had swelling, an abrasion to the knee and was unable to stand. On [DATE] at 3:15 P.M a new order was written for an x-ray of the area. X-ray results on [DATE] at 9:15 P.M. were positive for a right femur fracture. However, facility staff did not locate the x-ray results until [DATE] at 4:00 A.M. at which time they failed to seek medical intervention/treatment for the resident. Resident #162 expired on [DATE] at 5:52 A.M. unrelated to the fracture following unsuccessful cardiopulmonary resuscitation (CPR) and emergency medical services (EMS) intervention. The Certified Nurse Practitioner (CNP) and Physician were not contacted until after Resident #162's passing of the injury related to the fall. This affected one resident (#162) of seven residents reviewed for falls. The facility census was 166 residents. Findings include: Review of the closed medical record for Resident #162 revealed an admitted [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), malignant neoplasm of bronchus or lung, atherosclerotic heart disease, essential hypertension, and history of fractures with a discharge date of [DATE]. Review of the care plan for Resident #162 initiated [DATE] revealed the resident was at risk for falls related to history of falls with fracture and weakness. Interventions included staff should follow the facility fall protocol and evaluate and treat the resident as needed. Review of the care plan for Resident #162 dated [DATE] revealed the resident was a full code status. Review of the Minimum Data Set (MDS) assessment for Resident #162 dated [DATE] revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Review of the fall incident report for Resident #162 dated [DATE] timed at 4:22 P.M. revealed the resident had an unwitnessed fall in her room when she tried to get up unassisted. Resident #162 complained of pain at level of six out of 10 and sustained an abrasion to the right knee. Review of the physician's order for Resident #162 revealed an order dated [DATE] timed at 4:30 P.M. for an x-ray to the bilateral hips related to a fall. The order was discontinued. Review of a progress note for Resident #162 dated [DATE] timed at 4:31 P.M. revealed the resident was found on the floor in her room and was complaining of pain to the lower extremity. An x-ray was ordered, and no injuries were reported in the progress note. Review of medication administration note for Resident #162 dated [DATE] timed at 8:50 P.M. revealed staff administered Tylenol for pain to the resident with effective results. Review of medication administration note for Resident #162 dated [DATE] timed at 8:52 P.M. revealed staff administered oxycodone for pain to the resident with effective results. Review of the physician's orders for Resident #162 revealed an order dated [DATE] timed at 11:00 P.M. for an x-ray to the resident's bilateral hips related to a fall. The order was completed. Review of x-ray report for Resident #162 dated [DATE] timed at 11:47 P.M. revealed the bilateral hip x-rays showed no fractures or dislocations. Review of the nursing progress note for Resident #162 dated [DATE] timed at 12:28 P.M. revealed the note documented Licensed Practical Nurse (LPN)/Unit Manager (UM) #787 checked on the resident who was resting in bed, declined pain medication, and showed no signs of distress. Review of a witness statement for Resident #162 per LPN/UM #787 dated [DATE] revealed at 3:15 P.M. Certified Nursing Assistant (CNA) #825 had reported swelling to the resident right leg during a bed bath. LPN/UM #787 called Certified Nurse Practitioner (CNP) #833 and requested an x-ray of the right knee and lower leg. The nurse obtained the order and contacted the x-ray company. Review of the nursing progress note for Resident #162 dated [DATE] timed at 3:31 P.M. revealed a call was placed to CNP #833 regarding the negative results for the resident's bilateral hip x-rays. CNP #833 gave an order for an x-ray to the right knee and lower leg due to swelling. Review of the physician's orders for Resident #162 revealed an order dated [DATE] timed at 4:00 P.M. for an x-ray to the right lower leg and knee. The order was completed. Review of the health status note for Resident #162 dated [DATE] timed at 7:35 P.M. revealed the resident had no complaints of pain on day shift and did not want a shower. Resident #162 agreed to a bed bath and during the bed bath swelling to the resident's right knee was noted. The x-ray technician arrived to the facility on [DATE] at 5:30 P.M. to obtain the x-ray ordered to the resident's right knee and lower leg. Review of the x-ray report for Resident #162 dated [DATE] timed at 9:15 P.M. revealed an acute mildly displaced fracture of the resident's right distal femur. Review of the nursing progress note for Resident #162 dated [DATE] timed at 4:31 A.M. (over seven hours after the x-ray report was completed) revealed x-ray results were received and revealed an acute mildly displaced fracture of the distal femur. The note included the nurse had attempted to notify the physician of the x-ray results and was awaiting a response. Review of the nursing progress note for Resident #162 dated [DATE] timed at 5:35 A.M. revealed upon medication pass Resident #162 was found unresponsive. CPR was initiated and continued until EMS arrived. EMS pronounced Resident #162 deceased at 5:52 A.M. The nurse on call notified physician via urgent message and was awaiting a response. Review of the nursing progress note for Resident #162 dated [DATE] at 7:28 A.M. revealed the physician returned a call to the facility and was notified of the x-ray results for the resident's right leg and that the resident had passed away. Review of the police report for Resident #162 dated [DATE] revealed the resident appeared to have died from natural causes. Review of the medical examiner's report for Resident #162 dated [DATE] revealed the resident's cause of death was hypertensive and atherosclerotic cardiovascular disease and at the time of death the resident had a right femoral fracture sustained from an accidental fall on [DATE]. Review of the facility undated investigation timeline for Resident #162 revealed the resident had a fall on [DATE] and sustained an abrasion to the right knee. On [DATE] at 3:31 P.M. Resident #162 had swelling to the right knee and an x-ray to the area was ordered. The x-ray results for Resident #162 which showed a right femoral fracture were received via fax and in electronic medical record (EMR) on [DATE] at 9:15 P.M. The x-ray company called the facility on [DATE] at 11:20 P.M. to report the findings, but no one from the facility answered. Facility staff stated they did not receive a call from the x-ray company. The x-ray results showing the fracture for Resident #162 were not located by the facility until [DATE] at approximately 4:00 A.M. CNP #833 was notified via text by the Assistant Director of Nursing (ADON) at 7:10 A.M. and returned the call at 7:12 A.M. Physician #832 was notified via text by the ADON at 7:28 A.M. and returned call at 8:10 A.M. It was noted Physician #832's contact information was inaccurate and the information the x-ray company had to contact for significant findings was inaccurate. Review of facility Quality Improvement Performance (QAPI) Performance Improvement Plan (PIP) dated [DATE] revealed a root cause analysis was completed regarding Resident #162's fall with fracture. The problem was identified as lack of timely notification of a change in condition, lack of timely assessment for change in condition, and failure to follow protocol related to fall with injury. Interview on [DATE] at 11:34 A.M. with the Director of Nursing (DON) confirmed the facility had completed an investigation into Resident #162's fall and fracture. The DON confirmed Resident #162's x-ray results came through on the fax machine at 9:15 P.M. on [DATE] but were not identified by nursing staff until [DATE] at approximately 4:00 A.M. The DON confirmed Agency LPN #827 had not called the correct number for Physician #832 when attempting to make notification and consequently Resident #162 did not receive timely care for her right femoral fracture. Interview on [DATE] at 12:57 P.M. with CNA #825 via phone confirmed on [DATE] she had been assigned to care for Resident #162 on day shift. CNA #825 reported Resident #162 had refused meals on [DATE] and had remained in bed per her usual. CNA #825 reported Resident #162 had refused her scheduled shower however agreed to a bed bath sometime after lunch. CNA #825 indicated Resident #162 stated she was unable to stand up for a shower and told CNA #825 about her fall. Resident #162 asked CNA #825 not to touch or move her knee during bed bath. CNA #825 stated when she pulled down the covers, she observed Resident #162's knee to be swollen and had a red rug burn type mark on her knee. CNA #825 stated she notified LPN UM #787. Interview on [DATE] at 1:39 P.M. with LPN #769 via phone revealed on [DATE] she found Resident #162 lying on the floor of her room and she did a quick assessment of the resident, took vital signs, and notified the resident's nurse, Agency LPN #828 of the fall. Interview on [DATE] at 2:12 P.M. with LPN #690 via phone confirmed on [DATE] she had been assigned to care for Resident #162 on night shift. LPN #690 confirmed on [DATE] she had checked in on Resident #162 and the resident stated she had fallen earlier, and her leg was hurting. LPN #690 stated she looked at Resident #162's leg but noticed no bruising and administered pain medications. Interview on [DATE] at 7:56 A.M. with Agency LPN #827 via telephone confirmed on [DATE] she had been assigned to care for Resident #162 on night shift. Agency LPN #827 indicated during report at the beginning of her shift the previous nurse had notified her there was a pending x-ray result for Resident #162. Agency LPN #827 stated she saw Resident #162 at the beginning of her shift and Resident #162 was alert and reported no pain. Agency LPN #827 indicated she observed Resident #162's knee and noted it was swollen with some bruising. Agency LPN #827 indicated she questioned the other nurse on floor about how to receive lab and radiology reports at about 12:00 A.M. on [DATE]. Agency LPN #827 confirmed she did not locate the x-ray results for Resident #162 until approximately 4:00 A.M. on [DATE]. Agency LPN #827 confirmed he attempted to reach the physician regarding the x-ray results which showed a fracture for Resident #162 at 4:41 A.M. on [DATE]. Agency LPN #827 confirmed she had not sent Resident #162 to the hospital for the fracture as she had not contacted the physician and indicated she was told by an unknown person they were treating in house. Agency LPN #827 confirmed on [DATE] at approximately 5:30 A.M. Resident #162 was found unresponsive, required CPR, and was pronounced deceased at 5:52 A.M. by EMS. Agency LPN #827 confirmed she was unable to contact the physician prior to the end of her shift. Interview on [DATE] at 8:45 A.M. with LPN/UM #787 confirmed on [DATE] he was notified by a housekeeper that a resident had fallen. LPN/UM #787 confirmed he found Resident #162 in her room sitting on her buttocks leaning against dresser. LPN/UM #787 stated Resident #162 was complaining of pain to leg and thigh/knee area and an x-ray to the bilateral hips was obtained. LPN/UM #787 confirmed on [DATE] at 3:15 P.M. STNA #825 reported the resident had swelling to right knee and he contacted CNP #833 for an x-ray of the right knee. Interview on [DATE] at 9:26 A.M. via phone with RN Supervisor #671 confirmed x-ray results were released directly under the results tab in the electronic medical record (EMR). RN Supervisor #671 confirmed if a resident had an unwitnessed fall and complained of pain or had swelling, they were supposed to be sent to the hospital. RN Supervisor #671 confirmed she was not sure why Resident #162 was not sent to the hospital on [DATE] following the fall. Interview on [DATE] at 2:30 P.M. with CNP #833 confirmed she was notified when Resident #162 fell on [DATE]. CNP #833 and she had ordered an x-ray of the resident's entire leg and was unsure why only the hip was initially obtained. CNP #833 indicated she was again notified on [DATE] by LPN Unit Manager #787 that Resident #162 was complaining of knee pain. CNP #833 questioned why the entire leg was not x-rayed as initially requested and gave order to x-ray resident's right knee. CNP #833 reported she was not required to be on call throughout the night. CNP #833 stated at about 8:00 A.M. on [DATE] the ADON called her to inform her of Resident #162's passing and the fracture. CNP #833 indicated the results came through on fax machine and was unsure why there was a delay with the results being reported. CNP #833 indicated had she been notified of the fracture at a reasonable hour Resident #162 would have been sent out to the hospital for evaluation. Interview on [DATE] at 4:04 P.M. with Physician #832 confirmed she had not been notified of Resident #162's fall on [DATE]. Physician #832 stated if she had been notified, she would have ordered an x-ray and for a fracture she would have sent Resident #162 to the hospital. Physician #832 stated she was on call at night and was able to be reached directly on her cell phone. Physician #832 stated she was not notified of Resident #162's fracture or passing until approximately 6:00 A.M. on [DATE]. Review of facility policy titled Fall Protocol dated [DATE] revealed the facility when a resident experienced a fall the facility would assess for injury, complete an incident report, notify physician and family, review care plan, initiate interventions, and document actions. The nurse should call the medical director if there was no return call from the attending physician. Review of facility policy titled Change in a Resident's Condition or Status undated revealed the nurse supervisor or charge nurse would notify the resident's attending physician or on-call physician when there was an accident involving the resident, a significant change to the resident's physical or mental condition, a need to alter the resident's medical treatment significantly, and/or a need to transfer the resident to a hospital or treatment center. This deficiency represents noncompliance investigated under Complaint Number OH00158882 and OH00158529.

Based on record review, observation and interview, the facility failed to ensure all menu items were prepared in advance and menus and/or substitutions were followed for resident meal service. This had the potential to affect all 159 residents receiving meals from the kitchen excluding the seven residents (#44, #46, #97, #110, #111, #137, and #315) the facility identified as receiving nothing by mouth (NPO). The facility census was 166. Findings include: 1. Review of the facility menu for 10/30/24 lunch revealed the meal was to consist of tomato soup, grilled cheese on Texas toast, potato chips, oven roasted vegetables and banana cake. Review of the resident's menu extension sheets for 10/30/24 revealed residents on a regular and mechanical soft texture diet were to receive four ounces of an oven roasted vegetable, and residents on a puree texture diet should receive the equivalent of one pureed grilled cheese sandwich. Review of the recipe Grilled Swiss Cheese Sandwich, Puree undated, revealed the grilled cheese sandwich would be served with a four-ounce scoop. Observation on 10/30/24 at 11:58 A.M. of lunch meal service revealed tray line had begun and there was no evidence of oven roasted vegetables being served to the residents on regular and mechanical soft textured diets. There was also no evidence of pureed grilled cheese being served to the residents on puree textured diets. It was not until approximately halfway through tray line that [NAME] #684 brought out a cart with pans of Brussels sprouts and carrots. The facility had not identified pureed grilled cheese was not prepared for the tray line lunch meal until questioned by the surveyor. Interview on 10/30/24 12:36 P.M. with Dietary Director #813 and Dietary Manager #836 confirmed the vegetables were not served to the residents on regular and mechanical soft textured diets and pureed grilled cheese was not served to the residents on puree textured diets. It was not until 12:46 P.M. that pureed grilled cheese was available to serve. There was no evidence portions of vegetable or grilled cheese were sent for trays that were already served. 48567 2. Review of the facility menu for breakfast on 10/30/24 revealed the meal was to consist of farina (hot cereal), vegetable and potato egg skillet, Danish and canned fruit. At the bottom of the menu was a section titled also available and for breakfast listed fresh fruit, assorted cold cereal, hard boiled eggs and yogurt as alternative options for the meal. Review of the menu substitution log for 10/30/24 breakfast revealed cereal, yogurt and banana would be served secondary to no cook scheduled. The original menu that was being substituted was not indicated on the substitution log and there were no additional substitutes listed for the yogurt or banana. Observation on 10/28/24 at 9:38 A.M. of resident breakfast meal service revealed Resident #81 was complaining about her meal and described the facility food as horrible all the time. Interview on 10/30/24 at 9:34 A.M. to 9:40 A.M. with Resident #81 revealed she had not yet received her breakfast tray and she was expecting to be served eggs because that was what was on the menu. During the interview, Resident #81 received her breakfast, which did not include the eggs she expected. Further observation of the breakfast tray revealed Resident #81 received a Danish, applesauce, and farina instead of the eggs she expected. Review of the meal ticket revealed the meal Resident #81 was to receive that morning included a Danish, farina, yogurt, and a banana. There was no yogurt or banana served to Resident #81. Interview on 10/30/24 at 9:44 AM with Certified Nursing Assistant (CNA) #845 confirmed Resident #81's meal ticket and food served on her meal tray did not match the meal ticket. CNA #845 verified Resident #81 should have received the yogurt and banana. CNA #845 also verified there were several residents who received applesauce instead of yogurt and a banana and she had only seen three resident trays with bananas on them during this meal tray pass. During this interview, CNA #845 stated several residents had asked her why they did not get eggs this morning because that was what they were expecting according to the original menu. CNA #845 was not sure if there were hard boiled eggs or any eggs available in the kitchen if a resident wished to have an egg for breakfast. A group interview on 10/31/24 2:55 P.M. with Residents #18, #20, #29, #43, #69, #78, and #96 revealed food served often did not match the menu and the food on their trays often did not match the meal tickets on their trays. All confirmed not being informed when there would be a substitution from what they expected to receive. Review of the policy Menu Substitutions last revised January 2023 revealed menus may be revised to accommodate unforeseen circumstances and should be recorded in the binder, indicating the food that was supposed to be served, the substituted food, and the reason for the substitution, and the residents should be notified as soon as possible.

Based on observation, interview, and food committee meeting minutes review, the facility failed to ensure palatable and appealing meals were served. This had the potential to affect all residents receiving meals from the kitchen. The facility identified seven Residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: 1. Interview on 10/30/24 at 1:26 P.M. with Dietary Director (DD) #813 revealed he had identified an issue with meal timeliness and keeping good temperatures. DD #813 indicated it would be easier and faster to serve from the pantry on each unit. DD #813 indicated the new facility ownership had changed the process from serving from the pantry to serving from the main kitchen. Observation on 10/30/24 at 1:37 P.M. of a test tray with DD #813 and Dietary Manager (DM) #836 revealed the tray was served to the last unit identified as [NAME] Two. All resident trays were passed prior to taking temperatures. The temperatures were taken using the facility's digital thermometer by DM #836. Final temperatures were 124 degrees Fahrenheit (F) for grilled cheese, 127 degrees F for carrots, and 120 degrees F for tomato soup. Taste test with DD #813 revealed the grilled cheese was soggy and not palatable. The sandwich consisted of two slices of bread and one piece of cheese. DD #813 confirmed there was not enough cheese on the sandwich and it would taste better with more cheese. Taste test of the carrots revealed no concerns. Taste test of the tomato soup revealed the soup was lukewarm and not palatable. DD #813 verified the soup was not palatable. Interview on 10/30/24 at 1:42 P.M. with DD #813 and DM #836 confirmed the food temperatures and palability were not acceptable for the grilled cheese and tomato soup. Review of Food Committee Meeting Minutes dated 08/16/24 revealed proper food temperatures and meal delivery was a focus of the meeting. 48567 2. Interview on 10/29/24 at 11:22 A.M. with Resident #68 revealed she thought the food served by the facility was absolutely horrible and gave the following examples/descriptions: a cabbage roll burnt to (expletive), a baked potato that was so undercooked it was too hard to eat, chicken breast small, dry, and so hard it could not be cut. During the interview, Resident #68 revealed her son brought in food three times a week so she could get enough to eat. Observation and interview conducted on 10/30/24 at 9:18 A.M. revealed Resident #68 lifted the lid off of the plate to expose one piece of hard dry toast which she picked up and dropped back down onto the plate to demonstrate how hard the toast was, as it made a noise when it hit the plate. Resident #68 stated there was no butter or jelly to even put on the toast. Further observation of the meal tray revealed Resident #68 also received a container of non-fat yogurt, one banana, and farina (hot cereal). There were zero condiments on the tray. Resident #68 stated she did not like or eat hot cereal, would not eat anything on her tray, and would only drink her hot tea. Resident #81 stated the items she received were not what was listed on the menu for this date and residents were supposed to have access to an alternate menu, but she had never been given an alternate menu to review. Group interview on 10/31/24 2:55 P.M. with Residents #18, #20, #29, #43, #69, #78, and #96 confirmed they each had the following concerns related to dietary services and food palatability: Any food item that is breaded, such as chicken nuggets or patty's, all get overcooked, which made it too hard to eat. Resident #20 stated he would rather eat nothing at all than try to eat those overcooked breaded items. Breakfast was always boring and not filling. Interview on 10/31/24 with Resident #18 at 3:00 P.M. revealed food was sometimes plated in a manner that allowed all the food to run together, which gave the appearance of dog food' on his lunch and dinner plates. This deficiency represents non-compliance investigated under Complaint Number OH00158389.

Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This had the potential to affect all residents receiving meals from the kitchen. The facility identified seven Residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: Review of the facility meal times revised on 04/10/24 revealed breakfast was served from 7:45 A.M. to 8:55 A.M., lunch was served from 11:45 A.M. to 12:50 P.M., and dinner was served from 5:00 P.M. to 6:00 P.M. The identified order of serving was first [NAME] One Unit, [NAME] Unit, [NAME] Three Unit, [NAME] Two Unit, and last [NAME] Two Unit. It was noted meal times were based on census and may deviate 15 minutes from scheduled time. Review of Food Committee Meeting Minutes dated 07/16/24 revealed meal times were reviewed and the committee discussed reasons for delays in meal delivery. Review of Food Committee Meeting Minutes dated 08/16/24 revealed residents reviewed the focus on meal times and proper food temperatures. Review of Food Committee Meeting Minutes dated 10/22/24 revealed concerns remained with meal times and the times were reviewed. Residents were notified deviation can occur by 15-20 minutes as the census was growing. The meal times were planned to be revised if the census consistently stayed above 150 and the attending residents agreed. Residents also requested the Administrator attend next meeting as there was a motion to consider resuming dining room steam table meal service. Interview on 10/28/24 at 10:01 A.M. with Resident #40 stated the meals were always served late and she had not even had breakfast yet. Observation on 10/28/24 at 10:08 A.M. revealed Resident #40's breakfast tray was delivered. Interview on 10/28/24 at 10:14 A.M. with Licensed Practical Nurse (LPN) #787 confirmed the breakfast trays were being delivered at that time. LPN #787 further stated they were at the mercy of the kitchen and delivered meal trays whenever the kitchen brought them to the unit. Observation during an interview with Resident #147 on 10/28/24 at 10:20 A.M. revealed her breakfast tray was passed at this time. Observation on 10/28/24 at 10:24 A.M. revealed two staff passing general breakfast trays on Resident #147's unit. Interview with Certified Nursing Assistant (CNA) #740 at this time revealed this was the usual time for breakfast trays to be passed on the unit. Observation on 10/28/24 at 10:28 A.M. revealed the breakfast meal service was in progress. Staff were delivering the meal trays to the residents in their room. Interview with LPN #768 on 10/28/24 at 10:30 A.M. revealed the breakfast trays were routinely delivered late on the secured dementia unit. LPN #768 stated the lunch meal was usually served at approximately 1:00 P.M. which was later than the time scheduled to be delivered for both breakfast and lunch. Interview on 10/30/24 at 11:42 A.M. with Dietary Supervisor #676 revealed with the increased census the meal times needed revised. Observation on 10/30/24 at 12:30 P.M. revealed Resident #13 and Resident #24 were seated in the dining room waiting for their lunch to be served. Both residents stated they often had to wait an extended period of time for meals to be served. The meal cart arrived in the dining room at 1:04 P.M. and the staff started to serve the meal trays to the residents. All the meal trays were delivered to the residents and Resident #13 and Resident #24 did not receive their meal. Residents were not served at the same time who were seated together. Resident #13 and Resident #24 stated they were not informed why their meal tray was late and thought they were not going to receive a meal tray for lunch. At 1:34 P.M. Resident #13 and Resident #24 received their meal tray. Interview on 10/30/24 at 1:26 P.M. with Dietary Director (DD) #813 revealed he had identified an issue with meal timeliness and keeping good temperatures. DD #813 indicated it would be easier and faster to serve from the pantry on each unit. DD #813 indicated the new facility ownership had changed the process from serving from the pantry to serving from the main kitchen. DD #813 indicated he has noted an improvement since he started in September 2024 however was still not able to always serve meals on time. Observation on 10/30/24 at 1:37 P.M. revealed the last meal tray had been served on [NAME] Two unit which was identified as the last unit served. Observation on 10/31/24 at 8:15 A.M. revealed a breakfast tray cart arrived on [NAME] Three unit and a second cart was delivered at 8:20 A.M. Observations revealed CNAs did not completed tray pass until 9:37 A.M. Interview on 10/31/24 at 9:49 A.M. with CNA #607 confirmed tray pass took over an hour to complete. CNA #607 indicated the other two aides on shift were agency and were stopping in the middle of tray pass to provide morning care. Interview on 10/31/24 at 11:07 A.M. with Registered Nurse (RN) #661 stated there was no consistency with meal times. Interview on 11/04/24 at 8:55 A.M. with Registered Dietitian (RD) #711 revealed there had been three dietary managers since June 2024. RD #711 reported concerns with meal times had been identified. RD #711 indicated the issue was both from the kitchen and with staff passing trays. RD #711 indicated the meal times were based on census of 150 and they had a 15-20 minute leeway however indicated they were considering revising. RD #711 indicated the residents have been requesting to go back to dining room service and noted we had good customer satisfaction with serving from the pantry. RD #711 indicated she had mentioned this multiple times from June 2024 to October 2024 and the concern had been mentioned formally in food committee. RD #711 indicated the Administrator was aware of the concerns.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff followed appropriate food safety and handling techniques including equipment cleaning and sanitation, glove use, handwashing, hairnet use. This had the potential to affect all 159 residents receiving meals from the kitchen. The facility identified seven residents (#44, #46, #97, #110, #111, #137, and #315) as receiving nothing by mouth (NPO). The facility census was 166. Findings include: Observation on 10/30/24 at 8:51 A.M. revealed Mashgiach #837 (a person in the Judaism religion who supervises the kosher status of a food establishment) in the kitchen area. Mashgiach #837 was not wearing a hair net. Dietary Director (DD) #813 asked Mashgiach #837 to wear a hair net and Mashgiach refused and stated she was wearing a wig, so she does not need to. Observation on 10/30/24 at 10:19 A.M. to 10:55 A.M. of [NAME] #684 preparing pureed cake revealed [NAME] #684 adjusted his beard net with gloved hands and did not change gloves or wash hands. [NAME] #684 used the food processor and a rubber spatula during pureed cake preparation. [NAME] #684 used gloved hands to scoop pureed cake from food processor into a pan. [NAME] #684 transferred the pureed cake back into processor from the pan and continued to puree. [NAME] #684 scooped cake with gloved hand back into pan. [NAME] #684 removed gloves and tossed soiled gloves at a trash can across the kitchen, missed, and picked up gloves off the floor and put into trash. [NAME] #684 did not wash his hands and donned another pair of gloves. [NAME] #684 rinsed the food processor parts and a rubber spatula used to demonstrate texture in a preparation sink under running water. The water from the sink was observed to splash into the pan with pureed cake. [NAME] #684 used the rinsed spatula in the pureed cake then set aside the pureed cake. [NAME] #684 did not allow the food processor time to dry before next use. There was visible residue on the food processor from pureed cake. [NAME] #684 then moved on to preparing pureed Brussels sprouts. [NAME] #684 used the food processor, a whisk, a rubber spatula, and a scoop during preparation. [NAME] #684 transferred pureed Brussels sprouts from food processor to a pan. [NAME] #684 used gloved hand to sift through puree and pull-out large chunks of brussels sprouts. [NAME] #684 rinsed his gloved hands in sink and continued wearing wet gloves. [NAME] #684 whisked in food thickener and checked texture using a scoop then removed gloves. [NAME] #684 walked over to hand wash sink and wiped the sweat from his face with paper towel then donned new gloves without washing hands. [NAME] #684 again rinsed food processor parts, spatula, scoop, and whisk in sink. [NAME] #684 was wearing gloves throughout rinsing and did not change when wet. [NAME] #684 left food processor parts in sink at this time. The spatula, scoop, and whisk were not allowed time to dry before next use. [NAME] #684 then moved on to preparing pureed sweet potatoes. [NAME] #684 drained two large cans of sweet potatoes in the sink. The liquid from the cans was drained over the food processor parts in the sink. [NAME] #684 then re-rinsed food processor and did not allow time to dry then added sweet potatoes and water from sink to food processor. While sweet potatoes were pureeing in the food processor [NAME] #684 walked over to the dairy pot washing area and grabbed a pitcher off of a cart of what appeared to be dirty dishes. [NAME] #684 then rinsed pitcher in the sink with water then used to scoop tomato soup into a pan. [NAME] #684 added water from the sink to the soup then whisked thickener into the soup. The mixture was not run through food processor. [NAME] #684 rinsed whisk, spatula and scoop in sink. [NAME] #684 had not yet changed gloves. [NAME] #684 used gloved hands to scoop sweet potatoes into pan and whisked in food thickener. [NAME] #684 then rinsed scoop and demonstrated final texture. Interview on 10/30/24 at 10:55 A.M. with [NAME] #684, DD #813, and Dietary Manager (DM) #836 confirmed above findings during puree preparation. [NAME] #684 confirmed he had not properly cleaned and sanitized equipment in dish machine or three compartment sink. [NAME] #684 confirmed he had not allowed the equipment time to dry between uses. Observation on 10/30/24 at 11:04 A.M. revealed Mashgiach #837 in the area of the dairy dish machine washing dishes. Mashgiach #837 continued to not wear a hair net. Interview on 10/30/24 at 11:45 A.M. with DM #836 confirmed observations of Mashgiach #837 not wearing a hair net in the kitchen area. DM #836 indicated he worked at a sister facility and had no issues with his Mashgiach wearing a hair net in the kitchen area. Review of facility policy, Hair and [NAME] Restraints, revised January 2023 revealed hair restraints must be worn at all times in the kitchen. Review of facility policy, Hand Washing, revised January 2023 revealed staff would wash hands frequently to ensure safe food handling. Hands should be washed after using a handkerchief or disposable tissue, after handling soiled equipment or utensils, during food preparation to remove soil and contaminants, when changing tasks, and after engaging in any activity that may soil or contaminate hands. Review of facility policy, General Safe Food Handling, revised February 2024 revealed kitchen equipment was to be cleaned after each use. Review of facility policy, Disposable Gloves, revised May 2024 revealed single-use disposable gloves shall be used for only one task and discarded when damaged or soiled and when interruptions occur in task completion. Hands were to be washed before and after wearing disposable gloves.

Based on observation, record review and interview the facility failed to ensure a dignified dining experience for Resident #62, Resident #13, Resident #52 and Resident #24. This affected four residents (#62, #13, #52 and #24) out of 12 residents observed eating their meals in the secured unit dining room. The facility census was 166. Findings include: 1. Review of the medical record revealed Resident #62 was admitted on [DATE] and readmitted on [DATE] with diagnoses including severe dementia with behaviors, hemiplegia (one sided paralysis) and hemiparesis (weakness on one side) following a cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing), and osteoarthritis. Resident #62 had medical conditions including weakness with abnormal gait and mobility, used a wheelchair for mobility, and needed assistance with personal care. A review of the Resident #62's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was rarely or never understood. A review of Resident #62's plan of care revised 12/19/22 indicated an activity of living deficit related to cognition and ability. Interventions on the plan of care indicated she required one person to feed her meals and required two-person assistance for toileting, transfers, and assistance with bathing, showering, bed mobility, dressing, personal hygiene and oral care. An observation of the meal service on 10/30/24 from 12:30 P.M. to 2:00 P.M. revealed Resident #62 was assisted to the dining room in her wheelchair at 12:40 P.M. Loud rock-n-roll music was playing on the radio in the dining room. At 1:15 P.M. Resident #62 was served her lunch by Certified Nursing Assistant (CNA) #900. CNA #900 set the meal tray in front of Resident #62 and repositioned Resident #62 in an upright position, uncovered her meal plate and set-up the tray for Resident #62 and then walked away to continue to serve the meal trays to the other residents in the dining room. At 1:19 P.M. Licensed Practical Nurse (LPN) #763 walked over and fed Resident #62 a few bites of her meal while standing next to her. LPN #763 walked away from Resident #62 and left the dining room. Resident #62 sat in front of her meal tray and tried to eat a few bites of her meal. At 1:48 P.M. Resident #62's meal tray was removed from the table and CNA #900 assisted Resident #62 back to the common area in the nursing unit. Resident #62 ate approximately 10% of her meal. Residents who were seated together were not served at the same time. Some residents were eating their meal before other residents received their meal who were seated together at the same table. Interviews with Resident #13, Resident #24, Resident #52 on 10/30/24 at 1:00 P.M. revealed they did not like the music playing on the radio and were not given a choice of their preference for the type of music they wanted to play during their meals. On 10/30/24 at 1:33 P.M. LPN #734 verified the music was not appreciated by several of the residents and turned the music off and did not change the radio station. LPN #734 agreed the residents probably did not like the music and was unable to say who chose the music. An interview with Activity Director #824 on 10/30/24 at 1:33 P.M. indicated the staff had chosen the type of music played during meals and the music could be changed to a different radio station according to resident preference. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the above findings and stated she worked for a contracted staffing agency and did not know Resident #62 needed fed her meal and verified the residents were not served their meal at the same time who were seated together. An interview with LPN #763 on 10/30/24 at 1:59 P.M. stated Resident #62 needed fed her meals and verified the above findings and stated the CNA assigned to supervise the residents in the dining room were responsible for feeding the residents. 2. Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses including anemia, adult failure to thrive, diabetes mellitus, cognitive communication deficit, heart arrhythmia, Alzheimer's dementia, anxiety, intestinal disease, osteoarthritis, spinal stenosis, morbid obesity, asthma, severe malnutrition, dysphagia and gastroesophageal reflux disease. Resident #13's plan of care revised on 10/10/24 indicated she had an activity of daily living performance deficit. Interventions on the plan of care revealed she needed assistance with setting up her meals with food cut in to small bites and close supervision for safety. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses including dementia, high blood pressure, embolism (object or bodily substance obstructing blood flow) and thrombus (blood clot) of the superficial and deep veins of the left lower extremity, end-stage glaucoma, peripheral vascular disease, pulmonary embolism, neurocognitive disorder, dysphagia, high cholesterol, diabetes mellitus, and osteoarthritis. Resident #24's plan of care revised on 01/22/24 indicated she had an activity of daily living self-care performance deficit. Intervention on the care plan included assisting Resident 324 with setting up her meal and provide supervision of one staff member. Resident #13 and Resident #24 were seated in the dining room on 10/30/24 at 12:30 P.M. waiting for their lunch to be served. Both residents stated they often had to wait an extended period of time for meals to be served. The meal cart arrived in the dining room at 1:04 P.M. and the staff started to serve the meal trays to the residents. All the meal trays were delivered to the residents and Resident #13 and Resident #24 did not receive their meal. Residents were not served at the same time who were seated together. Resident #13 and Resident #24 stated they were not informed why their meal tray was late and thought they were not going to receive a meal tray for lunch. At 1:34 P.M. Resident #13 and Resident #24 received their meal tray. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the residents were not served their meal at the same time who were seated together. This deficieny represents non-compliance investigated under Complaint Number OH00158389 and OH00159168.

Based on observation, interview, and recipe review, the facility failed to ensure appropriate puree preparation techniques were followed. This had the potential to affect 17 Residents (#17, #37, #42, #53, #62, #63, #74, #79, #80, #86, #88, #98, #105, #106, #113, #132, and #326) the facility identified as requiring a puree textured diet. The facility census was 166. Findings include: Observation on 10/30/24 from 10:19 A.M. to 10:55 A.M. of puree preparation by [NAME] #684 revealed preparation of puree cake, Brussels sprouts, sweet potatoes, and tomato soup. Dietary Director (DD) #813 and Dietary Manager (DM) #836 were also present for observation. [NAME] #684 did not refer to any recipes or diet manual during the preparation. [NAME] #684 indicated he was looking for a pudding like consistency. [NAME] #684 was noted to add large amounts of water and thickener (a powdered substance used to alter the texture of foods and beverages to allow for safe swallowing) to the Brussels sprouts, sweet potatoes, and tomato soup. After completing the puree preparation [NAME] #684 was observed to add a seasoning to the Brussels sprouts and tomato soup. The seasoning was not powdered and had large chunks of what appeared to be dried garlic, onion, and other spices. There was no additional check to ensure appropriate consistency. Interview on 10/30/24 at 10:55 A.M. with [NAME] #684, DD #813, and DM #836 confirmed findings of excessive use of water to thin, excessive use of powdered thickener, and use of chunky seasoning. [NAME] #684 confirmed he had not referred to the puree recipes or diet manual during puree preparation. [NAME] #684 indicated he had been working at the facility for some time and knew the texture he was looking for. Review of recipe Mashed Sweet Potatoes undated revealed the sweet potatoes were prepared with milk, margarine, ground cinnamon, and ground nutmeg. None of which was added to the mixture. Review of recipe Sweet Potatoes, Puree undated revealed the sweet potatoes were prepared with apple juice and food thickener as needed. Review of recipe Garlic Brussels Sprouts, Puree undated revealed the Brussels sprouts were prepared with broth or gravy. It was noted food thickener should be added as needed and gradually only until desired consistency is reached. Review of recipe Tomato Soup undated revealed tomato soup was appropriate as prepared for puree texture and did not require thickening or seasoning.

Based on interview, medical record reivew, and facility policy review, the facility failed to ensure the physician was notified in a timely manner for a change in condition for Resident #162 and for Resident #126. This affected two Residents (#126 and #162) of two reviewed for notification of change. The facility census was 166. Findings include: 1. Review of the closed medical record for Resident #162 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), malignant neoplasm of bronchus or lung, atherosclerotic heart disease, essential hypertension, generalized muscle weakness, difficulty in walking, repeated falls, and history of fractures including right femur, left tibia, T9-T10 (thoracic spine) vertebra, and right clavicle. Review of the plan of care initiated on [DATE] revealed Resident #162 was at risk for falls related to history of falls with fracture and weakness. Interventions included Dycem (non-slip self-adhesive strip) to wheelchair, ensure call light in reach, encourage use of call light, wear appropriate footwear when ambulating, follow facility fall protocol, evaluate and treat as needed, and offer to toilet resident every two hours and as needed. Review of the Un-Witnessed Fall incident report dated [DATE] at 4:22 P.M. revealed Resident #162 had an unwitnessed fall in her room. It was noted Certified Nurse Practitioner (CNP) #833 was notified on [DATE] at 4:12 P.M. and Resident #162's brother was notified on [DATE] at 4:21 P.M. Review of the progress note dated [DATE] at 4:31 P.M. revealed Resident #162 was found on the floor in her room and was complaining of pain in the lower extremity. An X-ray was ordered, CNP notified, and voicemail left for Resident #162's brother. Resident #162's vitals were stable. Review of the Radiology Results Report dated [DATE] at 11:47 P.M. revealed bilateral hip X-rays with two to three views on each side. The left hip results showed no evidence of acute fracture or dislocation. The right hip results showed near anatomic alignment of the intertrochanteric right femur post fixation and no dislocation. Review of the witness statement dated [DATE] for Licensed Practical Nurse (LPN) Unit Manager #787 stated he called CNP #833 and requested another X-ray of the knee and lower leg. An order was obtained and X-ray company was contacted. Review of Nursing Progress Note dated [DATE] at 3:31 P.M. revealed a call was placed to CNP regarding hip X-rays being negative by LPN Unit Manager #787. Increased swelling to right knee and lower leg was noted with new order for X-ray to right knee and lower leg. Review of Nursing Progress Note dated [DATE] at 4:31 A.M. revealed X-ray results were received and revealed an acute mildly displaced fracture of the distal femur and tri-compartmental degenerative changes in the knee. It was noted nurse attempted to notify physician of X-ray result however was awaiting response. Review of Nursing Progress Note dated [DATE] at 5:35 A.M. revealed upon medication pass Resident #162 was found unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated and continued until Emergency Medical Services (EMS) arrived. EMS pronounced Resident #162 deceased at 5:52 A.M. The nurse on call notified physician via urgent message and was awaiting response. Resident #162's family was contacted several times however was awaiting return call. Review of Nursing Progress Note dated [DATE] at 6:37 A.M. revealed numerous attempts were made to contact the physician without success by Agency LPN #827. Review of Nursing Progress Note dated [DATE] at 7:12 A.M. revealed a message was left for physician without successful contact by Assistant Director of Nursing (ADON). CNP was notified at this time by phone and notified Resident #162 had expired. Review of Nursing Progress Note dated [DATE] at 7:28 A.M. revealed the physician retuned call to ADON and was notified of the x-ray result from [DATE] and Resident #162 had expired. Physician to call the coroner's office. Review of the undated facility Investigation Timeline revealed Resident #162 had fall on [DATE]. On [DATE] at 3:31 P.M. it was noted Resident #162 had swelling to knee and an x-ray to the area was ordered. Results were received via fax and in electronic medical record (EMR) at 9:15 P.M. on [DATE]. The facility identified X-ray results were located at approximately 4:00 A.M. on [DATE]. Resident #162 was found unresponsive at approximately 5:30 A.M. on [DATE] and CPR started, EMS arrived at approximately 5:40 A.M, and Resident #162 was pronounced deceased at 5:52 A.M. LPN Night Supervisor #608 notified ADON at 6:03 A.M. NP #833 was notified via text by ADON at 7:10 A.M. and returned call at 7:12 A.M. Physician #832 was notified via text by ADON at 7:28 A.M. and returned call at 8:10 A.M. It was noted Physician #832's contact information was inaccurate on the face sheet. All nurses were educated on notification of change and to call the medical director if no response was received within one hour and checking the fax machine every four hours. Interview on [DATE] at 11:34 A.M. with Director of Nursing (DON) and ADON revealed they had completed an investigation into Resident #162's fall, fracture, and subsequent death. DON and ADON confirmed the radiology results came through on the fax machine at 9:15 P.M. on [DATE] and were not identified by nursing staff until [DATE] at approximately 4:00 A.M. DON and ADON confirmed Agency LPN #827 had not called the correct number for Physician #832 when attempting to make notification. DON indicated Agency LPN #827 had used the number on the face sheet which was the office phone number for Physician #833 and not a line that was monitored 24 hours per day. DON indicated Physician #833's direct line had to be updated into the face sheets following the incident. Interview on [DATE] at 7:56 A.M. with Agency LPN #827 via phone revealed on [DATE] she had been assigned to care for Resident #162 on night shift. Agency LPN #827 indicated during report at the beginning of her shift the previous nurse had notified her there was a pending X-ray result for Resident #162. Agency LPN #827 indicated she questioned the other nurse on floor about how to receive lab and radiology reports at about 12:00 A.M. on [DATE]. Agency LPN #827 confirmed she did not locate the X-ray results for Resident #162 until approximately 4:00 A.M. on [DATE]. Agency LPN #827 reported she attempted to reach the physician on the results at approximately 4:41 A.M. on [DATE]. Agency LPN #827 confirmed on [DATE] at approximately 5:30 A.M. Resident #162 was found unresponsive, required CPR, and was pronounced deceased at 5:52 A.M. by EMS. Agency LPN #827 confirmed she was unable to contact the physician or family prior to the end of her shift. Interview on [DATE] at 2:30 P.M. with CNP #833 confirmed she had been notified when Resident #162 fell on [DATE]. CNP #833 indicated she was again notified on [DATE] by LPN Unit Manager #787 that Resident #162 was complaining of knee pain. CNP #833 reported she was not required to be on call throughout the night. CNP #833 stated at about 8:00 A.M. on [DATE] the ADON called her to inform her of Resident #162's passing and the fracture. CNP #833 indicated the results came through on fax and was unsure what the delay was in results being reported. CNP #833 indicated had she been notified of the fracture at a reasonable hour Resident #162 would have been sent out to the hospital for evaluation. Interview on [DATE] at 4:04 P.M. with Physician #832 revealed she had not been notified of Resident #162's fall on [DATE]. Physician #832 indicated when she questioned why she had not been notified she was not given an answer and just told they were trying to figure out what had happened. Physician #832 stated if she had been notified, she would have ordered an X-ray and for a fracture she would have sent Resident #162 to the hospital. Physician #832 stated she was on call at night and was able to be reached directly on her cell phone. Physician #832 stated she was not notified of Resident #162's fracture or passing until approximately 6:00 A.M. on [DATE]. Review of facility policy Change in a Resident's Condition or Status, undated revealed The nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there was an accident involving the resident, significant change to the resident's physical or mental condition, a need to alter the resident's medical treatment significantly, and a need to transfer the resident to a hospital or treatment center. 48567 2. Review of the medical record for Resident #126 revealed an admitted [DATE] with diagnoses including end stage renal disease, peripheral vascular disease, dependence on renal dialysis, type one diabetes mellitus with kidney complications and retinopathy, chronic diastolic congestive heart failure, dysarthria, anxiety disorder, acquired absence of kidney, and neuromuscular dysfunction of the bladder. Review of the significant change Minimum Data Set (MDS) 3.0 assessment completed on [DATE] revealed Resident #126 had intact cognition and required substantial to maximal assistance with chair to bed, toilet, and shower transfers. Further review of the MDS revealed Resident #126 was on dialysis. Review of the physician orders revealed an order dated [DATE] for Resident #126 to be transported to Centers for Dialysis Care (CDC) every Monday, Wednesday, and Friday to receive dialysis related to end stage renal disease. Review of the care plan dated [DATE] revealed Resident #126 required dialysis every Monday, Wednesday, and Friday at CDC related to renal failure. Interventions included monitoring and reporting complications related to dialysis. Review of the progress notes from [DATE] through [DATE] revealed no indication Resident #126 did not receive her scheduled dialysis treatment on [DATE] or that any medical provider was notified she had not received dialysis on [DATE]. Interview on [DATE] at 3:18 P.M. with Resident #126 confirmed she did not receive her ordered dialysis that day because the transportation company responsible for taking her to the appointment never showed up. During the interview, Resident #126 stated she had missed a previous dialysis appointment due to the lack of transportation, but she was unable to provide detail as to the date it had occurred. Interview on [DATE] at 11:48 A.M. with Unit Secretary #681 confirmed Resident #126 did not go to dialysis on [DATE] due to the lack of transportation and the appointment had to be rescheduled for [DATE]. Further interview confirmed Unit Secretary #681 called the nurses station on [DATE] to inform them Resident #126 had missed her dialysis appointment but she was unable to recall who she spoke with. Unit Secretary #126 also confirmed Resident #126 was transported to the hospital prior to the rescheduled dialysis appointment. Interview on [DATE] with Registered Nurse (RN) #814 confirmed Resident #126 missed her dialysis appointment on [DATE] and that she was supposed to receive dialysis three times a week. RN #814 further explained when a resident misses a scheduled dialysis appointment, the protocol was to reschedule the appointment for the next day, unless the resident refuses. During RN #814's explanation of missed dialysis appointment protocols, physician or provider notification was not mentioned. Interview on [DATE] at 12:05 P.M. with CDC Representative #840 confirmed Resident #126 did not receive her scheduled dialysis on [DATE]. Interview on [DATE] at 12:45 P.M. with Nurse Practitioner (NP) #839 confirmed she was supposed to be notified when dialysis residents did not receive their scheduled dialysis. NP #839 further confirmed she was not notified Resident #126 did not receive dialysis on [DATE]. During the interview, NP #839 revealed that had she been informed, she would have ordered Resident #126 to have a chest x-ray and labs to make sure there were no concerns related to fluid overload due to the missed dialysis treatment. Review of the policy titled End-Stage Renal Disease, Care of Resident with revised [DATE] revealed the facility was to communicate dialysis concerns with the dietician, staff, and medical provider. This deficiency represents non-compliance investigated under Complaint Number OH00158529.

Based on record review and interview with staff the facility failed to follow-up with grievances involving Resident #167 in a timely manner. This affected one resident (#167) of three residents reviewed for grievances. The census was 166. Findings include: Review of the closed medical record for Resident #167 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included heart failure, dysphagia and dementia without behavioral disturbance. Review of the concern log revealed an entry on 01/04/24 from the family of Resident #167 regarding issues including missing dentures and request for medical records. The notes indicated the team met with the family regarding concerns and gave a consent to be seen by the dentist for replacement dentures. It stated the Administrator discussed replacement options. Review of the email dated 01/08/24 at 1:30 P.M. from the son to the Administrator revealed the son typed he had left five voicemails in the past ten days for Medical Records department. He was asking for a response by the next day. Review of the email dated 08/23/24 at 1:01 P.M. from the daughter to the Administrator revealed the subject line was marked as Dentures- IMPORTANT (time sensitive). Attached to the email was an itemized receipt for the dentures. The daughter requested a response by 08/30/24. Interview on 10/30/24 at 10:30 A.M. with the Administrator revealed he was aware of Resident #167's missing dentures and acknowledged they had a meeting with family who also requested medical records. The Administrator verified he received the email dated 01/08/24 stating he forwarded the request for medical records and sent the son a request form to be completed. He stated he never heard from him again regarding the medical records. A follow-up interview at 5:16 P.M. with the Administrator revealed the resident was put on the list to be seen by the dentist however Resident #167 was discharged prior to the visit stating he lost touch with the son after that. He stated the facility was not going to pay for the dentures but wanted to see if they would be covered under insurance. A subsequent interview on 11/04/24 at 9:30 A.M. with the Administrator revealed he denied receiving the email dated 08/23/24 regarding reimbursement for dentures but verified it was the correct email address for him as it changed with new ownership. He denied having any further interaction after Resident #167 was discharged on [DATE]. This deficiency represents non-compliance investigated under Complaint Number OH00159071, OH00158529 and OH00158389.

Based on observation, record review and interview the facility failed to ensure Resident #62, Resident #108 and Resident #79 were assisted with eating their meal. This affected three residents (#62, #108 and #79) out of seven residents reviewed for activity of daily living (ADL) assistance. The facility census was 166. Findings include: 1. Resident #62 was admitted on [DATE] and readmitted on [DATE] with diagnoses including severe dementia with behaviors, hemiplegia (one sided paralysis) and hemiparesis (weakness on one side) following a cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing), osteoarthritis, and hyperlipidemia (high cholesterol). Resident #62 had medical conditions including weakness with abnormal gait and mobility, used a wheelchair for mobility, and needed assistance with personal care. A review of the Resident #62's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was rarely or never understood. Resident #62's physician order dated 09/14/24 revealed the nurse was to ensure Resident #62 was fed all her meals. If Resident #62 pushed her food away then re-approach Resident #62 with food. A review of Resident #62's plan of care revised 12/19/22 indicated an activity of living deficit related to cognition and ability. Interventions on the plan of care indicated she required one person to feed her meals and required two-person assistance for toileting, transfers, and assistance with bathing, showering, bed mobility, dressing, personal hygiene and oral care. An observation of the meal service on 10/30/24 from 12:30 P.M. to 2:00 P.M. revealed Resident #62 was assisted to the dining room in her wheelchair at 12:40 P.M. At 1:15 P.M. Resident #62 was served her lunch by Certified Nursing Assistant (CNA) #900. CNA #900 set the meal tray in front of Resident #62 and repositioned Resident #62 in an upright position, uncovered her meal plate and set-up the tray for Resident #62 and then walked away to continue to serve the meal trays to the other residents in the dining room. At 1:19 P.M. Licensed Practical Nurse (LPN) #763 walked over and fed Resident #62 a few bites of her meal while standing next to her. LPN #763 walked away from Resident #62 and left the dining room. Resident #62 sat in front of her meal tray and tried to eat a few bites of her meal. At 1:48 P.M. Resident #62's meal tray was removed from the table and CNA #900 assisted Resident #62 back to the common area in the nursing unit. Resident #62 ate approximately 10% of her meal. An interview with CNA #900 on 10/30/24 at 1:48 P.M. verified the above findings and stated she worked for a contracted staffing agency and did not know Resident #62 needed fed her meal and verified the residents were not fed at the same time who were seated together. An interview with LPN #763 on 10/30/24 at 1:59 P.M. stated Resident #62 needed fed her meals and verified the above findings and stated the CNAs assigned to supervise the residents in the dining room were responsible for feeding the residents. 2. Resident #108 was admitted on [DATE] with diagnoses including osteoporosis, vitamin D deficiency, and hemorrhagic thrombocytopenia. A review of Resident #108's nursing ADL functional assessment dated [DATE] indicted she needed assistance with setting up her meal and encourage her to be out of bed for all of her meals. Resident #108's plan of care revised on 02/07/24 indicated an activity of daily living self-care performance deficit. Interventions on the care plan indicated Resident #108 needed assistance with setting up her meal and supervision when eating her meal. An interview with Resident #108 on 10/28/24 at 10:42 AM revealed she needed assistance with getting out of bed and had to wait a long time in the morning for assistance. Resident #108 stated the staff had not offered to assist her out of bed yet today. An observation on 11/04/24 at 10:16 A.M. revealed CNA #841 delivered Resident #108 her meal tray. CNA #841 repositioned Resident #108 in her bed, raised the head of the bed and placed the meal tray on the over-the-bed tray across her lap while lying in bed. CNA #841 set up the meal for Resident #108 and left the room. Resident #108 was not encouraged to get out of bed or supervised during the meal. An interview with CNA #841 on 11/04/24 at 10:16 A.M. verified the above findings and stated the only time Resident #108 was assisted out of bed was when her daughter visited and assisted with feeding her meal. CNA #841 stated Resident #108 did not need supervision during meals and verified the staff were unable to supervise Resident #108 for her meals when she was eating in bed. Review of the facility policy and procedure titled Meal Assistance revised March 2022 indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 48567 3. Review of the medical record for Resident #79 revealed an initial admitted [DATE] and a re-entry date of 06/05/23. Diagnoses included epilepsy, hypertensive heart with heart failure, gastrostomy status, type two diabetes mellitus, hyperlipidemia, primary hypertension, unspecified protein-calorie malnutrition, anemia, neuromuscular dysfunction of bladder, vascular dementia, major depression, schizoaffective disorder, and oropharyngeal phase dysphagia. Review of the quarterly MDS 3.0 assessment completed on 10/06/24 revealed Resident #79 had moderate cognitive impairment with no behaviors or rejection of care. Further review of the MDS revealed Resident #79 required partial to moderate feeding assistance, had a history of holding food in her mouth or cheeks, coughed or choked during meals or with medication administration, complained of swallowing difficulty, was on a mechanically altered diet and received 51 percent or more of her nutrition through a feeing tube. Review of the physician order revealed a diet order dated 08/13/24 for a regular diet with pureed texture and mildly thick (nectar) consistency liquids with no straw related to oropharyngeal dysphagia. Review of the care plan dated 07/02/19 to 01/06/25 revealed Resident #79 had the potential for weight and hydration issues related to variable oral intake, mechanically altered diet, and varying ability to feed herself. Interventions included assisting Resident #79 to eat per Occupation Therapist (OT) recommendation and providing enteral feeds per physician orders. The care plan also indicated a deficit in activities of daily living (ADL) self-care deficit. Interventions included directions for staff to feed Resident #79 at all meals and indicated she was a full feed with no straws. Review of the Speech-Language Pathology (SLP) dated 10/14/24 revealed Resident #79 had minimum to mild progress toward maintaining ability to consume pureed solids and nectar thick liquids to maximize nutritional intake and enhance hydration to reduce risk of aspiration, penetration, malnutrition, and weight loss by exhibiting minimal to mild oropharyngeal impairment. Review of the point of care feeding assistance response history from 09/12/24 (date the care plan was last updated to reflect Resident #79 was a full feed) through 11/04/24 revealed one date, 09/25/24, when Resident #79 was unavailable, and 52 days she was available for meals. During that time, Resident #79 had documentation indicating limited feeding assistance was provided zero days, extensive assistance was provided for at least one meal on two dates (09/19/24 and 11/04/24), and total assistance was provided for at least one meal on eight dates (09/12/24, 09/13/24, 09/16/24, 09/19/24, 09/20/24, 10/08/24, 10/24/24, and 10/30/24). Documentation from all other dates in that time span indicated no assistance was provided or supervision only was provided. Review of the pre-printed [NAME] 2 Assignment sheet for the CNAs revealed Resident #79 was on a mechanical soft, thin liquid diet. There was no mention of her requiring feeding assistance. This was confirmed by LPN #787 on 11/05/24 at 11:15 A.M. Review of the [NAME] 2, South 1 preprinted assignment sheet for unit nurses revealed Resident # 79 took pills crushed and was on a mechanical soft diet. There was nothing regarding Resident #79's need for feeding assistance. It was confirmed during an interview with LPN #787 on 11/05/24 at 11:15 A.M. that the assignment sheet did not indicate Resident # 79 needed feeding assistance. Interview on 10/28/24 from 10:36 A.M. to 10:45 A.M. with Resident #79 revealed she felt she never got help to eat as she asked the surveyor to help feed her. At the time of this interview, a breakfast tray was observed on the bedside table alongside the left side of the bed, out of reach from the resident with lids and plate cover intact and silverware undisturbed. At 10:45 A.M., Resident #79 placed her call light on to request staff assistance with breakfast. Observation on 10/28/24 at 10:52 A.M. revealed Certified Nursing Assistant (CNA) #841 brought a rewarmed tray of breakfast food to Resident #79, set-up the tray, in front of Resident #79, and exited the resident's room. Interview with CNA #79 at this time confirmed Resident #79 had not received assistance with her breakfast earlier that morning so she just rewarmed the food and completed meal set-up prior to exiting the room just then. CNA #841 further confirmed Resident #79 was left to eat alone and that as per the report she received, Resident #79 only needed assistance with the set-up for meals and not hands-on feeding assistance or supervision. Observation on 10/31/24 at 9:31 A.M. revealed the tube feeding pump beeping and a breakfast tray set-up in front of Resident # 79. At the time of the observation, no staff were providing feeding assistance, and a towel was noted over Resident #79's chest with food dropped on it and a small amount pureed food was noted on the left side of her mouth. An interview with Resident #79 at the time of this observation confirmed that staff set her tray up and placed it in front of her about 15 to 20 minutes earlier and did not offer to help her eat, which she reiterated happened frequently. She stated she tried to eat on her own and was too tired to continue. Interview on 10/31/24 at 9:41 A.M. with CNA #842 confirmed she received report from the nurse or off going CNA at the change of shift and was only informed of one of her assigned residents (Resident #98) who needed feeding assistance. She further confirmed Resident #79 was one of her assigned residents and she received assistance with meal set-up. During the interview, CNA #842 pulled an assignment sheet from her pocket and verified that Resident #79 was not listed as requiring feeding assistance. Observations continued from the hallway on the unit on 10/31/24 until 10:11 A.M. which revealed no staff had entered the room of Resident #79 to offer assistance with breakfast. Interview on 10/31/24 at 10:23 A.M. with Dietitian #711 confirmed Resident #79 had pretty poor oral intake of meals and that she relied on tube feedings as her primary source of nutrition. During the interview, Dietitian #711 confirmed that Resident #79's level of feeding assistance was inconsistent but staff were to provide assistance with meals. Interview on 11/04/24 at 3:07 P.M. with CNA #843 revealed she arrived at the unit at 11:30 A.M. and Resident #79 still had her breakfast tray beside her bed which was untouched. She further confirmed Resident #79 did not eat anything from her lunch tray on this date and received no feeding assistance because she was unaware Resident #79 required any assistance. During this interview, another CNA was present (CNA #749) who confirmed she was unaware Resident #79 received meals and thought she was only fed through a feeding tube. Interview on 11/05/24 at 11:10 A.M. with Licensed Practical Nurse (LPN) Unit Manager #787 confirmed if a resident required feeding assistance, it should be noted on the staff assignment sheets. LPN Unit Manager #787 also revealed he was aware staff do not like to use the new assignment sheets, but nurses still were required to give a run-down of resident needs to CNAs in morning change of shift report, which should include residents needing feeding assistance. Interview on 11/05/24 at 11:35 AM with Director of Therapy (DOT) #658 revealed Resident #79 was currently on a functional maintenance program with the SLP to ensure she maintains safety with her current diet. DOT #658 further confirmed Resident #79 needed cues to maintain safe eating strategies, which included small bites and sips, alternating liquids and solids, time between bites, and double swallows. Review of the policy titled Assistance with Meals last revised March 2022 revealed staff were to help feed residents who needed assistance with eating. The policy further revealed residents were to be fed with attention to safety, comfort, and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00159168 and OH00158529.

Based on observation, resident interview, staff interview, and review of the medical record, the facility failed to ensure residents received prescribed treatments or application of appliances as prescribed to maintain or prevent a decline in range of motion (ROM). This affected one resident (Resident #27) of one resident reviewed for ROM/mobility. The facility census was 166. Findings include: Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), depression, primary hypertension, osteoarthritis, muscle weakness, pain in left shoulder, and hemiplegia or hemiparesis following a cerebral infarction affecting the left non-dominant side. Review of the annual Minimum Data Set (MDS) 3.0 assessment completed on 10/13/24 revealed Resident #27 had intact cognition and no behaviors or rejection of care. Further review of the MDS revealed Resident #27 had impaired range of motion (ROM) on one side of her upper and lower extremities and suffered from hemiparesis or hemiplegia. Review of the physician orders revealed orders dated 07/06/23 for Resident #27 to wear a left hand split throughout the day as tolerated and a PRAFO boot (a custom fit ankle foot orthosis) on the left foot when in bed. Further review of the orders revealed staff were to monitor for skin breakdown or adverse reactions to the splint. Review of the care plan dated 01/07/23 to 01/13/25 revealed Resident #27 had an activities of daily living (ADL) self-care deficit weakness and poor left-sided mobility and required the assistance of one to two staff for all ADLs. Further review of the care plan interventions revealed Resident #27 was to wear a left hand splint throughout the day as tolerated and a PRAFO boot to the left foot when in bed. The interventions further directed staff to monitor for skin breakdown related to left hand splint and left foot brace use. Review of the occupational therapy discharge summary signed 06/18/24 for dates span 02/28/24 to 06/18/24 revealed a recommendation Resident #27 continue to wear the left resting hand splint throughout the day as tolerated and for staff to monitor for skin breakdown or any adverse reactions. Review of the medical record point-of-care task documentation list revealed there were no required tasks related to staff ensuring a left hand splint or left PRAFO boot was applied to Resident #27. Review of the medication administration record (MAR) and the treatment administration record (TAR) from the past three months revealed no nursing documentation indicating application of splints or braces for Resident #27. Interview on 10/28/24 at 10:05 A.M. with Resident #27 revealed she felt she needed therapy as she stated her foot was stuck downward and her hand was too tight and closed all the time. During the interview, Resident #27 confirmed she had a hand splint, but did not know where it went, hadn't worn it in what she described as possibly a few months, and staff did not provide any exercises to prevent her hand from getting worse. Observation of Resident #27 and her surroundings at the time of the interview revealed a contracture of the left hand, no left hand splint in place and two signs on Resident #27's bulletin board, one with a picture of the hand splint and the other with instructions on how to properly apply the hand splint. Follow-up observations on 10/29/24 at 4:05 P.M., 10/30/24 at 9:48 A.M., and 10/31/24 at 9:55 A.M. revealed Resident #27 was not wearing a left hand splint. Interviews with Resident #27 at the time of each observation confirmed that staff had not inquired about the hand splint or attempt to apply one. Interview on 10/31/24 at 10:51 A.M. with Licensed Practical Nurse (LPN) #715 confirmed she had observed a blue splint on Resident # 27's left hand in the past, but did not know when she was supposed to wear it. At the time of the interview, LPN #715 confirmed Resident #27 was not wearing a hand splint and that she confirmed with Resident #27 she did not know where the splint was. Interview on 11/04/24 at 12:38 P.M. with LPN #844 confirmed she had nothing on her report sheet stating Resident # 27 was to wear a hand splint and had no other information pertaining to the hand splint to offer. Interview on 11/04/24 at 9:27 A.M. with Director of Therapy #658 confirmed Resident #27 was last admitted to Occupation Therapy (OT) services on 02/28/24 for evaluation of splinting of the left hand. Director of Therapy #658 further confirmed Resident #27 was discharged on [DATE] and was able to tolerate the resting left hand splint up to four hours daily. During the interview, Director of Therapy #658 confirmed therapy discharge recommendations were for Resident #27 to wear the left hand splint daily as tolerated, and staff were to monitor for skin breakdown or adverse reactions. Observation on 11/04/24 at 12:23 P.M. revealed Resident #27 was in bed with no hand split. An Interview conducted at the time of the observation with Resident #27 confirmed no staff had offered to help find her left hand splint or apply it. Resident #27 further stated it was very difficult to put the splint on herself without staff assistance but could sometimes do it herself if she had it available. Resident #27 further stated she felt like her left hand was closed tighter than when she was previously wearing her brace consistently. Interview on 11/04/24 at 2:50 P.M. CNA #843 confirmed she received no report that Resident #27 had a hand splint or a PRAFO boot. She further confirmed Resident #27 was wearing neither and searched the drawers in one of Resident #27's dressers, with permission of Resident #27, and did not find the hand splint. She further confirmed the foot brace was on Resident #27's bedroom floor but she did not know when it was to be applied. Interview on 11/04/24 at 2:53 P.M. with CNA #749 confirmed she had not provided care for Resident #27 in a long time and she was unaware of an order for any splints or braces. Interview on 11/04/24 with Resident #27 at 3:05 P.M. confirmed she had a brace for her left foot that was lying on the floor, but she had not worn it in a while. She did not confirm or deny that she wanted to wear the PRAFO boot while she was in bed or whether staff had offered to place it on her left foot. Resident #27 then reiterated she was more concerned with wearing her hand splint. Interview on 11/04/24 with LPN Unit Manager #787 at 3:10 P.M. confirmed the facility did not provide restorative nursing services and further confirmed Resident #27 had orders placed in 2023 for a left resting hand splint and Left foot PRAFO boot. He further confirmed both were listed on Resident #27's care plan but were not on the Kardex (a document describing resident care needs) for nursing staff due to them being entered on the care plan incorrectly. This deficiency represents non-compliance investigated under Complaint Number OH00158529.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure appropriate care and services were in place for Resident #111's enteral feeding tube. This affected one resident (Resident #111) of one reviewed for tube feeding concerns. The facility identified eleven residents ( #46, #63, #66, #79, #97, #98, #110, #111, #128, #137, and #148) who received enteral tube feedings. The facility census was 166. Findings include: Review of the medical record for Resident #111 revealed an initial admitted [DATE] and a facility re-entry date of 01/31/24. Diagnoses included hypertensive urgency, hematuria, altered mental status, benign prostatic hyperplasia, oropharyngeal phase dysphagia, type two diabetes mellitus with diabetic neuropathy, unspecified dementia, pure red cell aplasia, vesicointestinal fistula, flaccid neuropathic bladder, stage three chronic kidney disease, acquired absence of the right and left leg above the knee, and attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/26/24 revealed Resident #111 had intact cognition and exhibited no behaviors or rejection of care. Further review of the MDS revealed Resident #111 received his primary nutrition and hydration through a feeding tube. Review of the care plan dated 09/18/24 revealed Resident #111 required a PEG (percutaneous endoscopic gastrostomy) tube (a feeding tube inserted into the stomach which may be used for nutrition, hydration, and medication administration) secondary to dysphagia. Interventions included providing local PEG tube site care per orders and monitoring for signs and symptoms of infection. Review of all active physician orders revealed no orders related to care of Resident #111's PEG tube insertion site. Observation on 10/28/24 at 2:22 P.M. revealed the tube pump beeping hold error (a water flush had been infusing) and a PEG tube PEG dressing with several yellowish to yellow-brown stains which was dated 10/25/24. An interview with Resident #111 at the time of the observation confirmed the feeding pump had been beeping for 10 minutes, it beeps all the time, and staff take a long time to check to see why it is beeping. During the interview, Resident #111 stated he was uncertain how often his PEG tube dressing got changed because it tends to vary, but thought this one had been on since last week. Continued observation from the hallway revealed no staff entered the room of Resident #111 to check on the beeping feeding pump until 2:50 P.M., though one staff member was observed walking past the room twice. Interview on 10/28/24 at 2:50 P.M. with Certified Nursing Assistant (CNA) #841 confirmed the PEG tube dressing was dated 10/25/24 and confirmed she was on the way to let the nurse know the feeding pump had been beeping. Interview on 10/30/24 at 2:18 P.M. with Resident #111 revealed something around his abdomen was bothering him after his shower and he thought there might still be a dressing on his PEG tube insertion site. At the time of the interview, he began pulling at his gown and grabbing around the PEG tube stating he wanted it off. Interview on 10/30/24 at 2:24 P.M. with Licensed Practical Nurse (LPN) #795 confirmed her knowledge of Resident #111's PEG tube care was that if it is dirty, change it. LPN #795 further revealed nurses were to follow orders, adding if they have them. Observation on 10/30/24 at 2:36 P.M. of Resident #111 receiving PEG tube site care from LPN #795 revealed there was no dressing (he had just been showered within the hour), and the site appeared clean, dry, and intact. LPN #795 was observed cleaning the PEG site with moistened gauze, drying with a clean gauze pad, and applying a clean split gauze which was dated and initialed. An interview with LPN #795 after the PEG tube care was completed confirmed the gauze used to clean around the PEG tube insertion site was moistened with Dakin's solution (a strong topical antiseptic solution used to treat or prevent wound infections), but she was uncertain the strength of the solution she used and was unable to verbalize what the orders were for the PEG tube site care she just performed for Resident #111. Interview on 10/31/24 at 10:48 A.M. with LPN #715 confirmed Resident #111 had no orders regarding PEG site care. Interview on 10/31/24 at 11:20 A.M. with LPN Unit Manager #787 confirmed PEG tube site care should be done daily and as needed by cleaning and applying a clean split gauze. During the interview, LPN #787 confirmed Resident #111 had no orders related to PEG site care, just checking placement and residuals every eight hours. Review of the policy titled Peg Tube Care and Maintenance revised October 2017 revealed no creams, powders, or dressings were to be applied underneath the external anchor device unless ordered by a physician.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo (QSO ,[DATE]-NH), review of the facility Infection Surveillance Plan, review of the facility memo Process and Approach Strategy for Mandatory COVID-19 Testing in Nursing Homes, review of a facility investigative summary and staff interview, the facility failed to ensure COVID-19 testing was completed as required. This resulted in Immediate Jeopardy on [DATE] when the facility failed to ensure resident specific accurate COVID 19 testing was done for 35 residents on the Mandel 3 Unit resulting in inaccurate results when Director of Nursing (DON) #600 and Assistant Director of Nursing (ADON) #605 failed to collect samples from the affected residents and submitted false samples to the laboratory. This falsification in testing, done by DON #600 and ADON #605 placed the facility in a situation which delayed identification of COVID-19 positive results and had the potential to delay proper infection control measures to prevent the spread of COVID 19. Upon re-testing on [DATE], 22 residents, many of whom displayed symptoms, tested positive. Swift identification of confirmed COVID-19 cases allows the facility to take immediate action to remove exposure risks to nursing home residents and staff. The lack of effective and accurate COVID-19 testing practices during a COVID-19 outbreak in the facility placed all 183 residents at risk for the likelihood of harm, complications and/or death. This affected 35 residents, #3, #16, #23, #29, #40, #41, #42, #45, #50, #54, #71, #76, #78, #80, #91, #96, #103, #104,#106, #111, #113, #116, #120, #121, #130, #133, #145, #147, #150, #155, #157, #169, #174, #175, #176 residing on the Mandel 3 and had the potential to affect all 183 residents residing in the facility. The facility census was 183. On [DATE] at 12:22 P.M. the Interim Administrator, Infection Preventionist #301, Interim Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified that the Immediate Jeopardy began on [DATE] when DON #600 and ADON #605, who are no longer employed by the facility, failed to collect samples for COVID-19 from residents on the Mandel 3 unit and submitted false samples to the laboratory which delayed identification of COVID-19 positive results and had the potential to delay proper infection control measures to prevent the spread of COVID 19. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · On [DATE] COVID-19 testing was to be completed in the facility due to a current outbreak. This testing included testing of 35 residents on Mandel 3 unit. On [DATE] tests returned negative for all residents but one from this unit. However, residents on this unit began/continued to exhibit symptoms of COVID-19. · On [DATE] Licensed Practical Nurse (LPN) #200 reported concerns to Unit Manager Registered Nurse (RN) #305 related to the COVID-19 testing done on [DATE] on the Mandel 3 unit. The LPN indicated she did not believe the staff responsible for the testing (DON #600 and ADON #605) had been on the unit to complete the testing, but yet testing specimens were sent to the laboratory. · On [DATE] COVID-19 testing completed in the facility for all residents, including the residents on the Mandel 3 unit as part of the facility COVID-19 outbreak testing cadence revealed 22 residents (who had tested negative on [DATE]) who resided on the Mandel 3 unit had tested positive. · On [DATE], per the facility investigative summary report, LPN #200 reported to Administrator #400 a concern with the COVID-19 testing done for the residents on the Mandel 3 unit on [DATE]. The concern was reported to Compliance Officer #500 and an investigation was initiated at that time. · On [DATE] Administrator #400, DON #600 and ADON #605 were suspended pending result of the investigation. · On [DATE], a new Interim Administrator and Infection Preventionist #301 were assigned to the facility. · On [DATE], the members of the Ohio Department of Health (ODH) Strike team and Cuyahoga County Local Health Department (CCPH) initiated baseline resident and staff testing at the facility. Residents and staff were tested by CCPH team and nurses. · On [DATE] an Interim DON was assigned to the facility. · As of [DATE] the facility investigation was still on-going but contained evidence DON #600 and ADON #605 had not obtained COVID-19 testing specimens from the 35 residents on Mandel 3 on [DATE] and that the testing specimens sent to the laboratory on that date had been falsified. · On [DATE] Administrator #400, DON #600 and ADON #605 were terminated from employment. The Board of Executives of Long-Term Services and Supports (BELTSS) and the Ohio Board of Nursing were notified of the incident by the facility. · On [DATE] the facility obtained the services of two expert consultant infection preventionists (IPs) with a plan for one to be onsite on [DATE]. The plan was for the IPs to conduct an infection control self-assessment and building tour, develop and implement recommendations based on the assessment and other information related to this investigation. In addition, the IPs would develop staff educational programs based on their review and findings. · On [DATE], an Ad Hoc Quality Assurance (QA) meeting was held with the Interim Administrator, Interim DON, the facility Media Employee and additional department heads to discuss the facility plan and plan for in-servicing staff. Although not present for the meeting, the medical director was contacted and updated with the facility plan. · On [DATE] a letter from the President and Chief Executive Officer (CEO) was issued to all residents and families regarding the falsification of testing done in the facility. · On [DATE] Infection Preventionist #301 and Staff Development Nurse #305 provided staff education via handouts. Materials included COVID-19 exposure and symptoms; COVID-19 prevention (hand hygiene, social distancing, staying home when sick); how to apply and remove PPE, and on the following policies: Isolation Precautions; Applying and removing a mask; PPE and Disinfection; Admitting, Readmitting, Room Changing, and Quarantine; Admitting Clients Previously Positive for COVID-19; Prevention of Infection Transmission during Aerosolized Treatments. As of [DATE] Staff Development Nurse #305 revealed of the facility 300 employees, 141 employees had acknowledged the training materials. · On [DATE] Infection Preventionist #301 and Staff Development Nurse #305 provided infection control binders at five nursing stations (Myers 1, 2 and 3 and Mandel 2 and 3) for staff to review. The binders included the facility coronavirus policy, which included how to identify potentially infected patients and on obtaining a proper swab sample to test for COVID-19. As of [DATE] Staff Development Nurse #305 revealed of the facility 300 employees, 79 employees had acknowledged the training materials. Staff Development Nurse #305 revealed she was in the process of following up with this training as she believed some staff had reviewed the training materials but had not yet acknowledged it. A plan was in place for the status of each employee's education to be determined upon arrival to the facility during COVID-19 screening, any employee working who had not acknowledged the above training materials, would do so at that time. This plan would continue until all staff had reviewed the training materials. · On [DATE] a plan for Infection Preventionist #301, the ADON and the Interim DON to audit nurses obtaining COVID test samples to ensure they were obtained appropriately, staff compliance with use of PPE, patient assessments for COVID symptoms, and hand hygiene was initiated. The facility indicated the audits would be completed daily with no end date provided. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the facility survey history revealed on [DATE] a complaint survey and COVID 19 Focused Infection Control survey were completed which identified concerns related to the facility's failure to maintain self-quarantine precautions and proper hand hygiene to prevent the spread of COVID-19. Review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo ,[DATE]-NH, dated [DATE] revealed guidance to nursing homes related to COVID-19 testing. The memo included the following information: On [DATE], CMS published an interim final rule with comment period (IFC), CMS-340- IFC, entitled Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments of 1988 (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. CMS's recommendation at this time was to test with authorized nucleic acid or [MEDICATION NAME] detection assays as an important addition to other infection prevention and control (IPC) recommendations aimed at preventing COVID-19 from entering nursing homes, detecting cases quickly, and stopping transmission. Swift identification of confirmed COVID-19 cases allows the facility to take immediate action to remove exposure risks to nursing home residents and staff. CMS has added this requirement at 42 CFR § 483.80(h) which requires that the facility test all residents and staff for COVID-19. The QSO memo also included the following information: Collecting and handling specimens correctly and safely is imperative to ensure the accuracy of test results and prevent any unnecessary exposures. The specimen should be collected and, if necessary, stored in accordance with the manufacturer's instructions for use for the test and CDC guidelines. Review of the facility census revealed on [DATE] there were 35 residents, Resident #3, #16, #23, #29, #40, #41, #42, #45, #50, #54, #71, #76, #78, #80, #91, #96, #103, #104,#106, #111, #113, #116, #120, #121, #130, #133, #145, #147, #150, #155, #157, #169, #174, #175, #176 residing on the Mandel 3 unit and two additional residents, Resident #7 and #74 who were hospitalized related to Covid-19. During the onsite investigation, beginning on [DATE] at 11:40 A.M. review of a resident list provided by Infection Control Preventionist #301 revealed there were currently confirmed cases of COVID-19 in the facility. The facility identified seven current residents, Resident #29, #103, #121, #150, #155, #158 and #178 who were in isolation after testing positive for COVID-19 and two current residents, Resident #62 and #171 currently in insolation after exhibiting signs/symptoms of COVID-19. Of the 183 residents currently residing in the facility, 27 additional residents had tested positive for COVID-19 and were considered to be recovered as of this date. Of the residents who had tested positive for Covid-19 six residents, Resident #3, #25, #96, #145, #147 and #174 remained hospitalized related to Covid-19. Three residents, Resident #130, #175 and #178 expired from Covid-19 related symptoms. On [DATE] at 12:00 P.M. interview with the Interim Administrator revealed she had only been in her role at the facility since [DATE]. At the time of the interview, the Interim Administrator revealed the facility had an ongoing investigation into an allegation of falsification of COVID-19 testing associated with residents residing on the facility Mandel 3 unit. The Interim Administrator revealed the situation began when LPN #200 brought concerns to the former Administrator (Administrator #400) and facility Compliance Officer #500 that COVID-19 testing supposedly performed by the previous DON (DON #600) and previous ADON (ADON #605) on [DATE] was not done and the swabs submitted to the laboratory for testing were falsified. The Interim Administrator further explained the nurse managers were typically responsible for swabbing residents for COVID-19 testing on their units and if there was no nurse manager for that particular unit, the DON or ADON would do the swab testing. The Interim Administrator revealed in the situation of the [DATE] testing, DON #600 and ADON #605 allegedly swabbed 35 residents on Mandel 3 Unit, labeled the swabs and sent the swabs into the laboratory per the facility normal process. The Interim Administrator revealed at that time, on the Mandel 3 Unit, there were residents who were symptomatic for COVID-19. The Interim Administrator revealed LPN #200 voiced concerns to Administrator #400 and facility Compliance Officer #500 regarding medical record documentation that indicated DON #600 and ADON #605 had swabbed 35 residents on the Mandel 3 unit for COVID-19 on [DATE] at approximately 4:00 A.M. that morning. The Interim Administrator indicated LPN #200 was suspicious because she had only briefly seen these staff on the unit and indicated it would have been difficult for them to perform testing on 35 residents and not been seen entering or exiting any of the resident rooms. The Interim Administrator revealed once LPN #200 took her concerns to Administrator #400 and Compliance Officer #500, a facility investigation began. The Interim Administrator revealed Compliance Officer #500 was conducting an ongoing investigation into the incident and could provide additional information. Review of the facility Summary Investigative Report, completed by Administrator #405, dated [DATE] revealed on [DATE] it was reported by Administrator #400 that a nurse (LPN #200) on the Mandel 3 unit reported to him that she was concerned regarding whether the [DATE] COVID-19 testing for the residents on that unit were actually obtained by DON #600 and ADON #605. The summary revealed DON #600 and ADON #605 came to the facility early in the morning (approximately 5:00 A.M.) to complete outbreak testing, but LPN #200 indicated she did not observe them going into any resident rooms. The summary report revealed an interview with Administrator #400 done by Compliance Officer #500 revealed when the allegation was made to him on [DATE] he reported it to Administrator #405 and Vice President of Human Resources #700 and denied any knowledge of the issue. Administrator #400 also reported he watched the hall (video) tapes for the time in question and did not observe DON #600 or ADON #605 go into any resident rooms. Administrator #400 was interviewed again on [DATE] and admitted at that time that he was aware the testing was not performed on Mandel 3 residents on [DATE], even though the test swabs for the Mandel 3 residents were delivered to the laboratory and showed negative results. Administrator #400 revealed he was informed by DON #600 and ADON #605 not to worry that they would all be negative (and they winked indicating that the swabs were not obtained for the residents) and further admitted he told DON #600 and ADON #605 to send the swabs to the lab, knowing the actual tests had not been performed on the Mandel 3 residents. Continued review of the summary report revealed information from Unit Manager RN #305 that LPN #200 had actually reported concerns to her on [DATE] that she did not believe any of the residents (on Mandel 3) were tested (on [DATE]) and that staff and families were suspicious of this. As a result of the testing samples sent to the laboratory on [DATE], from the testing completed by DON #600 and ADON #605 the following COVID-19 test results were obtained: 33 negative (Resident #3, #16, #23, #29, #40, #41, #42, #45, #50, #54, #71, #76, #78, #80, #91, #96, #103, #104, #106, #113, #116, #120, #121, #130, #133, #145, #147, #150, #155, #157, #169, #174, #175), one positive (Resident #176) , two residents with no test provided (hospitalized residents #70 and #74) and one resident whose specimen leaked (Resident #111) for a total of 37 residents. The facility investigation revealed Unit Manager RN #305 had obtained the specimen from Resident #176. On [DATE] testing samples sent to the laboratory for the residents residing on the Mandel 3 unit revealed the following results: Nine negative, 22 positive (Resident #3, #16, #23, #40, #41, #45, #50, #54, #71, #78, #91, #104, #106, #111, #116, #120, #121, #130, #133, #147, #174 and #175), five residents with no test provided and one that indicated specific incorrect for a total of 37 residents. On [DATE] the facility President and Chief Executive Office (CEO) issued a letter to residents and family members. The letter was titled Re: Important Update: COVID-19 Testing at Montefiore. The letter included the following communication: In mid-October, a number of Montefiore residents in one of our units began exhibiting symptoms of COVID-19. Tests were conducted, but the results were negative. After rerunning the tests, several residents tested positive. Fearing that we might be facing a widespread outbreak on our campus, we immediately called in resources from throughout the county and the state to assist us. We were able to retest all the residents in question, confirm positive [DIAGNOSES REDACTED]. As we were addressing this situation, we also began investigating information provided by a member of the nursing staff in the affected unit, who alerted her manager as well as Human Resources that the original tests might not have been conducted appropriately. I am very sorry to report that after conducting a number of interviews with staff, confirming lab results and reviewing patient records, our investigator concluded that Montefiore's Director of Nursing and the Assistant Director of Nursing actually submitted false tests, thereby failing to follow official protocols and procedures related to COVID-19 and failing to follow nursing standards of practice as it related to conducting the tests. I am also sorry to tell you that Montefiore's Administrator failed to oversee the situation appropriately . In this case, these three individuals clearly failed to meet that standard. They violated the values that are at the core of our organization and we've terminated their employment. On [DATE] at 11:45 A.M. interview with Compliance Officer #500 revealed the facility had an ongoing investigation related to the COVID-19 testing on the Mandel 3 unit on [DATE] at this time. Compliance Officer #500 revealed she had conducted interviews with the staff involved and the investigation was currently being conducted on a different level. Compliance Officer #500 revealed LPN #200 had notified her nurse manager (RN #305) and then Administrator #400 and then Administrator #400 notified Administrator #405 (the Administrator of a sister facility) who notified her. She stated this all happened very quickly. Compliance Officer #500 reiterated similar information as the Interim Administrator and then stated she did not know if Administrator #400, DON #600 or ADON #605 ultimately admitted to any wrongdoing but after she obtained interviews from them, there were mostly cohesive statements from those involved with the exception of variations from DON #600 and ADON #605. She said the statements were detailed and substantiated the concerns. Compliance Officer #500 revealed there had been video footage in the facility from [DATE], but she did not view any of it. On [DATE] at 12:05 P.M. attempts to interview Unit Manager RN #305 were unsuccessful as the RN was off work due to illness. On [DATE] at 7:00 P.M. interview with LPN #200 revealed she worked on the Mandel 3 unit on [DATE] from 7:00 P.M. until 7:00 A.M. LPN #200 indicated Tuesdays were the regular COVID-19 testing days for residents. LPN #200 indicated on [DATE] there were residents on the Mandel 3 Unit showing signs/symptoms of COVID-19 who had been placed in isolation. LPN #200 stated on [DATE] between 4:45 A.M. and 5:00 A.M., she observed DON #600 and ADON #605 in Unit Manager RN #305's office gathering COVID-19 testing supplies. DON #600 and ADON #605 indicated they would be performing resident testing on the unit. LPN #200 stated she observed DON #600 and ADON #605 on the unit for approximately 30 minutes before they left. LPN #200 indicated she did not observe either staff enter or exit any resident rooms. LPN #200 indicated Unit Manager RN #305 came onto the unit at approximately 6:00 A.M. and asked LPN #200 for assistance swabbing Resident #176. LPN #200 stated she asked Unit Manager RN #305 if they were going to test all of the residents. LPN #200 indicated the unit manager responded DON #600 told her she and ADON #605 had already done the testing for the other 34 residents on the unit and only one resident (Resident #176) remained to be done. LPN #200 stated she voiced her concern to Unit Manager RN #305 that she had not seen DON #600 and ADON #605 perform any testing that morning. Unit Manager RN #305 then confirmed she was told testing of the residents had been done. LPN #200 stated she continued to be concerned about the validity of the testing after test results were returned indicating all residents tested by DON #600 and ADON #605 had tested negative for COVID-19 although residents were showing signs and symptoms (of COVID-19). LPN #200 again indicated she voiced her concerns to Unit Manager RN #305 who then obtained an order on [DATE] to have nine residents showing signs/symptoms tested for influenza as well as COVID-19 and stated some of these results came back positive for COVID-19. LPN #200 indicated the remaining residents and staff were tested on [DATE] and on [DATE] with more results starting to come back positive. LPN #200 indicated she then contacted the facilities sister facility and received a call back from a Human Resources employee. LPN #200 also stated she had voiced her concerns to Administrator #400 who thanked her and indicated someone from Human Resources would be contacting her. Review of facility policy titled Infection Surveillance Plan, revised [DATE], indicated the Infection Preventionist conducts ongoing surveillance for Healthcare Associated Infections (HAI), Community Acquired Infections (CAI), and other epidemiologically significant infections that have a substantial impact on potential resident and patient outcomes and that may require transmission-based precautions and other preventative interventions, to guide appropriate interventions and to prevent future infections. Residents and patients are monitored for signs and symptoms that suggest an infection, according to current criteria of infections, and are to document and report suspected infections to the Charge Nurse immediately. The Charge Nurse notifies the Attending Physician or Practitioner who determines if laboratory tests are indicated, and whether precautions are warranted. The Infection Preventionist determines if the infection is reportable to the (State Agency) or local agencies. The Attending Physician and interdisciplinary team determines the treatment plan for the resident or patient. Review of a facility memo, titled Process and Approach Strategy for Mandatory COVID-19 Testing in Nursing Homes, dated [DATE], revised [DATE] and revised [DATE] revealed effective [DATE], all nursing home facilities are subject to the Ohio Department of Health (ODH) Director's Order and Guidelines for Testing of Nursing Home Residents and Staff. The memo also included testing language from CMS QSO-,[DATE]-NH. The memo included that the facility meets the requirements of the order by participating with State support testing which will be conducted as currently directed by ODH and CMS and the process required at the time of the mandated testing. This deficiency substantiates Complaint Number OH 951, Complaint Number OH 871, Complaint Number OH 858 and Complaint Number OH 766.

Based on observation, interview, medical record review and policy review the facility failed to ensure adequate supervision to prevent a fall with subsequent head injury for Resident #46 and failed to ensure a new intervention was added to prevent further injury related to Resident #84 banging her left hand on a transfer bar. Actual harm occurred on 02/24/20 when Resident #46, was left unsupervised in the dining room, and was found on the floor with her head in a pool of blood. Resident #46 sustained bruising and a 0.1 centimeter (cm) x 0.1 cm open area to the forehead for which she was sent to the hospital for treatment. This affected two of five residents reviewed for accidents. The facility census was 222. Findings include: 1. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment (MDS 3.0) dated 12/19/19 indicated she was severely cognitively impaired and had no signs of [MEDICAL CONDITION] or displayed behavioral symptoms. Resident #46 required the extensive assistance of one person for transfers, toileting and personal hygiene. No falls were indicated. Review of fall risk assessment dated [DATE] indicated she was at risk for falls. Review of the fall care plan initiated on admission revealed interventions included to get the resident up between 7:00 A.M. and 7:30 A.M., put her in the common area and provide music, and to assist the resident to bed between 8:00 P.M. and 9:00 P.M. An intervention dated 05/30/19 indicated staff were to ensure no items on the floor for her to try and pick up, and one dated 06/16/19 indicated staff were to assist her into the recliner and place in a common area when restless in bed. Interventions dated 08/23/19 indicated to assist the resident to the dining room last for monitoring and observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended. An intervention dated 02/24/20 indicated a physical therapy consult for wheelchair seating. Review of the nursing progress notes indicated she was known to bend forward and try to pick things up off the floor. A progress note dated 05/30/19 at 5:45 P.M. revealed Resident #46 was in the dining room with one knee on the floor and the other bent bearing her body weight, both hands touching the floor. She appeared to be picking up a piece of paper off the floor. Nursing progress notes dated 02/24/20 at 8:20 A.M. revealed Resident #46 was found in the dining room laying on her left side with her head in a puddle of blood. Her left arm was tucked underneath her and both legs were flexed. Resident #46 was alert and sent to the hospital. Review of the investigation dated 02/24/20 at 8:20 A.M. indicated Resident #46 was observed in the dining room laying on her left side and her head was in a puddle of blood. Her left arm was tucked underneath her and both legs were flexed resting on the floor. The investigation determined Resident #46 fell trying to reach and pick something off the floor, striking her face, and suffering a laceration. She had bruising and a 0.1 centimeter (cm) x 0.1 cm open area to the forehead. Review of staffing for 02/24/20 indicated there were three State tested Nurse Aides (STNAs) assigned to provide care for 40 residents on Mandel II. One STNA was assigned to the secured dementia unit where Resident #46 resided. The one STNA was assigned to 14 residents. Interview with Licensed Practical Nurse (LPN) #35 on 03/02/20 at 10:00 A.M. revealed Resident #46 recently fell in the dining room during breakfast and sustained a bruise. Interview with LPN #65 on 03/02/10 at 10:00 A.M. reported two aides were necessary on the secured dementia unit. She indicated the residents on the secured unit were very busy and required constant supervision. LPN #65 reported last Monday (02/24/20) there was only one aide on the secured dementia unit and that was when Resident #46 fell . Interview with STNA #115 on 03/02/20 at 10:30 A.M. revealed there were usually two aides on the secured unit but last Monday (02/24/20) there were only three STNAs for the entire floor, and that was when Resident #46 fell . STNA #115 said she and the nurse (LPN #65) were providing care to another resident in their room, leaving no one to supervise Resident #46 and the other residents in the dining room. Resident #46 was observed on 03/02/20 at 12:40 P.M. in the common television lounge with other residents. She was in a custom wheelchair with padded leg rests and a head rest. She was wearing glasses. A yellowing bruise was visible above and below her left eye. There was a nickel sized scab on her forehead. On 03/02/20 at 3:01 P.M. she was observed in a tilt and space wheelchair, reaching forward trying to adjust her pants. 2. Review of the nurses note dated 06/05/19 at 3:59 P.M. indicated the STNA noted Resident #84 had a bruise on her left fourth finger. The area was bluish purple from the tip of her finger to the second joint and at the knuckle. The resident was banging on the left transfer bar with her left hand prior to the bruise. The transfer bar was recovered with foam and tape. The transfer bar had been padded with foam prior to discovery of the bruising but the resident took it off and threw it on the floor. Review of the investigation dated 06/05/19 revealed a pain evaluation indicating Resident #84's left back hand and left fourth finger was bruised from the tip of the finger to the second joint and also near the knuckle. Review of the X-ray of the left fingers revealed there was a fracture involving the fourth proximal phalanx without displacement. There was associated soft tissue swelling and significant [MEDICAL CONDITION] evident. There was no evidence of a new intervention to prevent further injury due to the resident banging her hand on the transfer bar. Resident #84 was observed on 03/02/20 at 10:00 A.M. lying in a low bed with a mat next to the bed. The resident was hitting her left hand against the transfer bar which was not padded. A wheel of blue foam padding was laying on the floor mat next to the bed. On 03/03/20 at 4:47 P.M. Resident #84 was observed lying in a low bed and the foam padding was on the floor mat next to her bed. On 03/04/20 at 8:24 A.M. the resident was in a low bed, and the foam padding was on the floor mat. The resident was pulling on the transfer bar. On 03/04/20 at 3:22 P.M. Resident #84 was observed in bed, and there was no padding on the transfer bar. Interview with STNA #115 on 03/04/20 at 3:30 P.M. verified the padding was not on Resident #84's transfer bar. STNA #115 said the resident was able to remove the padding and then she would bang her hand on the bar. The padding did not stay securely on the transfer bar and she showed evidence of where she tried to tape the padding to the bar but it failed. Interview with Registered Nurse (RN) #204 on 03/04/20 at 5:40 P.M. verified Resident #84 pulled the foam padding off the transfer bar frequently and they had not tried any alternative interventions to protect the resident from possibly injuring herself by banging her had on the transfer bar. Review of the fall intervention program revised November 2017 indicated upon admission, the admitting nurse would gather information that may identify risks for falls and complete the fall intervention review. A fall intervention review was to be completed when a resident was admitted , found on the floor, witnessed fall, change in status, change in medication regimen, unwitnessed fall. A nurse would complete an investigation reviewing risk factors, update the care plan with alternative interventions as necessary. The nurse manager would review the information. Therapy would be notified of all falls and make recommendations when applicable. The nurse manager forwards the report to the director of nursing for review. The resident would be monitored for three days and document in the nurses notes and 24- hour report.

Based on observation, interview and medical record review the facility failed to ensure consistent adequate staffing to meet the care needs of residents residing on the secured dementia unit. Actual harm occurred on 02/24/20 when Resident #46, was left unsupervised in the dining room, and was found on the floor with her head in a pool of blood. Resident #46 sustained bruising and a 0.1 centimeter (cm) x 0.1 cm open area to the forehead for which she was sent to the hospital for treatment. This affected one (Resident #46) of five residents reviewed for accidents and had the potential to affect 13 additional residents (Residents #18, #22, #31, #36, #47, #60, #71, #78, #84, #131, #149, #167 and #208) currently residing on the secured dementia unit. The facility census was 222. Findings include: 1. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment (MDS 3.0) dated 12/19/19 indicated she was severely cognitively impaired and had no signs of [MEDICAL CONDITION] or displayed behavioral symptoms. Resident #46 required the extensive assistance of one person for transfers, toileting and personal hygiene. No falls were indicated. Review of fall risk assessment dated [DATE] indicated she was at risk for falls. Review of the fall care plan initiated on admission revealed interventions included to get the resident up between 7:00 A.M. and 7:30 A.M., put her in the common area and provide music, and to assist the resident to bed between 8:00 P.M. and 9:00 P.M. An intervention dated 05/30/19 indicated staff were to ensure no items on the floor for her to try and pick up, and one dated 06/16/19 indicated staff were to assist her into the recliner and place in a common area when restless in bed. Interventions dated 08/23/19 indicated to assist the resident to the dining room last for monitoring and observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended. An intervention dated 02/24/20 indicated a physical therapy consult for wheelchair seating. Review of the nursing progress notes revealed Resident #46 was known to bend over to pick items off the floor and required frequent redirection. Resident #46 was noted on 05/30/19 at 5:45 P.M. in the dining room with one knee on the floor and the other bent bearing her body weight with both hands touching the floor. She appeared to be picking up a piece of paper off the floor. On 06/18/19 at 6:20 P.M. she was agitated throughout the shift continually trying to get out of her chair. On 09/11/19 at 2:41 P.M. she was on hourly checks due to two recent falls. She was redirected a few times for trying to get out of the chair. An anti-anxiety medication was given to help calm the resident. On 11/19/19 at 07:21 P.M. the resident had an adjustment in her psychotic medication due to her becoming more restless, and constantly trying to get up out of her chair. On 11/25/19 at 06:57 P.M. the resident continued to be very anxious, trying continually to get out of her chair. Nursing progress notes dated 02/24/20 at 8:20 A.M. revealed Resident #46 was found in the dining room laying on her left side with her head in a puddle of blood. Her left arm was tucked underneath her and both legs were flexed. Resident #46 was alert and sent to the hospital. Review of the investigation dated 02/24/20 at 8:20 A.M. indicated Resident #46 was observed in the dining room laying on her left side and her head was in a puddle of blood. Her left arm was tucked underneath her and both legs were flexed resting on the floor. The investigation determined Resident #46 fell trying to reach and pick something off the floor, striking her face, and suffering a laceration. She had bruising and a 0.1 centimeter (cm) x 0.1 cm open area to the forehead. Review of staffing for 02/24/20 indicated there were three State tested Nurse Aides (STNAs) assigned to provide care for 40 residents on Mandel II. One STNA was assigned to the secured dementia unit where Resident #46 resided. The one STNA was assigned to 14 residents. Interview with Licensed Practical Nurse (LPN) #35 on 03/02/20 at 10:00 A.M. revealed Resident #46 recently fell in the dining room during breakfast and sustained a bruise. Interview with LPN #65 on 03/02/10 at 10:00 A.M. reported two aides were necessary on the secured dementia unit. She indicated the residents on the secured unit were very busy and required constant supervision. LPN #65 reported last Monday (02/24/20) there was only one aide on the secured dementia unit and that was when Resident #46 fell . Interview with STNA #115 on 03/02/20 at 10:30 A.M. revealed there were usually two aides on the secured unit but last Monday (02/24/20) there were only three STNAs for the entire floor, and that was when Resident #46 fell . STNA #115 said she and the nurse (LPN #65) were providing care to another resident in their room, leaving no one to supervise Resident #46 and the other residents in the dining room. Resident #46 was observed on 03/02/20 at 12:40 P.M. in the common television lounge with other residents. She was in a custom wheelchair with padded leg rests and a head rest. She was wearing glasses. A yellowing bruise was visible above and below her left eye. There was a nickel sized scab on her forehead. On 03/02/20 at 3:01 P.M. she was observed in a tilt and space wheelchair, reaching forward trying to adjust her pants. 2. The secured dementia unit staff identified two residents (#46 and #128) who required the use of a stand up lift for transfers that required two staff to operate safely, two residents (#47 and #131) who required a mechanical lift for transfers that required two staff to operate safely, five residents who required frequent observations (#18, #38, #46, #71 and #84) one resident who required two staff assistance for ADLs (#78) and one resident who had a private sitter (#47). The staff acknowledged that agency staff had been utilized. The nurse assigned to the secured dementia unit was also responsible for residents outside of the unit. Interviews from 03/02/10 through 03/05/20 during various shifts with LPN #37, STNA #106, STNA #167 and STNA #195 revealed there was often just one STNA assigned to the secured dementia unit with an STNA with an assignment on another floor being assigned to two or three of the residents. The nurse assigned to the secure dementia unit was assigned to residents off the unit. Those interviewed agreed this was not enough staff to meet the care needs of the residents on the secured dementia unit. Staff interviewed said they had expressed concerns to administrative staff. Interviews from 03/02/10 through 03/05/20 at various times with Residents #31, #46, #47, #60, #71, #125, and #188 revealed concerns related to insufficient facility staffing. On 03/04/20 at 5:43 A.M. interview with STNA #106 revealed sometimes she was the only one working on the dementia unit. When that happened the resident showers were not done. When she worked by herself on the secured dementia unit she kept doors open when providing resident care so she could hear the other residents. When working alone she had to leave the unit to get assistance. She said she also carried a personal [MEDICATION NAME] to blow if things got too bad for her to handle. Interview on 03/04/20 at 9:05 A.M. with Scheduler #500 revealed the facility staffed based on census. For Mendel II, which included the secured dementia unit, there were always two STNAs assigned to the secured dementia unit on the day shift and afternoon shift with two nurses who were also assigned to additional residents on the adjacent unit. On the third shift there were four STNAs and one nurse scheduled. However, how they assigned staff, and decided who would work on the secured dementia unit, was up to the nurse on the unit. The nurse assigned to the dementia unit on third shift was also assigned to residents on the adjacent unit. On 03/04/20 at 11:08 A.M. agency STNA #600 was observed on the secure dementia unit. She was asked about the care needs of the residents. She simply said she was agency and was not sure. On 03/04/20 at 3:30 P.M. STNA #167 reported occasionally she was the only STNA assigned to the secured dementia unit. She reported the residents on the dementia unit frequently needed redirection when they attempted to stand unassisted. She acknowledged an STNA outside of the unit had two to three residents in the secured dementia unit in addition to her assigned residents off the unit. However, that STNA was not usually on the dementia unit very much. On 03/05/20 at 2:00 P.M. the Director of Nursing and Assistant Director of Nursing were informed about concerns with not enough staff to properly supervise and provide care to the residents who resided on the secured dementia unit. They verified they had been supplementing their staff with agency staff to attempt meet the residents' needs. This deficiency substantiates Complaint Number OH 459.

Based on observation, interview and medical record review, the facility did not implement planned interventions to monitor and report skin changes to prevent the development of pressure ulcers. Actual Harm occurrred to Resident #127 whose pressure ulcer was not discovered until it was unstageable. This affected one (Resident #127) of three residents reviewed for pressure ulcers, of 21 residents in the facility with pressure ulcers. Findings include: Review of the medical record revealed Resident #127 was readmitted to the facility from the hospital on [DATE]. His [DIAGNOSES REDACTED]. Review of a plan of care to address Resident #127's risk of skin breakdown initiated on 04/15/16 prior to hospitalization , included the following intervention: state tested nurse aide (STNA) to check skin daily during care and during bath/showers. Report abnormalities to charge nurse. Review of the pressure ulcer risk assessments found in Resident #127's medical record dated 05/17/16 and 05/25/16 revealed the resident scored 13 on the Braden scale assessment tool, which placed him at moderate risk for pressure ulcer development. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #127 was oriented to person, place and time, was totally dependent on the assistance of at least two persons for bed mobility and transfers, always incontinent of bowel, did not reject care that was necessary to achieve his goals for health and well-being, was at risk for the development of pressure ulcers, but did not have any pressure ulcers at the time of the assessment on 05/21/16. Review of the Point of Care daily charting for Resident #127 revealed he was incontinent of bowel and was dependent of staff for personal hygiene support on 05/18/16, 05/20/16, 05/21/16 and 05/25/16. He received bathing assistance from staff on 05/18/16, 05/22/16 and 05/25/16. On 05/26/16 at 9:35 A.M., Registered Nurse (RN) #25 indicated Resident #127 was found to have skin breakdown on his buttocks on 05/25/16. She indicated she believed Resident #127's wound was a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) pressure ulcer. RN #25 stated she notified Clinical Nurse Practitioner (CNP) #56 on 05/25/16 that Resident #127 had developed skin breakdown on his buttocks. Resident #127's skin breakdown was observed with RN #25 and the Director of Nursing (DON) on 05/26/16 at 9:45 A.M. The wound appaered as a dry brown scab with an irregular border, about the size of a quarter. RN #25 described the brown area as beefy red, bloody tissue. She indicated Resident #127's wound had not changed in appearance since it was first discovered on 05/25/16. A second observation of Resident #127's wound was made with CNP #56 and the DON on 05/26/16 at 10:20 A.M. Resident #127 reported to CNP #56 that his buttocks area was sore. CNP #56 observed Resident #127's wound and described it as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is completely covered by slough and/or eschar (tan, brown, or black) in the wound bed) on his ischium. The ischium is a bone at the lower and back part of the hip that absorbs most of the body's weight when a person is seated. An interview with RN #34 on 05/26/16 at 3:50 P.M. revealed Resident #127 had received care from STNA agency staff or an STNA who floated from another unit for most days since his re-admission from the hospital on [DATE]. RN #34 indicated all STNA staff were required to report any skin changes to the nurse. The above findings were confirmed with RN #34 and Vice President of Clinical Services #1 on 05/26/16 at 4:10 P.M. This deficiency substantiates Complaint Number OH 424.

Based on observation, interview and record review, the facility failed to ensure that Resident #101 was provided ordered pain medication in a timely fashion prior to the application of a compression wrap to the right arm. The facility also failed to ensure Resident #101's heals were off loaded to prevent excess pressure according to the physician's orders [REDACTED].#101, of seven residents reviewed for quality of care and treatment. The facility census was 226. Findings include: 1. Resident #101 had physician's orders [REDACTED]. The physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. and 3:00 P.M. On 03/02/15 at 7:25 P.M., Resident #101 was observed in a chair in his room with his dinner tray in front of him. There were ace wraps applied on both lower legs with anti-slip socks applied to both feet. The resident's right arm was observed swollen approximately two times the size of his left arm. Interview with Resident #101 revealed he was doing alright except for his right arm. A procedure had been done on the arm, but something went wrong and it was very swollen and painful. On 03/03/15 at 6:38 A.M., interview with Resident #101 revealed a PICC line (peripherally inserted central catheter, which is a form of intravenous access that can be used for a prolonged period of time), had been put in his (right) arm "and it got all swollen. I had more pain than I ever had in my life." He indicated they were giving him medication for pain, but he did not know if it was working enough. Resident #101 described his pain as "about a 6 or a 7." He indicated that he guessed he might need something stronger, but had not yet gotten any pain medication yet that morning. On 03/03/15 from 6:42 A.M. through 7:20 A.M., registered nurse (RN) #430 and RN #431 were observed performing the physician ordered wrap treatments. Prior to beginning the treatments, neither RN #430 or RN #431 asked Resident #101 if he was in pain or if he needed any pain interventions during the treatments. At 6:59 A.M. Resident #101 groaned when RN #431 handled his right arm gently. Then RN #430 touched the right arm; Resident #101 groaned and moved his legs and grabbed his right hand with his left hand as RN #430 said "sorry, sorry". The two RN's removed the hospital gown from the resident ' s right arm as he groaned and writhed moving his legs and left arm with his eyebrows tensed down toward his eyes. Resident #101 continued grimacing, writhing, and breathing heavily while RN #430 held the right arm for RN #431 to wrap. At 7:03 A.M., Resident #101 continued to writhe and asked RN #430 to "hold it up miss" as RN #430 was holding the resident ' s wrist. RN #431 told RN #430 to hold the arm under the resident ' s elbow. At 7:04 A.M. RN #431 asked Resident #101, "Are you taking anything for pain for this?" Resident #101 answered that he had not had anything yet this morning. RN #431 asked "Is it working for you?" Resident #101 replied "Not really." On 03/03/15 at 7:17 A.M., interview with RN #431 confirmed that no one asked the resident about pain before beginning the treatments and he had exhibited a great deal of pain during the treatment to the right arm. On 03/05/15 at 10:15 A.M., Resident #101 was observed in his room up in a wheelchair with a compression sleeve applied to his right arm. When Resident #101 was asked how it was going today, the resident indicated the new sleeve was not working, it hurt and his arm was "swelling up more." He wanted the wraps back. When asked if he had gotten any pain medication that morning, he replied "Not yet." Resident #101 indicated he asked to speak to the nurse, but she has not come in yet. At 10:16 A.M., Resident #101 activated his call light and an unidentified state tested nurse aide (STNA) responded and asked how she could help. Resident #101 indicated he wanted to see the nurse. At 10:18 A.M., RN #433 entered the room and identified herself as the resident's nurse today; she asked how she could help him. Resident #101 indicated he needed a muscle relaxed, pain medication and the wraps back on his legs. Resident #101 also stated that he wanted the wraps back on his arm because the compression sleeve was not helping his arm. He stated that his hand and arm were swelling up with this sleeve and the wraps were better. RN #433 told Resident #101 that she would see what she could find out regarding his pain medication and would get back to him. At 10:19 A.M., the interview with Resident #101 continued and revealed that the staff had put the compression sleeve on his arm the night before and had put a bag over the sleeve. The plastic bag was placed due to the resident having a shower on the morning of 03/05/15 before breakfast. At 10:29 A.M. RN #433 returned to the room and asked Resident #101 "what is hurting you, you said your shoulder? Do you know what you take for that? Can you rate your pain for me?" Resident #101 replied that it was a new medicine and his pan was at about a five right now. RN #433 indicated she would " figure out what you take for that" and left the room [ROOM NUMBER]:30 A.M. At 10:41 A.M., RN #433 returned to the room with several medication cards. RN #433 indicated that the following medications were ordered. She told Resident #101 that a muscle relaxant was ordered, 1000 mg of Tylenol, 2.5 mg of an [MEDICATION NAME] for mild pain and all of the other morning medications. RN #433 indicated the medications were to be administered at 9:00 AM so she was a little behind. At 10:50 A.M., after administering the medications by mouth and a subcutaneous medication to the resident's abdomen, RN #433 asked Resident #101 where he wanted the Pliocene patch as the order just said on the right arm. Resident #101 pointed to the area on the upper arm where the top of the compression sleeve ended. RN #433 lifted the short sleeve of the resident ' s shirt and pulled down the top of the compression sleeve. When she pulled the sleeve down, an indentation around the circumference of the top of the resident' s arm was visible. RN #433 pulled the entire sleeve off the resident ' s arm and applied the [MEDICATION NAME] to the upper arm on top of the part of the indentation. The resident again indicated he wanted the wraps back as they worked better and did not hurt him so much. Interview with RN #433 at 10:55 A.M., confirmed the first time she had been in to see Resident #101 on the morning of 03/05/15 was at 10:18 A.M. and his medications were due at 9:00 A.M. She also confirmed the compression sleeved had left an indentation of the upper part of the right arm and may have been too tight, but was not sure when the treatment order had been changed. 2. Resident #101 had a physicians order dated 02/26/15 to off load heals while in bed. On 03/02/15 at 10:24 P.M., Resident #101 was observed in bed with a thin pillow under his calves and his heels resting directly on the mattress. On 03/03/15 between 6:07 A.M. and 6:27 A.M., licensed practical nurse (LPN) #429 was observed providing care for Resident #101. Prior to leaving the room, LPN #429 placed a thin pillow under the resident's lower legs and allowed his heels to rest directly on the pillow instead of off loading the heels. Interview with LPN #429 at 6:28 A.M. confirmed she did not place the resident's heels in a floating position and left them directly on the pillow. 3. Resident #101 had a physician's orders [REDACTED].M. Interview with RN #431 on 03/03/15 at 6:05 A.M. revealed it was important to put the wraps on Resident #101 before he got out of bed because they were for [MEDICAL CONDITION]. On 03/05/15 at 10:15 A.M., Resident #101 was observed up in his wheelchair with his feet resting on the floor. Interview with Resident #101 revealed the wraps had been removed when he took his shower that morning before breakfast. The wraps were not put on after the shower and he went to breakfast. At 10:18 A.M. RN #433 was observed to enter the room per the resident's request. After Resident #101 stated that he needed the wraps put on his legs, RN #433 indicated she would check on his orders and return. When RN #433 returned at 10:29 A.M., she indicated there was some confusion about the orders for the wraps but confirmed the resident's legs were not wrapped. This deficiency substantiates complaint OH 738