Every finding on record at Dixon Healthcare Center

Based on review of the medical record and staff interview, the facility failed to document timely care conferences for Residents #204 and #236. This affected two residents (#204 and #236) of three resident records reviewed for care conference communication. The facility census was 49.Findings Include:1. Review of the medical record for Resident #204 revealed admission to the facility on [DATE] with diagnoses including stroke with left side paralysis, aphasia (difficulty speaking), high blood pressure, heart disease, seizures, gastric reflux, poor circulation, depression, insomnia (difficulty sleeping), and depression.Review of the most recent Minimum Data Set (MDS) 3.0 quarterly assessment completed on 05/23/26 for Resident #204 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating severe cognitive impairment. Further review of the quarterly assessment revealed Resident #204 refused showering/bathing, and required supervision for transfers, and toileting/personal hygiene and dressing. Resident #204 was able to navigate in his specialty wheelchair independently using his right arm.Review of the Care Plan Report dated 06/23/26 for Resident #204 revealed a care conference occurred with Social Services Designee (SDD) #330 and Unit Manager, Registered Nurse (RN) #559 on 06/23/26 and Resident #204 declined to attend. There was no evidence of what occurred or was discussed during the meeting in the report. There was no evidence of a corresponding care conference note in the electronic medical record (EMR). The most recent care conference note for Resident #204 found in the EMR was dated 11/13/25. This was verified by the Director of Nursing (DON) on 07/16/26 at 12:45 P.M. who reported that SSD #330 stated she must have forgotten to do it.2. Review of the medical record for Resident #236 revealed admission to facility on 01/21/21 with diagnoses including heart disease, atrial fibrillation (irregular heart rhythm), high blood pressure, kidney disease, arthritis, stroke, depression, anxiety, and enlarged prostate.Review of most recent MDS 3.0 quarterly assessment completed on 04/20/26 for Resident #236 revealed a BIMS score of 10/15 indicating moderate cognitive deficit. Further review of the MDS 3.0 assessment revealed Resident #236 was dependent on staff for bathing, toileting, dressing, and transfers with a mechanical lift.Review of the Care Plan Report dated 06/18/26 for Resident #236 revealed a care conference occurred with the SDD #330 only on 06/18/26 and Resident #236 declined to sign in. There was only one signature of attendees, SSD #330, on the sign-in sheet. There was no evidence of what occurred or was discussed during the meeting in the report. There was no evidence of a corresponding care conference note in the EMR. The most recent care conference note for Resident #236 found in the EMR was dated 11/11/25. This was also verified by the DON on 07/16/26 at 12:45 P.M.Interview on 07/16/26 at 11:20 A.M. with SSD #330 revealed she was responsible for organizing and documenting care conference quarterly for each resident. SSD #330 further reported she does care conferences on Tuesday and Thursdays and generally does five or six per day and this could be why she probably missed writing the care conference notes for Residents #204 and #236.Review of the undated policy titled, Plan of Care Overview revealed, care plan documents are resident specific/resident focused and reflect resident/representative opportunities for participation and preferences.This was an incidental finding discovered during the complaint survey for complaint number 3070271.

Based on open and closed medical record review, facility policy review, and interviews, the facility failed to timely identify a change in resident condition and notify the medical provider to prevent a delay in treatment/timely medical intervention. The facility also failed to ensure bowel protocols were implemented for residents on hospice services. Actual harm occurred on 03/11/26 when Resident #54, who had bilateral nephrostomy tubes and history of kidney disease, experienced a decline in functional status, decreased urine output from the nephrostomy tubes, and decreased food and fluid intake without evidence of necessary and timely medical intervention or notification to the resident's medical provider. When ordered laboratory work was obtained (five days after ordered) the resident had a critical creatinine level (blood test for monitoring kidney function with normal results between 0.6 to 1.3) of 4.9, was hypotensive (low blood pressure) and tachycardic (increased heart rate). The Nurse Practitioner ordered to transfer the resident to the emergency room where he was admitted to the intensive care unit with acute kidney injury, dehydration and sepsis related to a urinary tract infection. The resident did not return to the facility and expired at the hospital under the care of hospice services. This affected one resident (#54) of one resident reviewed for hospitalization and one resident (#13) of one reviewed for urinary tract infection. The facility census was 51. Findings Include: 1.Review of the closed medical record for Resident #54 revealed admission to the facility on [DATE] after an acute hospital stay with diagnoses including hydronephrosis (back up of water on the kidney), urinary tract infection, chronic kidney disease stage 3, bilateral nephrostomy tubes (tube placed in the kidneys to drain the urine directly from the kidneys), prostate cancer with metastases to spine and left adrenal gland, anemia and a blood clot to the left lower leg. Review of the resident's hospital medical records revealed Resident #54 was at a tertiary hospital from [DATE] through 02/01/26 (prior to admission) with diagnoses of septic shock and bilateral hydronephrosis status post bilateral nephrostomy tube placements completed in 2019. Resident #54 had weakness and a low blood pressure with lab values which indicated acute on chronic kidney failure with a creatine level (blood test for monitoring kidney function with normal results between 0.6 to 1.3) of 4.84. Resident #54 was admitted to the intensive care unit for treatment. Further review revealed Resident #54 was treated with intravenous antibiotics, intravenous medications to improve blood pressure and replacement of bilateral nephrostomy tubes. Resident #54 also had a prostate cancer diagnosis (prior to the hospitalization and the resident was receiving treatment prior) which was not addressed during the hospitalization with recommendations made to follow up with oncologist in one to two weeks as well as radiation oncology in one week post discharge. Further recommendations were made by the hospital for Resident #54 to discharge to a nursing rehabilitation facility for diagnosis of deconditioning and to receive physical and occupational therapy services to improve stamina and strength. Please note, the resident was to be admitted for short term placement of rehabilitation with a discharge goal to return home after the rehabilitative stay at the facility. Review of the physician orders for Resident #54 revealed an order dated 02/01/26 (admission) for irrigation of bilateral nephrostomy tubes with 10 milliliters (ml) of normal saline every day shift to maintain patency. On 02/02/26 an order was received to begin weekly weights. Further review of orders revealed an order dated 02/06/26 to monitor/record nephrostomy outputs every shift. Review of the nephrostomy care plan for Resident #54 initiated on 02/01/26 revealed nursing staff were to provide nephrostomy catheter care every shift and as needed and notify medical provider if urine was abnormal in color, consistency, or odor. Review of weight logs for Resident #54 revealed an admission weight to the facility on [DATE] of 182.6 pounds. On 02/16/26 the resident's weight was documented to be 188.6 pounds. Weight were obtained by Resident #54 standing on a scale. Review of Resident #54's Minimum Data Set (MDS) assessment completed on 02/03/26 revealed the resident was cognitively intact with no vision or hearing deficits and was able to understand others and make self-understood. The resident's life expectancy was not indicated as six months or less and the resident was not receiving hospice services. Further review of the MDS assessment revealed Resident #54 was independent in self-care, mobility, and stair climbing prior to recent exacerbation of illness. On admission to facility Resident #54 required substantial/maximum assistance from staff for toileting, bathing, dressing upper body and putting on socks and shoes. Resident #54 was able to perform oral hygiene and grooming tasks with set-up assistance. Resident #54 required a wheelchair and staff assistance for mobility with the wheelchair. Review of a facility care conference note for Resident #54 conducted with the resident, his daughter and care team on 02/03/26 revealed discharge planning to include Resident #54 returning home after rehabilitation to get stronger. Code status was reviewed with Resident #54 and noted to continue full code status (full measures to be provided in the event of cardiac/respiratory arrest; conduct cardiopulmonary resuscitation). Review of laboratory results related to kidney function for Resident #54 obtained while in nursing facility revealed on 02/06/26 the resident's creatinine level was 1.7, on 02/19/26 creatinine level was 2.0, and on 02/25/26 creatinine level was 2.3. There were no orders to repeat labs for kidney function or electrolytes as a repeat or standing order after this date. Review of the care plan for renal disease and bilateral hydronephrosis for Resident #54 initiated on 02/12/26 revealed nursing staff were to observe for signs and symptoms of complications of renal disease i.e. decreased urine output, increased BUN/Creatinine levels, edema (swelling), dyspnea (shortness of breath), elevated blood pressure, increased heart rate, decreased peripheral pulses, fatigue, weight gain, confusion, and distended jugular veins. Staff were to notify medical provider, resident/ resident representative of abnormal findings. Further review of the care plan revealed the nursing staff were to obtain and monitor lab/ diagnostic studies, as ordered and report abnormal findings to the medical provider. Review of the output records on the treatment administration record (TAR) for February 2026 revealed 02/20/26 total daily outputs of 400 milliliters (ml), 02/21/26 320 ml, 02/22/26 210 ml, nothing recorded on 02/23/26, 02/24/26 245ml, 02/25/26 150 ml, 02/26/26 290 ml, 02/27/26 200 ml, and 02/28/26 125 ml. Review of a nurse practitioner (NP) progress note dated 03/01/26 revealed Resident #54 being seen for follow up to lab work. NP #224 noted renal function was worsened slightly and creatinine level was 2.0 referencing review of labs obtained from 02/25/26. Resident #54 had reported feeling better than he did prior. Resident #54 was noted to have loose stools and decreased appetite that was improving. His blood pressure (BP) was 118/60, heart rate 88, and respiratory rate was 16. His weight was 188.6 pounds. NP #224 noted diagnosis and plan on 03/01/26 included abnormal renal function-creatinine 2.0, encourage increasing water intake; dizziness, encourage him to drink at least one large pitcher of water a day, will follow up; edema to bilateral legs and arms, monitor weekly weights, increased will check next week. Review of the March of 2026 nephrostomy outputs revealed the following daily combined total outputs for Resident #54 03/01/26 through 03/11/26: On 03/01/26 230 ml, 100 ml documented for the left tube on dayshift only, no documentation on night shift on 03/02/26, on 03/03/26 300 ml total output, 03/04/26 only 100 ml from right tube only, no documentation on night shift output, on 03/05/06 80 ml total output, on 03/06/26 420 ml total output, on 03/07/26 195 ml total output, on 03/08/26 no outputs record from the bilateral nephrostomy tubes on either shift, on 03/09/26 190 ml of total output, on 03/10/26 30 ml of total output, and on 03/11/26 no outputs recorded for day shift. There was no evidence in the medical record of the medical provider being notified of any change in the recorded outputs not being obtained or the decrease in output during this time period. Review of the TAR for March 2026 revealed weekly weight monitoring for Resident #154 starting on 02/02/26 to be done every Monday. On 03/01/26 Resident #54 weighed 187.8 pounds and then a decrease on 03/09/26 down to 181.4 pounds. There was no evidence in the medical record of the 6.4 pound weight loss in one week being reported to the medical provider. Review of the bowel movement records for Resident #54 revealed bowel movements with formed stool 02/17/26 to 03/01/26. Beginning 03/02/26 Resident #54 had watery or loose stools documented twice a day and this continued through his hospitalization on 03/11/26. Review of meal intakes for Resident #54 beginning 03/03/26 through 03/11/26 revealed his meal intake decreased to an average of less than 25% or not eating at all and fluid intakes decreased to an average of 720 ml or less daily. Prior to this time period, meal and fluid intake reviewed from 02/13/26 through 03/02/26 revealed the resident ate mostly 100% of all meals and his fluid intake averaged 1,080 ml to 1,440 ml daily. On 03/09/26 Resident #54 was weighed by a mechanical lift for the first time and weighed 181.4 pounds. There was also a re-weight documented of 184 pounds on the same date. Of note, Resident #54 had a functional decline documented on 03/07/26 related to transfers and personal care.Review of a Telehealth note dated 03/06/26 at 7:07 P.M. revealed a telehealth visit occurred with Resident #54 and NP #223. Resident #54 complained of generalized weakness and did not go to his cancer appointment (scheduled this date as a follow up with his oncologist) due to feeling fatigued with no energy and no appetite. The note further revealed Resident #54 had labs done on 02/25/26 with notable Stage 3 kidney disease, an elevated creatine level of 2.3 and a blood urea nitrogen level of 5.0. An order was given to repeat a complete metabolic panel (CMP) lab test to rule out dehydration and electrolyte imbalance. Review of the physician orders for Resident #54 revealed an order on 03/06/26 by NP #223 for a CMP to be obtained that was placed in the electronic medical record. (Please note, the order did not specify when to be completed, however, the lab was ordered to rule out dehydration and electrolyte imbalance). Further review of the order audit for the CMP ordered on 03/06/026 revealed on 03/08/26 the order was acknowledged in the electronic medical record (EMR) by Registered Nurse (RN) #110. (The resident had labs (a complete blood count) scheduled on 03/09/26 but when the lab order was acknowledged on 03/08/25 by RN #110, the CMP was not scheduled to be completed with the CBC). Review of the treatment administration record for the month of March 2026 revealed a section titled changes noted in my resident today. Further review revealed nursing initials for each shift indicating yes or no followed by indication of change. On 03/07/26 there was a change in Resident #54 condition indicating the resident needed more help with walking, transferring, toileting more than usual. Review of the NP progress notes for Resident #54 revealed the next time Resident #54 had a medical provider visit was by NP #224 on 03/11/26 to follow up on weekly labs obtained on 03/09/26 for CBC due to leukocytosis (low white blood cells). NP #224 noted that his creatinine level on 02/25/26 was 2.0 approximately two weeks ago and now on 03/11/26 was 4.9. NP #224 further noted dark tea colored urine in nephrostomy tubes and when the NP asked Resident #54 about it he could not recall how long the urine had looked that way. Resident #54's blood pressure was noted to be low at that time 80/50 and he had an elevated heart rate of 101. NP #224's progress note revealed diagnoses for visit on 03/11/26 included acute kidney injury with creatinine 4.9 (1.7 on admission), diarrhea could contribute to dehydration and rule out sepsis. NP #224 ordered for Resident #54 to be sent to the local emergency for further evaluation after consultation with the primary physician. Review of the nursing progress note dated 03/11/26 at 2:18 P.M. revealed labs were reviewed with NP #224 and new order to send resident to the hospital due to increase in creatinine, increased weakness, and overall decline. At 2:40 P.M. Resident #54 was transported via ambulance to the hospital and he did not return to the facility. Interview on 4/07/26 at 2:17 P.M. with the Director of Nursing (DON) revealed labs were done at the facility Monday through Fridays and not obtained on weekends unless they were ordered STAT (immediately). The DON revealed orders for the CMP entered by the Telehealth NP #223 on 03/06/26 was not a STAT lab but ordered as routine. The DON reported if 03/06/26 was a Friday the lab should have been drawn on the next lab day which would have been the following Monday 03/09/26. The DON verified the CMP was not obtained on 03/09/26. Further interview on 04/07/26 at 3:04 P.M. with the DON revealed the procedure for lab orders included the medical provider or the nurse entering a verbal order would enter the lab order into the point click care electronic medical record (EMR). The nurse would then make sure the order was carried over to the treatment administration record (TAR) for the date prescribed, add to the Med Lab (the contracted lab service) list and enter order into Med Lab. Once Med Lab retrieved the blood specimen the nurse would sign off the lab as being completed on the TAR. The DON verified the CMP was never put on the TAR for completion and there was a CBC lab order on the TAR for 03/09/26. The DON verified there was no CMP completed but a basic metabolic panel (BMP) was obtained on 03/11/26 which indicated the critical lab value with the creatinine. On 04/09/26 at 10:30 A.M. interview with RN #200 verified the March 2026 MAR noted a decrease in Resident #54 being able to perform transfers and personal care on 03/07/26. The RN verified there was no communication with the resident's medical provider regarding the decline in the resident's functional status at this time. A telephone interview on 04/09/26 at 12:30 PM with NP #224 revealed she saw Resident #54 on 03/11/26 for follow up for weekly labs. NP #224 reported she was aware of the telehealth visit for Resident #54 on 03/06/26 and order for a CMP. NP #224 reported she was okay with Resident #54 having a BMP done with his weekly labs instead of the CMP originally ordered on 03/06/26. Interview on 04/13/26 at 9:30 A.M. with the DON revealed she had investigated further and looked at her logs from the Monday morning care meeting on 03/09/26 and the report did show that a CMP was ordered for Resident #54 over the weekend with no specified date to be obtained and the DON reported she did follow up the NP #224 to determine if Resident #54 still needed the CMP completed and when. The DON verbalized she notified the NP #224 in passing and the NP cancelled the CMP and was okay getting it with routine weekly labs. The DON confirmed there was no documentation of these communications between NP #224 and the DON regarding the labs in the medical record. The weekly labs ordered in the medical record were for a CBC which was obtained already on 03/09/26. (Please note, there was no documentation to support notification to the medical provider of the resident's missed labs, decline in functional abilities, decreased meal and fluid intakes or decreased output in conjunction with the missed labs). An additional interview on 04/13/26 at 10:53 A.M. with NP #224 revealed Resident #54 had been treating his prostate cancer for eight years. He had his most recent chemotherapy treatment in November or December of 2025 and chemotherapy was put on hold due to low blood pressure issues. The resident was very knowledgeable with his nephrostomy tubes and had them placed in 2019. NP #224 further revealed she was made aware of Resident #54 having a telehealth visit on 03/06/26 and corresponding CMP ordered on 03/06/26 verbally in passing from the DON on 03/09/26. NP #224 reported she discontinued the CMP that day and told the DON she would look over the chart and give new orders. NP #224 verified she did not enter any orders into the EMR herself on 03/09/26 and only gave a verbal order to the DON but was unaware the resident had decreased output prior to his hospitalization.Continued interview with NP #224 revealed she reviewed Residents #54's records and ordered on either Monday 03/09/26 or Tuesday 03/10/26 a BMP (telehealth had originally ordered a CMP on 03/06/26 however, that was not completed and the NP #224 ordered a BMP) to be obtained on Wednesday 03/11/26. NP #224 reported Resident #54 had a CMP completed about two weeks prior to this on 02/25/26 and she was following up with recheck of labs based on his history of labs (elevated creatinine). She also reported Resident #54 was not good at taking in oral fluids and she had discussed with him the prior week about possibility of providing intravenous fluids through his medical port (long term IV access for his chemotherapy medication). She further reported Resident #54 had been having bouts of diarrhea she was treating. The NP also verified the resident wanted full code status with no limit to his care, during his stay at the facility. Interview on 04/13/26 at 11:30 AM with the DON revealed confirmation there was no order to discontinue the CMP on 03/09/26 and no new order entered for the BMP to be obtained on 03/11/26. There was no lab order for a CMP or BMP on the TAR for the month of March 2026. A telephone interview on 04/17/26 at 11:58 A.M. with Resident #54's daughter revealed she had either visited or called her father at the nursing facility daily. Resident #54 daughter reported her dad did not mention feeling sick or different over the weekend prior to his hospital stay but stated he did not always tell her the truth about how he was feeling. Resident #54's daughter further reported Resident #54 did see his oncologist during his hospital stay and the oncologist reported the resident's cancer was throughout his body but that was not new information (he had prostate cancer for over seven years), it had been that way and was told by oncology that his cancer numbers were actually lower than they had been. Further interview with Resident #54's daughter revealed oncology discussed plans to resume chemotherapy with Resident #54 once he was stronger and in better health. Resident #54's daughter reported Resident #54 had initially went to the nursing facility to get rehabilitation with the intention of returning home and restarting chemotherapy and there was no discussion of hospice care until he was re-admitted to the hospital (on 03/11/26). The resident subsequently passed away in the hospital. Interview on 04/21/26 at 1:37 P.M. with the DON revealed Resident #54 was weighed for the first time on 03/09/26 in the mechanical lift scale and questioned the validity of the weight loss of six pounds. The resident was re-weighed at 184 pounds. The DON reported she did not know why Resident #54 was weighed in the mechanical lift that day and not standing scale as he had been for prior weights. Further interview with the DON revealed her expectation would be that staff would have reported the progressive decrease in oral intake, decreased meal consumption, decreased urine outputs, and the return of loose watery stools from 03/02/26 to 03/11/26 to the nurse practitioner or medical provider. There was no evidence in the medical record of the staff reporting the change in condition of Resident #54 to ensure timely and/or necessary medical intervention was provided for the resident. Review of the undated facility Physician Orders policy revealed when taking orders the nurse was to make sure and discontinue any previous contradicting order. Review of the undated facility Notification of Change in Condition policy revealed changes in condition of residents could include but were not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes, hospitalizations, and death. 2. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes, anemia, and cellulitis. On 03/05/26 the resident was admitted to hospice services. Review of Resident #13's at risk for constipation plan of care related to side effects of medication and poor mobility dated 02/23/26 revealed to administer medication per medical providers orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, resident/resident representative. Monitor bowel movements and side effects of medication for constipation. Keep medical provider, resident/resident representative informed of any problems. Observe for signs and symptoms of complication of constipation (vomiting and abdomen guarding, tenderness, rigidity of the abdomen, and fecal compaction). Review of Resident #13's hospice certification dated 03/05/26 revealed for the bowel protocol was one to two sennoside (stool softener) 8.6 milligrams (mg) at bedtime as needed. Bisacodyl (laxative) 10 mg rectally one daily as needed for constipation, enema of sodium phosphate rectally as needed for constipation, and loperamide 2 mg tablet by mouth as directed and as needed for diarrhea. Review of Resident #13's orders and medication records dated 03/2026 revealed on 03/02/26 the resident's scheduled Miralax and Naloxegol (used for opioid induced constipation) was discontinued on 03/02/26. On 03/06/26 the resident was ordered Oxycodone 5 mg every four hours as needed for pain or discomfort and to monitor for adverse side effects of pain medication: constipation. Staff had signed off twice a day they were monitoring for adverse effects of pain medication including constipation, and the resident had received eleven doses of Oxycodone from 03/06/26 to 03/30/26. On 03/13/26 the resident was ordered Senna 8.6 mg two tablets twice daily for constipation. Further review of Resident #13's orders and medication record review revealed no evidence of the hospice bowel protocol (1-2 sennoside 8.6 milligrams (mg) at bedtime as needed. Bisacodyl 10 mg rectally one daily as needed for constipation, enema of sodium phosphate rectally as needed for constipation, and loperamide 2 mg tablet by mouth as directed and as needed for loose stools) entered in the medical record as an active order for Resident #13. Review of Resident #13's significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had an indwelling urinary catheter (discontinued on 03/06/26), was occasionally incontinent of urine and frequency incontinent of bowel. Review of Resident #13's bowel records dated 03/25/26 to 03/29/26 revealed the resident did not have a bowel movement on 03/25/26, 03/26/25, 03/27/25, 03/28/25 and 03/29/26. Review of Resident #13's hospice note dated 03/27/26 revealed the resident's last bowel movement was three days ago. Review of Resident #13's progress notes dated 03/23/26 to 03/30/25 revealed no evidence the provider was notified of no bowel movements. Review of Resident #13's encounter note dated 04/03/26 revealed Resident #13 was seen for abdominal pain and no bowel movement. The resident reported she started having right side pain and she was still nauseated and vomiting. The resident reported she had one emesis this morning. The resident had as needed Zofran and Phenergan for nausea. The resident had not had a documented bowel movement for five days. She was on Movantik for opioid induced constipation but was discontinued by hospice. She is on senna two tablets twice a day. The resident denied diarrhea and was passing gas. The resident was ordered a urinalysis to rule out urinary tract infection as cause of the symptoms. Interview on 04/08/26 at 8:37 A.M. and 12:06 P.M., with the Director of Nursing (DON) confirmed the resident had gone five days without a bowel movement. The DON reported the facility didn't have a bowel policy; however the protocol was if the resident didn't have a bowel movement within three days, staff were to alert the provider. The DON confirmed the electronic medical record had a program on the dash board that would alert staff if the resident didn't have a bowel movement, however not all nurses reviewed each dash board daily for each resident. The DON confirmed hospice had a bowel protocol, however the facility never entered the orders.

Based on open and closed medical record review, review of notice of Medicare Non-Coverage (NOMNC) and//or Advance Beneficiary Notice of Non-Coverage (ABN), review of beneficiary protection notification review form, and interview the facility failed to ensure NOMNC's included Quality Improvement Organization (independent reviewer authorized by Medicare to review the decision to end these services) name and contract information, NOMNC and ABN was provided and or provided timely. This affected four residents (Resident's #7, #39 #60, and #61) of four residents reviewed for beneficiary protection notification review. The facility census was 51.1. Closed medical record review revealed Resident #60's was admitted to the facility on [DATE] with diagnoses of left femur fracture, heart failure, diabetes, convulsions, head injury, and hypothyroidism. Review of the beneficiary protection notification review form completed by the facility on 04/14/26 revealed the resident last covered day of Part A service was 12/09/25 and the resident was discharged home. The form indicated the resident was not issued a NOMNC and should have been issued one. Interview on 04/14/26 at 12:35 P.M., with Social Service Director (SSD) #149 and Administrator confirmed Resident #60 was discharged home and did not receive the NOMNC and should have received a NOMNC. 2. Closed record review revealed Resident #61 was admitted to the facility on [DATE] with a diagnoses of left knee effusion, diabetes, anemia, heart failure, and dementia. Review of Resident #61's beneficiary protection notification review completed by the facility on 04/14/26 revealed the resident's last covered day of Part A services was 10/23/25 due to the facility/provider initiated the discharge from Medicare part A services when benefit days were not exhausted. The resident remained in the facility and received ABN and NOMNC. Review of Resident #61's the NOMNC dated 10/22/25 revealed the resident was discharged from therapy services on 10/23/25. There was no evidence of the QIO name or contact information to appeal or ask questions was provided on the form. Further review revealed a handwritten note authored by SSD #149 that indicated she had called the resident's representative at 12:40 P.M. on 10/22/25 to review the NOMNC. The resident's representative reported verbal agreement of the discharged services and doesn't want to appeal. There was no documented evidence that the resident representative signed or received a copy of the NOMNC or was given a two-day notice prior to discharge of services on 10/23/25. Review of Resident #61's ABN dated 10/22/25 revealed the resident was discharged from therapy services on 10/23/25 due to meeting maximum potential. Staff had checked a box that indicated the resident did not want care listed above and understood that they would not be responsible for paying and couldn't appeal to see if Medicare would pay. There was an additional handwritten note dated 10/22/25 at 12:40 P.M., authored by SSD #149 that indicated the resident's representative was agreeable to determination of services and verbally understood. There was no documented evidence that the resident representative received a two-day notice of discharged services or received and signed a copy of the ABN. Interview on 04/14/26 at 12:35 P.M., with SSD #149 and Administrator confirmed Resident #61's representative was not provided with a two-day notice that Resident #61 was being discharged from therapy services nor was there documented evidence that a copy of the NOMNC or ABN was sent to the resident's representative for signatures. The SSD #149 confirmed the NOMNC did not contain the QIO name or contact information for the representative to appeal or ask questions. 3. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of thorax, and peripheral vascular disease. Review of Resident #39's beneficiary protection notification review form completed by the facility on 04/14/26 revealed the residents last covered Part A services was 02/25/26 and the resident remained in the facility and received the NOMNC and ABN. Review of Resident #39's NOMNC dated 02/23/26 revealed the resident last covered day for physical therapy service was 02/25/26. There was no documented evidence of the QIO name or contact information to appeal or ask questions was on the form. Interview on 04/14/26 at 12:35 P.M., with SSD #149 and Administrator confirmed the QIO name and contact information was not provided on the form signed by the resident. 4. Review of Resident #7's beneficiary protection notification review form completed on 04/14/26 by the facility revealed Resident #7's last covered day of Part A services was 01/26/26 and the resident remained in the facility. The resident received an ABN and NOMNC. Review of Resident #7's NOMNC dated 01/23/26 revealed the resident last covered day for therapy service was 01/26/26. There was no documented evidence of the QIO name or contact information to appeal or ask questions was on the form. Interview on 04/14/26 at 12:57 P.M., with SSD #149 confirmed Resident #7's NOMNC did not contain the QIO name or contact information to ensure the resident could appeal or ask questions. The SSD reported a few weeks ago (end of March) corporate office had provided training throughout the company on NOMNC and ABNs to staff, however she had not had to issue any ABN's or NOMNC since 03/16/26. The education included providing resident or resident representatives with QIO name and contact information, two day notice, and obtaining representative signature in person or mailing certified copy to representative to complete.

Based on medical record review, review of the infection control log, policy review, interviews, and observation the facility failed to ensure the infection control log was comprehensive and failed to ensure enhanced barrier precautions were maintained during incontinence care. This affected three (Resident #7, #9, and #13) of four residents reviewed for infections and one (Resident #1) of one residents observed for incontinence care. The facility census was 51. Findings include: 1.Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes, anemia, and cellulitis. Review of Resident #13's urinalysis dated 04/02/26 revealed on 04/02/26 the urine was collected and abnormal findings were reported on 04/03/26. The abnormal findings included: the urine was light orange in color, extra turbid, plus one ketones, plus three blood, protein plus one, positive nitrite, plus four positive, 21-50 red blood cells, greater than 50 white blood cells, few bacteria and epithial cells, and presence of mucous and white blood cells present in the urine. There was no evidence the culture was obtained. Review of Resident #13's order dated 04/05/26 revealed to administer one gram of Rocephin intramuscular times one then Vantin oral 100 milligrams (mg) twice daily for urinary tract infections (UTI) for five days. Review of Resident #13's medical administration record (MAR) dated 04/2026 revealed the resident received the one-time dose of Rocephin intramuscular on 04/04/26 and started Vantin 100 mg twice a day for UTI for five days on 04/05/26. Review of Resident #13's infection surveillance criteria report dated 04/05/26 revealed the resident had a urinary tract infection (UTI) acute dysuria (pain or discomfort) or acute pain, swelling, tenderness of the testes, epididymis or prostate. Greater than 100,000 colony forming units (cfu) per milliliter (ml) of no more than two species of organisms in a voided urine sample (there was no evidence in the medical record a urine culture was performed at that time). The report indicated the resident met criteria for treatment. The Infection Preventionist (P) #120 signed the report. Review of the infection control log dated 04/2026 revealed Resident #13 had a bacterial infection, the site was urinary tract infection (UTI), the resident had flank pain, the organism was UTI, the resident was treated with Vantin (antibiotic), and the infection met McGeer's criteria for treatment. Interview on 04/13/26 at 1:04 P.M., with IP #120 and the Director of Nursing (DON) confirmed Resident #13's infection surveillance criteria report and the infection control log were inaccurate due to the urine culture and sensitivity was not completed until 04/09/26 and the report and log on 04/07/26 indicated the resident's urine culture showed greater than 100,000 CFU/ML of no more than two species of organisms in a voided urine sample when the culture was not completed at that time. The IP and DON confirmed the infection control log was not comprehensive to include the organism and, at the time the log and criteria report were completed, there was no documented evidence the resident met McGeer's criteria due to the culture was not completed at that time. The infection control log didn't include the one dose of Rocephin that was administered as ordered. 2. Medical record review revealed Resident #7 was as admitted to the facility on [DATE] with diagnoses including dementia, depression, left femur fracture, hypertension, and age-related osteoporosis. Review of Resident #7's urinalysis results dated 03/18/26 revealed the resident's urine culture showed greater than 100,000 CFU/ml of enterococcus faecalis (bacteria) and was sensitive to ampicillin (antibiotic), cirpofloxin (antibiotic), nitrofurantoin (antibiotic), penicillin (antibiotic), and vancomycin (antibiotic). Review of Resident #7's progress note dated 03/18/26 revealed laboratory results were reviewed and no new orders. Review of the infection control log and trending map dated 03/2026 revealed no documented evidence of Resident #7 enterococcus faecalis infection or urinalysis. Interview on 04/13/26 at 1:04 P.M., with IP #120 and the Director of Nursing (DON) confirmed Resident #7's urinalysis indicated the Resident #7 had an enterococcus faecalis infection and it was not included on the infection control log or trending map. The DON confirmed all infections should be included on the infection control log and the facility map for trending even if the infection was not treated with an antibiotic. 3. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including pressure ulcer on sacral region, diabetes, chronic pain, chronic viral hepatitis C, gout, and colostomy. a. Review of March 2026 infection control log dated 03/2026 revealed on 03/10/26 the resident had other as the type of infection and site, the symptoms were altered mental status and elevated white blood cells, the diagnostic testing was urinalysis, the organism was marked not applicable, the treatment was Rocephin, and the infection met McGeer's criteria. Review of Resident #9's encounter note dated 03/11/26 revealed the Nurse Practitioner was following up on the resident's altered mental status and right lower extremity pain and edema. His urinalysis was negative. Rocephin continued for cellulitis and blood cultures were still pending. Review of Resident #9's infection surveillance criteria report dated 03/12/26 revealed the report was completed for a UTI. The criteria included the resident must have greater than 100,000 cfu/ml of no more than two species of organisms in a voided urine sample. The report did not indicate if the resident met criteria or not. There was no evidence that an infection surveillance criteria report was completed for cellulitis. Review of Resident #9's urinalysis dated 03/13/26 revealed the resident had less than 10,000 CFU/ml of gram-positive cocci and no sensitivity would be done. b. Review of Resident #9's blood culture results dated 03/18/26 revealed the final result was Methicillin-resistant Staphylococcus epidermidis (MRSE). Review of the March 2026 infection control log dated 03/2026 revealed on 03/23/26 the resident had a bacterial infection, the site was bacteremia, symptoms were elevated white blood cells, the organism was marked not applicable, the treatment was vancomycin, and the log indicated the resident met McGeer's criteria for treatment. There was no evidence of the organism MRSE. Review of infectious disease progress note dated 03/19/26 revealed the skilled nursing facility obtained four blood cultures and three of the four indicated Methicillin-resistant Staphylococcus epidermidis (MRSE), which was a common skin contaminant and the blood cultures were negative. There were concerns there may be occult bacteremia from his wounds that may be causing his pain. Recommend orthopedic consult for evaluation and aspiration to be sent for cell count, gram stain, and cultures and crystal analysis to rule out septic arthritis and gout. Continue on Vancomycin intravenously for 4-5 weeks and with laboratory monitoring. Recommend orthopedic consult for evaluation and aspiration to be sent for cell count, gram stain, and cultures and crystal analysis to rule out septic arthritis and gout. Review of Resident #9's infection surveillance criteria report dated 03/25/26 revealed the resident had bacteremia. There was no evidence if the resident met criteria or not. Review of the facility trending map dated 03/2026 revealed the resident had two skin infections and one blood infection. There was no documented evidence what the type of infection just the location of the infection. Interview on 04/13/26 at 1:04 P.M., with IP #120 and the Director of Nursing (DON) confirmed on 03/10/26 the resident was treated with antibiotics for cellulitis not a urinary tract infection per the infection surveillance criteria report and infection control log. The DON confirmed there was not a surveillance criteria report completed for the cellulites. The IP nurse confirmed there was no place on the surveillance criteria report to indicate if the resident meets or does not meet criteria. The DON confirmed the infection control log didn't include MRSE as the organism or trending map per the blood culture results. 4. Review of the facility's infection trending dated 01/2026 to 04/2026 revealed the facility utilized a facility map to trend infections. The map for January, February, and March only included the site (eye, oral, skin, blood, respiratory, UTI, osteo, fungal) of the infection and April's 2026 trending map was not started and the infection control log indicated there were three infections (one dental, one UTI without the organism, and one staphylococcus epidermis. Interview on 04/13/26 at 1:04 P.M., with IP #120 and the Director of Nursing (DON) confirmed the facility used a facility map of the rooms to trend infections. The IP and DON confirmed the log indicated the location/site of the infection but there was no way to indicate if there was an outbreak of infections such as Methicillin-resistant Staphylococcus Aurus (MRSA) or Escherichia coli which could be in different location/sites. Review of the facility's policy and procedure titled Infection Prevention Infection Control undated revealed the facility's infection prevention program was comprehensive in that it addresses detection, prevention, and control of infections among residents and employees. A systematic and organized data-driven method is in place to prevent infections, track existing infections, track and trend for in-house infections, surveillance for outbreaks effective and timely implementation of appropriate interventions and monitor infection control practices for compliance. 5. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, tracheostomy, quadriplegia, history of traumatic brain injury, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/03/26, revealed a Brief Interview for Mental Status (BIMS) interview could not be conducted. The MDS further revealed Resident #1 required staff assistance with activities of daily living (ADLs). Observation on 04/08/26 at 11:15 A.M. of Resident #1's incontinence care with Certified Nursing Assistant (CNA) #128 and #135 revealed neither staff donned personal protective equipment (PPE) while providing incontinence care. Enhanced barrier precautions (EBP) signage and equipment were located on the resident's door. The Assistant Director of Nursing (ADON) was also present in the room. Interview with ADON on 04/08 at 11:27 A.M. confirmed CNA #128 and CNA #135 did not wear PPE while providing incontinence care as they should have. Review of the facility's policy titled, Enhanced Barrier Precautions, undated, revealed EBP is an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care for: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care for any skin opening requiring a dressing. PPE required is gowns and gloves.

Based on record review, policy review, and interview, the facility failed to notify the resident representative of a newly identified pressure wound. This affected one (Resident #4) of one resident reviewed for notification of change. The facility census was 51.Findings include:Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, tracheostomy, gastrostomy, diabetes mellitus, hemiparesis and hemiplegia following cerebrovascular disease, anoxic brain damage, and seizures.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/26, revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition. The MDS further revealed Resident #4 required staff assistance with activities of daily living (ADLs). Review of the admission record revealed Resident #4's mother (Family Member #208) was listed as the resident's emergency contact and medical power of attorney.Review of nursing progress note, dated 03/18/26 at 7:30 P.M. (entered as a late entry), revealed a new pressure injury noted to left, lateral ankle, unstageable. Area was cleansed with normal saline, calcium alginate and foam dressing applied. Orders placed to reflect care, nurse practitioner aware, will notify responsible party when in facility tomorrow morning.Review of the progress notes revealed no documented evidence Family Member #208 was notified of the pressure ulcer on 03/19/26 as indicated in the progress note (responsible party would be notified when in facility tomorrow morning).Interview on 04/06/26 at 3:21 P.M. with Family Member #208 revealed her son developed a pressure wound on his left ankle and she was not notified by the facility. She stated while visiting her son, she inquired why he wasn't wearing his leg brace and was told he had developed a new pressure wound, on his outer ankle, a couple of days ago.Interview with Director of Nursing (DON) on 04/13/26 at 2:27 P.M stated she did recall speaking with Family Member #208 who voiced concern regarding not being notified of a newly identified pressure wound. The DON stated the resident representative should have been notified when the new pressure wound was discovered, however, because the resident's family member typically visited daily, the nurse planned to inform her the next day during her visit.Review of the undated facility policy titled, Notification of Change in Condition, revealed the center must inform the resident, consult with the resident's medical practitioner, and/or notify the resident's representative, authorized family member, or legal power of attorney when there is a change requiring such notification. Circumstances requiring notification including but not limited to: accidents resulting in injury, accidents with the potential to require physician intervention, circumstances that require a need to alter treatment which may include a new treatment.

Based on record review and interview, the facility failed to ensure the as needed (prn) order for a psychotropic medication was limited to 14 days. This affected one (Resident #19) of five residents reviewed for unnecessary medications.Findings include: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, psychoactive substance-induced psychotic disorder, chronic pain, and fibromyalgia. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/01/26, revealed the resident had intact cognition and a diagnosis of anxiety disorder. Review of the physician orders revealed an order, dated 06/17/25, for Ativan 0.5 milligrams (mg) one tablet by mouth every six hours as needed for anxiety. Review of the June and July 2025 Medication Administration Records (MAR) revealed Resident #19 received Ativan 0.5 mg one tablet by mouth on 06/17 through 06/24/25 and 06/26/25 through 06/30/25; and on 07/01/25 through 07/10/25. The prn psychotropic medication was received for a total of 23 days. Interview on 04/13/26 at 1:45 P.M. with the Director of Nursing (DON) confirmed the physician order for Ativan 0.5 mg every six hours prn for anxiety did not specify a 14-day stop date when Resident #19 received the medication for 23 days prior to the medication's discontinuation.

Based on record review, policy review, and staff interview, the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASRR) document accurately reflected all diagnoses. This affected one (Resident #19) of one resident reviewed for PASRR documents. The census was 52. Findings Include: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, psychoactive substance-induced psychotic disorder, chronic pain, and fibromyalgia. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/01/26, revealed the resident had intact cognition and a diagnosis of anxiety disorder. Review of Resident #19's PASRR document, dated 02/01/24, revealed under Section E: Indications of Serious mental Illness, no was selected incorrectly indicating there was not a diagnosis of mental illness. Review of the resident's diagnoses list revealed the diagnosis of anxiety disorder and psychoactive substance-induced psychotic disorder. Interview on 04/08/26 at 3:14 P.M. with Corporate Registered Nurse #200 confirmed Resident #19's PASRR document was not accurate and did not indicate the diagnosis of anxiety disorder and psychoactive substance-induces psychotic disorder. Interview on 04/08/26 at 3:32 P.M. with Social Services Designee (SSD) #149 confirmed Resident #19's PASRR document was not accurate and did not indicate the diagnosis of anxiety disorder and psychoactive substance-inducesd psychotic disorder and that she should have updated the document.

Based on record review, policy review, observation, and interview, the facility failed to ensure showers were provided as scheduled for a dependent resident. This affected one (Resident #2) of one resident reviewed for activities of daily living (ADL's). The facility census was 51. Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, cervical disk degeneration, diabetes mellitus, chronic pain, and morbid obesity. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 02/18/26, revealed Resident #2 had moderately impaired cognition and required physical staff assistance with ADL's. Review of the care plan, dated 02/28/26, revealed Resident #2 had an ADL self-care performance deficit and required physical assistance of two staff members for showers and baths. Observation and interview on 04/06/26 at 10:30 A.M revealed Resident #2 had excess oil noted in his hair and was wearing a hospital gown. The resident stated he was scheduled to receive a shower on Fridays but had not received a shower for the last couple of weeks. Interview on 04/13/2026 4:07 P.M. with Certified Nursing Assistant (CNA) #137 stated if a resident refused a bath or shower the refusal is documented in the shower binder that is kept in the nursing station and the nurse is notified of the resident's refusal. Review of the Shower Sheet Binder located at the nursing station revealed Resident #2 was scheduled to receive showers twice weekly on Tuesday and Friday. Review of Resident #2's Shower Sheet and Body/Skin Infection Forms for Nurse Aides revealed the resident last received a shower on 04/04/26; and refused showers on 04/11/26 and 04/17/26. The forms did not indicate documentation of the reason for the refusal or of a report to the nurse of the refusal per facility policy. Interview on 04/13/26 at 4:35 PM with the Director of Nursing (DON) confirmed according to the Shower Sheets, Resident #2 refused his showers on 04/07/26 and 04/11/26; however, the nurse did not follow-up with the resident and document an intervention per policy. Interview on 04/13/26 at 4:40 P.M., the DON stated she spoke with Resident #2 regarding his showers and will be moved from evening shift to day shift and twice weekly per his preference. Review or the facility's undated policy titled, Routine Resident Care, revealed routine resident care is care that is not necessarily medically or clinically based but necessary for quality-of-life promoting dignity and independence. Routine care by a nursing assistant includes but is not limited to the following: assisting or provides care including bathing, dressing, eating and hydration, and toileting.

Based on interviews, medical record review and Bureau of Motor Vehicles document review the facility failed to assist Resident #9 in obtaining a state photo identification. This affected one resident (Resident #9) of one residents reviewed for choices. The facility census was 51. Findings include:Review of Resident #9's medical record revealed an admission date of 09/25/23 with diagnoses that included pressure ulcer to the sacrum, diabetes mellitus and chronic kidney disease. Review of Resident #9's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed an intact and independent cognition level. Review of Ohio Department of Public Safety BMV form dated 01/08/25 revealed the BMV needed an affidavit from the provider that expressed the customer was homebound and unable to travel to the Deputy Registrar's Office. Upon receipt of the above, a license/identification card would be issued and mailed. Interview with Resident #9 on 04/06/26 at 12:59 P.M. revealed the facility still had not helped him obtain a state photo identification that was requested over a year ago.Interview with the Director of Nursing (DON) on 04/08/26 at 2:04 P.M. revealed the facility was to help the resident obtain a state issued photo ID and provided a letter from the BMV indicating the facility only needed an affidavit from the provider (dated 01/08/25) indicating he was homebound; however, a letter was never obtained and the resident still doesn't have a photo ID. The DON reported the Nurse Practitioner was present in the facility today and she would have her write a letter.

Based on record review, policy review, and interview, the facility failed to ensure a monthly regimen review (MRR) pharmacy recommendation for a psychotropic medication's 14-day stop date was addressed by the physician. This affected one (Resident #19) of five residents reviewed for unnecessary medications.Findings include: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, psychoactive substance-induced psychotic disorder, chronic pain, and fibromyalgia. Review of the physician orders revealed an order, dated 04/24/25, for Ativan 0.5 milligrams (mg) one tablet by mouth every six hours as needed for anxiety. The order did not include a 14-Day stop date. The medication was discontinued on 06/15/25. Review of the Monthly Regimen Reviews (MRR), dated 05/30/25, revealed the pharmacist recommended a 14-day stop date for the use of Ativan 0.5 mg every six hours as needed (prn) for anxiety; or a documented rationale if the prescriber believed the prn order should be extended beyond 14 days. Further review of the MRR revealed the physician did not address the recommendation as the form was blank, nor was there documentation in the medical record. Review of the physician orders revealed an order, dated 04/24/25, for Ativan 0.5 milligrams (mg) one tablet by mouth every six hours as needed for anxiety. The order did not include a 14-Day stop date. The medication was discontinued on 06/15/25. Review of the May and June 2025 Medication Administration Records (MAR) revealed Resident #19 received Ativan 0.5 mg one tablet by mouth prn for anxiety on 05/01/25, 05/03/25 through 05/05/25, 05/07/25 through 05/31/25; and 06/01 through 06/06/25 and 06/08/25 through 06/14/25. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/01/26, revealed the resident had intact cognition and a diagnosis of anxiety disorder. Interview on 04/13/26 at 1:35 P.M with the Director of Nursing (DON) confirmed Resident #19's MRR was not addressed timely by the physician. Review of the facility's undated policy titled, Medication Regimen Review, revealed psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. The monthly medication review will be performed by a licensed pharmacist according to Federal and State regulations meeting current standards of practice. The pharmacist will report any irregularities to the attending physician and DON and these reports must be acted upon in a timely manner that meets the needs of the resident.

Based on medical record review, interview, and review of laboratory contract the facility failed to ensure ordered urine culture and sensitivity laboratory testing was completed timely. This affected one (Resident #13) of one residents reviewed for urinary tract infection. The facility census was 51. Findings include:Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes, anemia, and cellulitis. Review of Resident #13's significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had an indwelling urinary catheter, occasionally incontinent of urine and frequently incontinent of bowel. The indwelling urinary catheter was discontinued 03/06/26. Review of Resident #13's urinalysis/culture dated 04/02/26 revealed on 04/02/26 the urine was collected and abnormal findings were reported on 04/03/26. The abnormal findings included: the urine was light orange in color, extra turbid (cloudy), plus one ketone, plus three blood, protein plus one, positive nitrite, plus four positive, 21-50 red blood cells, greater than 50 white blood cells, few bacteria and epithial cells, and presence of mucous and white blood cells present culture. There was no evidence the culture and sensitivity was performed. Review of Resident #13's encounter note dated 04/03/26 revealed resident was being seen for abdominal pain and no bowel movement. The resident reported she started having right side pain. She was still nauseous and vomiting and had one emesis this morning. The resident was on as needed Zofran and Phenergan for nausea. No concerns of dysuria (pain or discomfort) or hematuria (blood in the urine) at this time. She has not had a documented bowel movement in five days. Gastrointestinal: positive right flank pain, side pain to palpation. Genitourinary: There is no bladder tenderness or distention. Has urinalysis pending to rule out urinary tract infection (UTI) as cause of symptoms. Review of Resident #13's urine culture and sensitivity dated 04/09/26 (from the urine collected on 04/02/26) revealed the urine had greater than 100,000 colony forming units (CFU) per milliliter (ml) of proteus mirabilis (bacteria) and was sensitive to ceftriaxone (third generation antibiotic). Interview on 04/07/26 at 2:21 P.M., 04/08/26 at 8:37 A.M., and 04/13/26 at 7:41 A.M., with the Director of Nursing (DON) confirmed Resident #13's urine culture and sensitivity was not performed timely. The DON confirmed the urinalysis was collected on 04/02/26 and on 04/07/26 there was no evidence the culture and sensitivity was completed. The DON stated that the laboratory reported they were running behind as the reason why the culture and sensitivity was not completed until 04/09/26. Review of the laboratory contract dated 06/02/99 revealed the laboratory would report test results in a mutually agreeable manner. The nursing home ultimately bears responsibility for all services to its residents.

Based on medical record review, interview, review of infection control log, and policy review the facility failed to ensure an effective antibiotic stewardship program to ensure residents met criteria for antibiotic treatment. This affected one (Resident #13) of four residents reviewed for infections. The facility census was 51.Findings include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes, anemia, and cellulitis.Review of Resident #13's significant change MDS dated [DATE] revealed the resident had an indwelling urinary catheter, occasionally incontinent of urine and frequency incontinent of bowel. The urinary catheter was discontinued 03/06/26.Review of Resident #13's urinalysis/culture dated 04/02/26 revealed on 04/02/26 the urine was collected and abnormal findings were reported on 04/03/26. The abnormal findings included: the urine was light orange in color, extra turbid (cloudy), plus one ketones, plus three blood, protein plus one, positive nitrite, 21-50 red blood cells, greater than 50 white blood cells, few bacteria and epithial cells, and presence of mucous and white blood cells in the specimen. There was no evidence the culture was obtained.Review of Resident #13's alert charting dated 04/02/26, 04/03/26, 04/04/26, 04/05/26, 04/06/26 revealed no urinary changes noted. There was an additional note on 04/03/26 and 04/04/26 that revealed the resident complained of flank pain to nurse practitioner and hospice was notified. Urine specimen was sent out. Continue to monitor and give as needed pain medications.Review of Resident #13's encounter note dated 04/03/26 revealed the resident was being seen for abdominal pain and no bowel movement. The resident reported she started having right side pain. She was still nauseous and vomiting and had one emesis this morning. The resident was on as needed Zofran and Phenergan for nausea. No concerns of dysuria (pain or discomfort with urination) or hematuria (blood in the urine) at this time. She has not had a documented bowel movement in five days. Gastrointestinal: positive right flank pain, side pain to palpation. Genitourinary: There is no bladder tenderness or distention. Has urinalysis pending to rule out urinary tract infection (UTI) as cause of symptoms.Review of Resident #13's infection surveillance criteria report dated 04/05/26 revealed the resident had a UTI, acute dysuria or acute pain, swelling, tenderness of the testes, epididymis (part of male urinary/reproductive anatomy) or prostate. Greater than 100,000 colony forming unit (cfu) per milliliter (ml) of urine of no more than two species of organisms in a voided urine sample (there was no evidence in the medical record a urine culture was obtained). The report indicated the resident met criteria for treatment. The Infection Preventionist signed the report. Review of Resident #13's order dated 04/05/26 revealed to administer one gram of ceftriaxone (antibiotic) intramuscular times one then cefpodoxime proxetil (antibiotic) oral 100 milligrams (mg) twice daily for UTI for five days. Review of Resident #13's medical administration record (MAR) dated 04/2026 revealed the resident received the one time dose of ceftriaxone intramuscular on 04/04/26 and started cefpodoxime proxetil 100 mg twice a day for UTI for five days on 04/05/26. Review of the infection control log dated 04/2026 revealed on 04/05/26 Resident #13 had flank pain and the organism was a urinary tract infection (UTI) and the resident met criteria for treatment and was ordered cefpodoxime 100 mg. Review of Resident #13's current, comprehensive plan of care revealed no evidence of plan of care for urinary tract infection.Interview on 04/07/26 at 2:21 P.M. and 04/08/26 at 8:37 A.M., with the Director of Nursing (DON) confirmed the culture had not returned at this time. The DON reported she called the laboratory, and the preliminary should be here tomorrow and final on Thursday (04/09/26). The DON confirmed the resident was started on antibiotics without meeting criteria. The DON also confirmed the Infection Preventionist (IP) had completed the criteria form and infection control log inaccurately due to the urine culture report was still pending and there was no evidence the resident had greater than 100,000 CFU/ml or met criteria for treatment. The DON reported urine cultures were usually completed within 48 to 72 hours. Interview on 04/08/26 at 9:01 AM with Infection Preventionist (IP) #120 confirmed Resident #13 didn't meet criteria for treatment due to the culture report was still pending. The IP confirmed she completed the criteria form inaccurately because she indicated the resident met criteria and the resident didn't. The IP reported she would reach out to lab to see why there was a delay in the culture results. The IP confirmed the provider did not provide a rationale for treatment without meeting criteria.Review the of the facility policy titled Antibiotics Stewardship dated 03/22 revealed the facility aim of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotics use in resident in the nursing home facility.

Based on record review, interviews, observation and facility policy review, the facility failed to ensure Resident #3 was free from misappropriation. This affected one (Resident #3) of three records reviewed. Findings include:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left bronchus or lung, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage two chronic kidney disease. The resident was under hospice services.Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognition intact.Review of census revealed Resident #3 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on Unit 2 on 11/22/25. Review of the Grievance/Complaint log dated 11/2025, 12/2025, and 01/2026, revealed no evidence of Resident #3's concerns regarding the missing rings. Review of the missing items log dated 11/2025, 12/2025, and 01/2026 revealed no evidence of Resident #3's concerns regarding the missing rings.Review of anonymous complaint intake dated 01/12/26 revealed Resident #3's recently had a room change and several items were missing. The missing items were reported to social service office; however, none of these items have been located or replaced. The largest and most important item unaccounted for was an antique amethyst birthstone ring. The ring was real gold; the stone was [NAME] cut and beveled from years of wear. The anonymous complainant cleaned the ring for the resident, and it was irreplaceable. Resident #3 informed the anonymous complainant that the Administrator refused to replace it or come up with an amicable solution. There was another ring that was missing, this one was also real gold but with a green stone. Interview via email on 01/21/26 at 9:20 A.M., with the Ombudsman revealed the volunteer Ombudsman had visited the facility on 01/16/26 and spoken to the Unit Manger #12, due to the Director of Nursing (DON) was not there, regarding the missing rings. The Unit Manager told the volunteer Ombudsman she would relay the concern to management as soon as possible. Interview on 01/21/26 at 9:27 A.M., with the Administrator confirmed there were no grievances or concerns filed in the last three months, and he was not aware of any concerns regarding missing jewelry. Interview and observation of Resident #3 on 01/21/26 at 10:33 A.M., with the DON revealed Resident #3 was alert and oriented. The resident had a box hanging on the wall to display her rings. Resident #3 confirmed she had reported her rings missing to the Administrator the day of her room change. Both rings were gold and one had a purple stone, and one had a green stone. The rings were still missing. Interview on 01/21/26 at 11:15 A.M., with Unit Manager #12 confirmed she was notified on Friday 01/16/26 by the volunteer Ombudsman regarding Resident #3's missing rings; however, she knew the facility was aware. Interview on 01/21/26 at 11:28 A.M., with the Administrator, Social Worker #301, and Corporate Nurse #300 and follow up interview with the Administrator on 01/21/26 at 12:13 P.M., confirmed Resident #3 had reported an allegation she had rings missing a few days after her room change. The Administrator confirmed he was aware; however, he didn't complete a concern/grievance form, nor did he submit a self-reported incident to the state agency due to the resident could not describe the rings or when she last seen them. He was not convinced the resident even had the rings because she could not provide any details about the rings. The Social Worker reported she searched the resident's room and spoke to staff, but she didn't have any documented evidence to support an investigation was completed. The Administrator and Social Worker confirmed they didn't contact Resident #3's family to confirm the resident had the rings at the facility. The Administrator reported he started a self-reported incident today with the state.Review of the undated Ohio Abuse, Neglect, and Misappropriation policy revealed misappropriation was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This deficiency represents non-compliance investigated under Complaint Number 2714540.

Based on record review, interview, and review of the Ohio Gateway system (online system for reporting abuse) and facility policy review, the facility failed timely to report allegation of misappropriation to the state agency. This affected one (Resident #3) of three residents reviewed. Findings include:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left bronchus or lung, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage two chronic kidney disease. The resident was under hospice services.Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognition intact.Review of census revealed Resident #3 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on Unit 2 on 11/22/25.Review of anonymous complaint intake dated 01/12/26 revealed Resident #3's recently had a room change and several items were missing. The missing items were reported to social service office; however, none of these items have been located or replaced. The largest and most important item unaccounted for was an antique amethyst birthstone ring. The ring was real gold; the stone was [NAME] cut and beveled from years of wear. The anonymous complainant cleaned the ring for the resident, and it was irreplaceable. Resident #3 informed the anonymous complainant that the Administrator refused to replace it or come up with an amicable solution. There was another ring that was missing, this one was also real gold but with a green stone. Interview via email on 01/21/26 at 9:20 A.M., with the Ombudsman revealed the volunteer Ombudsman had visited the facility on 01/16/26 and spoken to the Unit Manger #12, due to the Director of Nursing (DON) was not there, regarding the missing rings. The Unit Manager told the volunteer Ombudsman she would relay the concern to management as soon as possible. Interview on 01/21/26 at 9:27 A.M., with the Administrator confirmed there were no grievances or concerns filed in the last three months and he was not aware of any concerns regarding missing jewelry. Interview and observation of Resident #3 on 01/21/26 at 10:33 A.M., with the DON revealed Resident #3 was alert and oriented. The resident had a box hanging on the wall to display her rings. Resident #3 confirmed she had reported her rings missing to the Administrator the day of her room change. Both rings were gold and one had a purple stone, and one had a green stone. The rings were still missing. Interview on 01/21/26 at 11:15 A.M., with Unit Manager #12 confirmed she was notified on Friday 01/16/26 by the volunteer Ombudsman regarding Resident #3's missing rings; however, she knew the facility was aware. Interview on 01/21/26 at 11:28 A.M., with the Administrator, Social Worker #301, and Corporate Nurse #300 and follow up interview with the Administrator on 01/21/26 at 12:13 P.M., confirmed Resident #3 had reported an allegation she had rings missing a few days after her room change. The Administrator confirmed he was aware; however, he didn't complete a concern/grievance form, nor did he submit a self-reported incident to the state agency due to the resident could not describe the rings or when she last seen them. He was not convinced the resident even had the rings because she could not provide any details about the rings. The Social Worker reported she searched the resident's room and spoke to staff, but she didn't have any documented evidence to support an investigation was completed. The Administrator and Social Worker confirmed they didn't contact Resident #3's family to confirm the resident had the rings at the facility. The Administrator reported he started a self-reported incident today with the state.Review of the undated Ohio Abuse, Neglect, and Misappropriation policy revealed misappropriation was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with state law. Each occurrence of misappropriation would be identified and reported to the supervisor and investigated timely. The supervisor or designee would notify the DON and Executive Director (ED) of the incident or allegation immediately. Required notification of agencies, physician, and resident representatives will be completed. The ED will direct the investigation. Statements would be obtained from the resident or from the reporter of the incident, in writing whenever possible by the ED or designee. Documentation of the facts and findings would be completed in each resident medical record. A suspected misappropriation investigation report would be initiated by the Director of Nursing or designee. Statement would be obtained from staff related to the incident, including the victim and witnesses. By the fifth day, the alleged abuse investigation form is completed and reviewed for completeness and accuracy by the ED or designee and submitted to the state. Investigation files are kept in confidential file located in the ED office. This file would be accessible for follow-up and state or local police review of the investigation. Allegations of misappropriation of resident property are reported immediately, but no later than two hours after the allegation was made. The results of the facility's investigation must be reported to the survey agency, the ED/designee and other officials in accordance with state law, within five working days of the incident. This deficiency represents non-compliance investigated under Complaint Number 2714540.

Based on record review, interview, observation and facility policy review the facility failed to investigate allegation of misappropriation. This affected one (Resident #3) of three residents reviewed.Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left bronchus or lung, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage two chronic kidney disease. The resident was under hospice services.Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognition intact.Review of census revealed the resident was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on Unit 2 on 11/22/25. Review of anonymous complaint intake dated 01/12/26 revealed Resident #3's recently had a room change and several items are missing. The missing items were reported to social service office, however none of these items have been located or replaced. The largest and most important item unaccounted for is an antique amethyst birthstone ring. The ring was real gold; the stone was [NAME] cut and beveled from years of wear. The anonymous complainant cleaned the ring for the resident, and it was irreplaceable. Resident #3 informed the anonymous complainant that the Administrator refused to replace it or come up with an amicable solution. There was another ring that was missing, this one was also real gold but with a green stone. Interview via email on 01/21/26 at 9:20 A.M., with the Ombudsman revealed the volunteer Ombudsman had visited the facility on 01/16/26 and spoken to the Unit Manger #12, due to the Director of Nursing (DON) was not there, regarding the missing rings. The Unit Manager told the volunteer Ombudsman she would relay the concern to management as soon as possible. Interview on 01/21/26 at 9:27 A.M., with the Administrator confirmed he was not aware of any concerns regarding missing jewelry. Interview and observation of Resident #3 on 01/21/26 at 10:33 A.M., with the DON revealed Resident #3 was alert and oriented. The resident had a box hanging on the wall to display her rings. Resident #3 confirmed she had reported her rings missing to the Administrator the day of her room change. Both rings were gold and one had a purple stone, and one had a green stone. The rings were still missing. Interview on 01/21/26 at 11:15 A.M., with Unit Manager #12 confirmed she was notified on Friday 01/16/26 by the volunteer Ombudsman regarding Resident #3's missing rings; however, she knew the facility was aware. Interview on 01/21/26 at 11:28 A.M., with the Administrator, Social Worker #301, and Corporate Nurse #300 and follow up interview with the Administrator on 01/21/26 at 12:13 P.M., confirmed Resident #3 had reported an allegation she had rings missing a few days after her room change. The Administrator confirmed he was aware; however, he didn't complete a concern/grievance form. He was not convinced the resident even had the rings because she could not provide any details about the rings. The Social Worker reported she searched the resident's room and spoke to staff, but she didn't have any documented evidence to support an investigation was completed. The Administrator and Social Worker confirmed they didn't contact Resident #3's family to confirm the resident had the rings at the facility. Review of the undated Ohio Abuse, Neglect, and Misappropriation policy revealed misappropriation was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Each occurrence of misappropriation would be identified and reported to the supervisor and investigated timely. The supervisor or designee would notify the DON and Executive Director (ED) of the incident or allegation immediately. Required notification of agencies, physician, and resident representatives will be completed. The ED will direct the investigation. Statements would be obtained from the resident or from the reporter of the incident, in writing whenever possible by the ED or designee. Documentation of the facts and findings would be completed in each resident medical record. A suspected misappropriation investigation report would be initiated by the Director of Nursing or designee. Statements would be obtained from staff related to the incident, including the victim and witnesses. By the fifth day, the alleged abuse investigation form is completed and reviewed for completeness and accuracy by the ED or designee and submitted to the state. Investigation files are kept in confidential file located in the ED office. This file would be accessible for follow-up and state or local police review of the investigation. This deficiency represents non-compliance investigated under Complaint Number 2714540.

Based on medical record review, review of work order, interview, observation and facility policy review, the facility failed to ensure bilateral enabler bars were in-place per orders to prevent Resident #3 from falling out of bed twice. This affected one (Resident #3) of three records reviewed for accidents. Findings include:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left bronchus or lung, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage two chronic kidney disease. The resident was under hospice services.Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognition intact. The resident didn't have any falls during the look back period. The resident was occasionally incontinent of urine and always incontinent of bowel. The resident had no restraints or alarms. The resident had no functional limitation with range of motion and used a wheelchair. The resident required supervision or touching assistance when sitting to stand and chair/bed to chair transfer.Review of census revealed Resident #3 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on Unit 2 on 11/22/25.Review of Resident #3 activity daily living (ADL) dated 08/26/25 and 11/24/25 revealed bilateral enabler to assist with turning and repositioning.Review of Resident #3's orders dated 01/2026 revealed the resident was ordered bilateral enabler bars to assist with turning and repositioning since 08/27/25. Review of Resident #3's progress notes dated 12/11/25 revealed the nurse was called to see the resident lying on the floor near her bed around 7:26 A.M. (witnessed) with her hands supporting her on the floor and leg lying flat. I was trying to get up from bed when I fell with my left hip. Resident denies pain and discomfort, pain zero out of ten. Resident #3 could move all extremities, pupils react to light, grips strongly, and vital signs obtained. Telehealth was called and notified with new orders for neurological checks, and call if there were any changes. The resident's family was informed of the current status of the resident. On 12/12/25, clarification, the fall was unwitnessed. Review of Resident #3's progress note dated 01/16/25 revealed at 5:30 A.M. the resident was observed lying on right side on floor next to bed, resident denied attempting to get out of bed and stated I slid oxygen was applied due to the resident removes per self. Oxygen saturation was 91%. Denies hitting head, range of motion adequate, two by two bruise noted to left lower extremity, blue in color. Assisted to wheelchair via two certified nursing assistants (CNAs) while linen was changed to bed. Neuro checks within normal limit. Provider called and new orders to apply foam dressing to left lower extremity bruise for protection for three days. The resident's representative was notified. Review of Resident #3's medication and treatment administration records dated 12/2025 and 01/2026 revealed staff had been signing off the resident had bilateral enabler bars to assist with turning and repositioning in-place even though there were no bars. Review of anonymous complaint intake dated 01/12/26 revealed the resident had fallen out of bed because she doesn't have assist bars on bed. The resident has had a stroke that affected one side of her body. The resident had asked four times since 12/18/25 for assist bars to be added to her bed. Review of work order dated 01/16/26 revealed the Unit Manger #12 put a work order in for room [ROOM NUMBER]-2 (Resident #3) for bed rail to right side of bed for transfer assistance. Interview on 01/21/26 at 9:20 A.M., via email with the Ombudsman revealed on 01/16/26 the volunteer Ombudsman had spoken to the Unit Manger #12 regarding Resident #3 was requesting assist bars to her bed to aid in getting in and out of bed independently. Observation and interview on 01/21/26 at 10:33 A.M., of Resident #3 confirmed she didn't have enabler bars on bed since moving into her new room until yesterday (01/20/26) the staff installed the half rail. The resident reported she would prefer the enabler bar. The resident's right side of bed was against the wall, and the resident had a half rail on the left side. Interview on 01/21/26 at 11:15 A.M., with Unit Manger #12 confirmed the volunteer Ombudsman had voiced concerns that Resident #3 did not have enabler bars on her bed on 01/16/26, and she put in a work order to have them added. Interview on 01/21/26 at 12:34 P.M., with the Maintenance Director (MD) confirmed he had received a work order to add a side rail to Resident #3's bed, but he could not find an enabler bar to fit the bed. Yesterday 01/20/26 he had found a 1/2 rail and placed it on her bed but was just told by the Director of Nursing (DON) she needed an enabler bar. The MD confirmed the resident's bed did not have any side rails until he put one on yesterday. Interview on 01/21/26 at 10:33 A.M. and 3:17 P.M., with the DON revealed she believes when Resident #3's room was changed on 11/22/25, the resident did not take the bed. On 12/17/25 hospice brought the resident a new bed; however, hospice did not bring the enabler bars. The DON confirmed the resident was ordered bilateral enabler bars since 08/27/25, and the enabler bars were not in place per orders and per the resident plan of care. The DON confirmed the resident had sustained two falls out of bed on 12/11/25 and 01/16/26. The DON confirmed the facility received an order today for the half bedrail until the enabler bar arrived due to it had to be ordered from hospice. The DON confirmed staff were signing off the enabler bars were in-place twice a day in 12/2025 and 01/2026 when the bilateral enabler bars were not in-place. Review of the undated facility policy titled Fall Prevention and Management revealed fall prevention and management was the process of identifying risk factors that can minimize the potential for falls and also a process to manage a resident's care if a fall occurs.This deficiency represents non-compliance investigated under Complaint Number 2714540.

Based on interview, record review, and policy review the facility failed to ensure medications were ordered timely and available for residents. This affected one resident (Resident #7) of four residents reviewed for pharmacy services. Findings include:Record review revealed Resident #7 admitted to the facility 10/10/19 with diagnoses including traumatic brain injury with loss of consciousness, insomnia, neuropathy, quadriplegia, muscle spasms, neuromuscular bladder dysfunction, and hyperkalemia.Record review of Resident #7 quarterly minimum data set (MDS) assessment completed 08/14/25 revealed the resident's cognition was intact, had no observed or exhibited behaviors, was dependent for toileting, showering, bathing, lower body dressing, and personal hygiene, and was dependent or required maximum assistance for mobility. MDS revealed Resident #7 received an opioid medication. Review of quarterly care plan initiated on 11/09/21 and revised on 08/25/25 revealed Resident #7 had complaints of chronic pain related to quadriplegia, idiopathic peripheral autonomic neuropathy, neurogenic bladder, and muscle spasms. Interventions include administer non-pharmacological interventions (repositioning, diversion activities, snacks and fluids, ice / heat, music therapy, relaxation techniques, imagery). As needed Transcutaneous electrical nerve stimulation (TENS) unit for pain. Review of quarterly care plan initiated on 11/09/21 and revised on 08/25/25 revealed Resident #7 had complaints of chronic pain related to quadriplegia, idiopathic peripheral autonomic neuropathy, neurogenic bladder, and muscle spasms. Interventions include administer non-pharmacological interventions (repositioning, diversion activities, snacks and fluids, ice / heat, music therapy, relaxation techniques, imagery). As needed Transcutaneous electrical nerve stimulation (TENS) unit for pain. Record review revealed a progress note dated 09/25/25 at 2:30 P.M. that a call was made to [NAME] pain management. Per pain management office staff, the prescription will be sent to the new pharmacy as soon as the pharmacy is established in the e-scribing system. Record review revealed a progress note dated 09/25/25 at 7:34 P.M. revealed Resident #7 was out of Percocet.Record review revealed a progress note dated 09/25/25 at 8:16 A.M. that Resident #7's room was entered to speak about pain medication. Resident #7 stated they need their pain medication before they had withdrawal symptoms. Resident #7 was explained measures that would be taken to get her pain medication into the facility. Resident #7 was offered to go to the emergency room (ER), Resident #7 declined transport to ER but requested to be informed of measures taken and their outcomes. Nurse Practitioner (NP) made aware. Record review revealed an order for Percocet oral tablet 7.5-325 milligram (mg) (Oxycodone with Acetaminophen). Give Resident #7 one tablet by mouth four times a day for pain and give one tablet by mouth one time a day for pain. Record review revealed a progress note dated 09/25/25 at 9:11 A.M. that Pharmacy notified facility to check on status of pain medication, pharmacy stated they received the script from the pain clinic and will be sending out on the 1:00 P.M. delivery. Nurse requested authorization to pull Percocet at that time. Resident #7 and Physician aware. Record review revealed a progress note dated 09/26/25 at 9:01 A.M. that Physician #100 placed new order for Ultram 50 mg every four hours for seven days until supply arrives of Percocet for pain clinic order and Resident #7 aware. Review of Resident #7 September Medication Administration Record (MAR) revealed Percocet oral tablet 7.5-325 mg give one tablet one time a day was given on 09/25/25 at 2:00 A.M. and was not given on 09/26/25 at 2:00 A.M. Review of Resident #7 September MAR revealed Percocet oral tablet 7.5-325 mg give one tablet by mouth four times a day for pain was not given on 09/25/25 for any occurrence as ordered for 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M Interview on 10/07/25 at 10:10 A.M. with anonymous staff member (ASM) #33 confirmed they just switched to a new pharmacy, within the last month it became official. ASM #33 stated they had an issue with narcotics, their understanding was it was supposed to be in one shipment and when that shipment came it wasn't there, and they were unable to get into the emergency stock. ASM #33 stated they do not recall which resident the prescription was for. Interview on 10/07/25 at 1:38 P.M. with Resident #7 revealed she was out of her pain medication for almost 30 hours a couple weeks ago. Resident #7 stated the longest she goes without her pain medication six hours, between 2 A.M. and 8 A.M., this is when its scheduled. The staff told her there was a pharmacy mix up. Resident #7 stated this has happened before, and they told her they were going to start ordering their pain medication seven days before it runs out due to the frequency she takes it. Resident #7 stated she was worried she was going to withdraw. The did offer her to go to the hospital but she did not feel that was necessary. Interview on 10/07/25 at 2:05 P.M. with Pain Clinic staff #54 revealed on 09/24/25 at 4:29 P.M. their office had a call, which was placed on voice mail due to it being after hours, from the facility regarding Resident #7 pain medication. It wasn't until the next day on 09/25/25 the pharmacy received the call from the answering machine. On 09/26/25 the provider sent the prescription to pharmacy solutions. Prior to 09/24/25 the last time Resident #7 pain medication was called in was on 09/05/25.Interview and review of Resident #7 MAR with Director of Nursing on 10/07/25 at 2:08 P.M. confirmed Resident #7 was last administered her pain medication on 09/25/25 at 2:00 A.M. and did not receive the next dose until 09/26/25 at 9:00 A.M., totaling 30 hours without their ordered pain medication and missing five ordered doses due to the medication not being available. This deficiency represents non-compliance investigated under Complaint Number 2631072.

Based on closed medical record review, review of hospital records, review of Medscape medical reference information, policy review, and interviews, the facility failed to protect Resident #64's right to be free from neglect. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE] when the facility failed to provide timely and appropriate goods and services to meet Resident #64's total care and medical needs and failed to ensure the resident received timely and necessary care and treatment to prevent serious illness and death. On [DATE] Resident #64 returned from the hospital with orders for Lasix (diuretic) 20 milligrams (mg) daily and basic metabolic profile (BMP) laboratory test to be completed on [DATE]. The orders for Lasix and the BMP were not initiated or completed per the hospital discharge orders. On [DATE], Resident #64 was ordered additional laboratory testing, including thyroid stimulating hormone (TSH), Vitamins B1, B6, and B12, plasma, folate, and Vitamin D and D3 levels that were not completed. Resident #64 was hospitalized from [DATE] to [DATE] for hypoglycemia, hyperkalemia with EKG changes, hyponatremia, and encephalopathy. On [DATE], the resident was ordered Lasix 80 mg upon discharge from the hospital that was not implemented. On [DATE], the resident was ordered to have laboratory testing including a complete blood count (CBC) and BMP completed STAT (immediately) to determine if the resident's Lasix was appropriate to continue. On [DATE], a one-time order for Lasix 40 mg and Potassium 20 milliequivalents (meq) was ordered and not administered. The STAT CBC and BMP lab results ordered on [DATE] and completed on [DATE] were not reported timely to the provider, resulting in the resident being hospitalized from [DATE] to [DATE] with edema requiring a Bumex (diuretic) continuous intravenous infusion. Additionally, upon re-admission on [DATE], Resident #64 was ordered Lactulose 15 mg/milliliter (ml), 45 ml four times daily. On [DATE], Resident #64 reported to the telehealth Nurse Practitioner (NP) that she had been on Lactulose and would like to restart it again to treat her cirrhosis. The telehealth NP inadvertently ordered a duplicate dose of Lactulose 30 ml, and the resident started the dosage on [DATE]. Resident #64 received duplicate doses of Lactulose, 45 ml and 30 ml doses, from [DATE] until [DATE] (with the exception of [DATE] and [DATE] when the medication was not administered). On [DATE], the resident's progress notes referenced the resident had left calf pain and was ordered an unspecified scan, which was not completed. Resident #64 continued to decline, could not stand, and requested to go the emergency room (ER) on [DATE]. However, Resident #64 was not transferred to the ER, nor was the nurse practitioner (NP) notified. On [DATE], Resident #64 again requested to go to the ER because she could not stand, which was abnormal for her. In the ER, the resident was diagnosed with hyperkalemia (elevated potassium level), acute kidney injury, and encephalopathy (a condition that affects brain function or structure and can lead to changes in mental state, behavior, or cognitive abilities). The resident subsequently went into acute respiratory arrest (in the ER) and expired in the hospital on [DATE]. This affected one resident (#64) of three residents reviewed for abuse and neglect. The facility census was 63. On [DATE] at 2:07 P.M., the Administrator, Interim Director of Nursing (IDON) #600, Assistant Director of Nursing/Registered Nurse (ADON/RN) #179, and Regional Nurse #601 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide timely and appropriate goods and services to meet Resident #64's total care and medical needs and failed to ensure the resident received timely and necessary care and treatment to prevent serious illness and death. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 3:00 P.M., Regional Director of Clinical Services #601 educated the Interim Director of Nursing #600 and Director of Nursing #179, LPN #135 and LPN #107 on the facility Abuse Neglect and Misappropriation, Residents Rights, Laboratory and Radiologic Services Reporting, Medication Administration, and Notification of Change in Condition policies, with emphasis on residents receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition. On [DATE] all new admissions (Resident #18, #28, #33, #43, #59 and #66) from [DATE] to current were audited and reviewed from 3:00 P.M. to 6:00 P.M., by Licensed Practical Nurse (LPN) #135 and LPN #107 to ensure all new admission orders were identified and implemented at time of admission. On [DATE], all 63 residents from [DATE] to current, were audited and reviewed from 3:00 P.M. to 8:00 P.M., by LPN #135 and LPN #107, to ensure all lab work was completed as ordered. Eight residents (Resident #4, #27, #28, #43, #50, #52, #59, #66) labs were re-scheduled due to the orders were not entered into lab portable. The physician was notified. On [DATE], all 63 residents from [DATE] to current were audited and reviewed from 3:00 P.M. to 3:30 P.M., by Registered Nurse (RN) #179, to ensure all lab results were identified and reported to the provider. On [DATE], all 63 residents from [DATE] to current were audited and reviewed from 3:00 P.M. to 3:30 P.M. by RN #179, for duplicated orders including lactulose orders awaiting clarification. On [DATE], all 63 residents from [DATE] to current were audited and reviewed from 3:00 P.M. to 3:30 P.M. by RN R#179, to ensure all diagnostic testing orders were identified and reported to the provider. One resident's (Resident #1) diagnostic tests were re-scheduled, and physician notified. On [DATE], all residents with a Brief Interview for Mental Status (BIMS) score of 13 or higher, total of 35 residents (Resident #3, #4, #8, #9, #10, #11, #12, #15, #17, #18, #20, #22, #28, #29, #32, #33, #35, #36, #41, #42, #43, #44, #45, #46, #47, #50, #51, #54, #55, #57, #58, #60, #61, #62, and #63) were interviewed by Social Service Designee (SSD) #116 and Director of Admissions #120, from 6:00 P.M. to 8:00 P.M., to ensure the residents were receiving goods and services as ordered such as medications, labs, and diagnostics. Three residents (Resident #3, #17, and #50), with concerns noted were addressed and MD notified. On [DATE], all 28 residents (Resident #1, #2, #5, #7, #13, #14, #16, #21, #23, #24, #25, #26, #27, #30, #31, #34, #37, #38, #39, #40, #48, #49, #52, #53, #56, #59, #64, and #66) with a BIMS less than 13 were assessed from 5:00 P.M. to 8:00 P.M. by LPN #135 and LPN #107 for potential neglect as a result of needed goods and services not being provided. Assessment included head to toe to assess for change of condition. Beginning on [DATE] the facility implemented a plan that upon hire, any new RN or LPN would receive education by the Assistant Director of Nursing/designee on Policies titled Abuse Neglect and Misappropriation, Residents Rights, Laboratory and Radiologic Services Reporting, Medication Administration, and Notification of Change in Condition, and verifying and confirming telehealth orders in a timely manner with emphasis on residents receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition. On [DATE] between 4:00 P.M and 10:00 P.M DON #600 and RN #179 educated all licensed nurses, (10 RNs and 9 LPNs) on the Abuse Neglect and Misappropriation, Residents Rights, Laboratory and Radiologic Services Reporting, Medication Administration, and Notification of Change in Condition policies, and verifying and confirming telehealth orders in a timely manner with emphasis on residents receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition. On [DATE] at 6:00 P.M, the Administrator presented the Quality Assessment and Performance Improvement (QAPI) Team with investigation and all findings for discussion and review. Discussion included abatement plan from incident regarding Resident #64, ensuring residents were receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition. Staff in attendance included the Administrator, Interim DON #600, LPN #107, Medical Records Director #188, SSD #116, LPN #135, Human Resource Director #155 and Regional Director of Clinical Operations #601. Via phone included the Medical Director #700, Regional Director of Operations (RDO) #701, Diversional Director of Clinical Operations (DDCO) #203, [NAME] President (VP) #702. A root cause analysis was performed on [DATE] by the interdisciplinary team with oversight by the Administrator. In review of the facilities non-compliance at Data Tag F600 current policies and procedures, documentation and staff interview, the root-cause analysis determined a need for improved clinical education and comprehensive oversight by clinical managers. Beginning on [DATE], the Administrator and DON or designee would conduct an audit on 3-5 residents/week for four weeks, and randomly thereafter to ensure residents were receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition, to prevent the same actions, situations, and/or practices from occurring in the future and to ensure on-going compliance. The audit would include reviewing new orders in the daily clinical meeting to ensure labs and diagnostics have been scheduled, results have been received, medications have been administered, and MD follow-up was complete. Three residents would be interviewed a week to identify if there were concerns. All findings of concern would be immediately addressed and reported to the QAPI committee for further review and prompt response and resolution. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included:Review of the closed medical record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, cirrhosis, asthma, encephalopathy, bipolar, epilepsy, anxiety, falls, hypertension, depression, sleep disorder, post-traumatic stress disorder, hyperlipidemia, type 2 diabetes, left leg deep vein thrombosis, peripheral artery disease, and anemia. Review of Resident #64's plan of care initiated [DATE] revealed the resident used anti-anxiety medications and was encouraged to voice feelings, discuss coping skills, provide a calm environment, and limit over-stimulation. A care plan focus initiated [DATE] revealed Resident #64 was at nutritional risk due to acute renal failure, depression, diabetes, bipolar, morbid obesity, hypertension, fatty liver cirrhosis, diuretic therapy, large weight fluctuations related to fluid shifts from advanced disease process, and the resident doesn't want a therapeutic diet. The interventions included establishing a baseline weight, notify the medical provider and resident representative of unplanned weight changes, obtain labs per medical provider orders, obtain weekly weights if unplanned loss was identified, and provided diet as ordered. A care plan focus initiated [DATE] revealed Resident #64 had renal failure with interventions including to administer medication per orders and to observe for side effects and effectiveness. Report abnormal findings to medical provider. Observe for signs and symptoms of complication of renal disease (decrease urine output, increased BUN/creatine, edema, dyspnea, elevated blood pressure and heart rate, decreased peripheral pulses, fatigue, weight gain, confusion, and distended jugular veins). Notify medical provider, resident/resident representation of abnormal findings. Obtain and monitor labs/diagnostic studies, as ordered. Report abnormal findings to medical provider. Obtain weight as ordered and report abnormal fluctuations to medical provider. Provide diuretics as ordered. A care plan focus initiated [DATE] revealed Resident #64's activity of daily living (ADL) listed Resident #64 as independent with toileting and toileting hygiene. A care plan focus dated [DATE] revealed Resident #64's was at risk for altered bowel elimination related to medication side effects. Interventions included to administer medication per medical provider's order, monitor bowel movements, monitor medication for side effects of constipation. Keep medical provider, resident/resident representative of any problems. A care plan focus initiated [DATE] revealed Resident #64's had cirrhosis of the liver. Listed interventions included administering medication as ordered, providing emergency care for excessive bleeding, observing for signs and symptoms of liver disease (malaise, fatigue, anorexia, weight loss, edema, bleeding, constipation, diarrhea, ascites, confusion, and jaundice). Notify the medical provider of abnormal findings. Obtain and monitor labs/diagnostic studies as ordered. Obtain weight as ordered. A care plan focus initiated [DATE] revealed Resident #64 utilized anti-platelet medication. Interventions included providing medication as ordered and obtaining labs per orders. A care plan focus initiated [DATE] revealed Resident #64 occasionally had urinary incontinence related to urgency but was continent of bowel. The resident tended to wait too long to summon assistance and was noted to rush to the bathroom. Resident #64 was noted to toilet herself independently but was alert and able to ask for assistance if needed. A care plan focus initiated [DATE] revealed Resident #64 had behaviors related to bipolar disorder (verbal/physical outburst and delusions). Interventions included ensuring the resident felt safe and was able to express feelings and encouragement from family. Review of Resident #64's quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The resident's height was 65 inches, and she weighed 343 pounds. The assessment revealed the resident had delusions, but no behaviors towards others or rejection of care. The resident was always continent of urine and bowel and only required supervision of touching assistance with toileting. The resident's active diagnoses included renal failure, diabetes mellitus, hyperlipidemia, epilepsy, anxiety disorder, depression, asthma, cirrhosis of liver, stage 3 chronic kidney disease, and sleep disorder. The resident had no condition or chronic disease that may result in life expectancy of less than six months. The assessment revealed the resident wanted to talk to someone regarding returning to the community. Review of the resident's medical record revealed beginning on [DATE] the facility failed to provide timely and appropriate goods and services to meet Resident #64's total care and medical needs resulting in resident neglect. The facility failed to ensure comprehensive and individualized systems were in place to prevent resident neglect and to ensure Resident #64 received timely and necessary care and treatment to prevent serious illness and death. The following concerns were identified: a. Review of Resident #64's hospital records revealed the resident was hospitalized from [DATE] to [DATE] with diagnoses including acute kidney injury, hyperkalemia, volume overload/edema, hypertension, and anemia. Resident #64 was discharged from the hospital with new orders to increase Lactulose to 45 ml four times daily and to continue Lasix 40 mg twice daily. Review of Resident #64's progress note authored by NP #803 and dated [DATE] revealed the residents' blood pressure was low, her speech was slurred, and she was slow to respond. The resident has a history of encephalopathy with elevated ammonia levels and acute kidney injury. The note stated to send Resident #64 to the emergency room for evaluation and STAT labs. Review of Resident #64's hospital record dated [DATE] to [DATE] revealed the resident was transferred to the emergency room for altered mental status. The resident was diagnosed with acute kidney injury. The resident's discharge instructions included to decrease Lasix to 20 mg daily and listed an order for a BMP laboratory test to be completed on [DATE]. Review of Resident #64's medical record revealed no evidence a medication reconciliation was reviewed with a provider following the resident's re-admission on [DATE]. Review of Resident #64's Medication Administration Record (MAR) and orders dated 05/2025 revealed the Lasix 40 mg twice daily was discontinued. However, the new order for Lasix 20 mg was not initiated upon the resident's return from the hospital on [DATE]. Review of Resident #64's medical record revealed no evidence a BMP was completed on [DATE] as ordered. Review of Resident #64's weights revealed no evidence the resident was weighed on re-admission on [DATE]. On [DATE], the resident weighed 315 pounds and on [DATE], the resident weighed 340 pounds (reflecting a 25-pound weight gain in a seven-day period). Review of Resident #64's progress note dated [DATE] authored by RN #103 revealed Resident #64 had orders for laboratory testing including thyroid-stimulating hormone (TSH), Vitamin B1, B6, and B12, plasma, folate, and Vitamin D2 and D3. Review of Resident #64's medical record revealed no evidence the laboratory testing order on [DATE] for TSH, Vitamin B1, B6, and B12, plasma, folate, and Vitamin D2 and D3 was done. Review of Resident #64's progress note dated [DATE] authored by LPN #163 revealed the resident was on her way to an appointment with the liver doctor and she got very lethargic and felt like she was about to black out. The residents' blood sugar was 57 (hypoglycemic) and she was transferred to the emergency room. The aide that accompanied the resident reported the hospital was discussing admitting the resident. Review of Resident #64's hospital records dated [DATE] to [DATE] revealed the resident was admitted for hypotension, hypoglycemia, and altered mental status and was found to have acute kidney injury, hyperkalemia, and acute anemia and was transferred to interventive care unit (ICU) due to hypotension. The resident was also managed for acute on chronic anemia, acute encephalopathy, cirrhosis, sub-occlusive deep vein thrombosis, and lactic acidosis. The resident was re-admitted to the facility on [DATE]. Interview on [DATE] at 3:14 P.M., with the Administrator, IDON #600, and Corporate Nurse #601 confirmed the hospital records dated [DATE] indicated to decrease Lasix to 20 mg daily, however the order was not implemented. IDON #600 and Corporate Nurse #601 confirmed there was no documented evidence that the re-admission orders were reconciled with the resident's physician. IDON #600 confirmed the resident was re-admitted to the hospital on [DATE] and noted the resident had a 25-pound weight gain. During the interview the Administrator, IDON #600, and Corporate Nurse #601 confirmed there was no evidence the TSH, Vitamin B1, B6, and B12, plasma, folate, and Vitamin D2 and D3 laboratory testing was completed on [DATE] as ordered. Interview on [DATE] at 9:06 A.M., with Corporate Nurse #802 confirmed Resident #64 did not have a BMP on [DATE] per the hospital orders on [DATE]. b. Review of Resident #64's re-admission weight dated [DATE] revealed the resident weighed 391.8 pounds. Review of Resident #64's re-admission orders dated [DATE] revealed the resident was ordered Lasix 80 mg daily until appropriately diuresed and in one week ([DATE]) follow up with (laboratory testing) iron panel, TIBC, ferritin, CBC, and BMP. Review of Resident #64's MAR and orders revealed no evidence the Lasix 80 mg was implemented per the hospital discharge orders dated [DATE]. Review of Resident #64 progress note dated [DATE] at 1:36 P.M. authored by LPN #107 revealed it was reported to the nurse manger Resident #64 had increased edema in her abdomen and pelvis. A call was placed to the facility NP who consulted with the physician. New orders were obtained for a STAT CBC and BMP laboratory test, and a one-time dose of Lasix 80 mg was ordered. Review of Resident #64 laboratory results dated [DATE] revealed Resident #64's CBC and BMP were collected on [DATE] at 12:26 P.M., received at 2:22 P.M., and resulted at 2:28 P.M. The residents' glucose, BUN, and creatine were high and red blood cells, hemoglobin and hematocrit were noted to be low. Review of Resident #64's NP #905 note dated [DATE] revealed the resident was seen for edema. The resident had requested Lasix. The nurse reported the facility had not received the laboratory testing that was completed on [DATE] due to it being sent to the hospital. The nurse would call the hospital to try to get renal function test to determine if routine Lasix was ordered. A one-time order of Lasix 40 mg and Potassium 20 meq was ordered until renal function could be evaluated. The note included to please call back with any changes in conditions. Further review of Resident #64's 05/2025 MAR revealed no documented evidence the one-time order for Lasix 40 mg or Potassium 20 meq was administered per the NP's order on [DATE]. Review of Resident #64's progress note dated [DATE] authored by LPN #178 revealed the nurse attempted to call the hospital, however an automated system indicated laboratory requests were only available Monday through Friday and if there was a holiday, you could not get results until the following day. Review of Resident #64's progress note dated [DATE] authored by LPN #163 revealed laboratory results were received. The resident potassium was 4.9, BUN was 38, and Creatinine was 2.4. There was no documented evidence that the provider was notified of laboratory results. Review of Resident #64's weight dated [DATE] revealed the resident weighed 407.2 pounds (reflecting a 15.4-pound weight gain from the [DATE] weight of 391.8 pounds). Review of Resident #64's progress note dated [DATE] authored by RN #902 revealed Resident #64 was requesting a water pill due to her feet swelling up. Upon checking orders, the resident was not on any Lasix. The resident insisted she wanted it back. The provider called and said she could only give a stat order as she was waiting for the resident's labs. Resident #64 stated the labs were already drawn. The note included the provider couldn't trace her recent labs and said they had to wait for the results to determine if the resident could continue to take the Lasix. STAT order for a one-time dose of Lasix 40 mg and Potassium 40 mEq were placed and administered. Resident #64 later complained of shortness of breath, but her oxygen saturation levels were withing normal limits. Review of Resident #64's progress note dated [DATE] authored by LPN #178 revealed during skin assessment the resident was noted to have plus three pitting edema (a moderate amount of swelling where an indentation remains on the skin after pressure is applied for a short period of time) in her bilateral lower extremities. The resident was swollen from her abdomen to her toes. Resident #64's abdomen was tight, bumpy and dimpled like an orange peel. The physician was previously notified, and new orders were received. Review of Resident #64's progress note dated [DATE] at 1:30 P.M. authored by RN #158 revealed the resident complained of not feeling well. On examination, the resident had a distended abdomen that was pitting to the touch, with clear fluid oozing from the left side. The resident had edema of both lower extremities that were pitting to the touch. The resident complained of pain with touch to both the abdomen and lower extremities. The note referred to a new order to transfer the resident to the hospital. Review of Resident #64's hospital record dated [DATE] to [DATE] revealed the resident was seen for swelling and weight gain. The resident was profoundly edematous and was symptomatic with shortness of breath from volume (fluid) overload. The records indicated Resident #64 likely required a trial of aggressive diuresis. The resident reported gaining over 100 pounds over the past few weeks. The resident had increased peripheral edema as well as shortness of breath associated with weight gain. Due to these symptoms, she was brought to the emergency department for evaluation. Laboratory studies in the emergency department revealed the resident had an acute kidney injury with her creatine (a waste product indicative of kidney health, with elevated levels indicating kidney issues) elevated at 3.73. The last known creatine was on [DATE] and it was 2.40. Resident #64's potassium was elevated at 5.6 (normal level 3.5 to 5.0 (when levels get too high it can cause problems such as muscle weakness, irregular heartbeat, and can become life-threatening). The notes indicated Resident #64 also had anemia, with a hemoglobin level of 7.9 (normal values between 10.5 to 12.5). A chest x-ray was completed with findings of vascular congestion. The resident was admitted to the intensive care unit (ICU) for further evaluation and management. Nephrology (kidney specialist) was consulted due to renal failure and hyperkalemia. Resident #64 was started on a Bumex (diuretic) continuous intravenous infusion. Review of Resident #64's hospital record dated [DATE] to [DATE] revealed Resident #64 was ordered 45 ml of Lactulose four times daily and Bumex 2 mg daily. Interview on [DATE] at 3:14 P.M., with the Administrator, IDON #600, and Corporate Nurse #601 confirmed there was no documented evidence the provider was notified of the STAT laboratory results that were collected and resulted on [DATE]. There was no documented evidence on the MAR the Lasix 40 milligram (mg) and Potassium 20 milliequivalent (meq) were administered on [DATE] per NP #905 progress note dated [DATE]. Corporate Nurse #601 confirmed the resident was hospitalized from [DATE] to [DATE]. Interview on [DATE] at 9:06 A.M., with Corporate Nurse #802 confirmed the resident's Lasix 80 mg was not implemented per the discharge orders dated [DATE]. c. Review of Resident #64 bowel history records dated 05/2025 revealed the resident was hospitalized on [DATE] and returned on [DATE] and had one large soft bowel movement (BM) on night shift. On [DATE] one large loose BM, on [DATE] no BM, [DATE] one medium loose BM, no BM on [DATE], on [DATE] one medium formed BM on day shift and one large loose BM on nights. On [DATE] and [DATE], one medium soft BM on nights, [DATE] and [DATE] large soft BM on nights, and [DATE] one medium formed BM on days. The resident was hospitalized from [DATE] to [DATE]. On [DATE], the resident had one medium formed BM on nights, [DATE] one large form BM on days, [DATE] one large loose BM on nights. The resident was hospitalized on [DATE] to [DATE]. Review of Resident #64's re-admission orders dated [DATE] revealed an order for Lactulose 10 grams (gm) per 15 ml, give 45 ml four times day. Review of NP #200's telehealth note dated [DATE], which was not part of the medical record, revealed NP #200 completed a telehealth visit on [DATE] for monthly rounds. Resident #64 reported she was previously on Lactulose and would like to restart back on Lactulose for history of cirrhosis. The resident denied nausea, vomiting, abdominal pain, constipation, and diarrhea. The resident was having regular bowel movements without bleeding. The plan was to restart the Lactulose and obtain laboratory testing to check ammonia, prealbumin, CBC, and BMP. There was an addendum added after the surveyor noted concerns with the Lactulose order on [DATE]. The addendum was dated [DATE] at 11:37 A.M., indicating that Lactulose had been previously increased due to lack of stools and a listed goal was for the resident to have two to three stools a day. Review of Resident #64's MAR dated 06/2025 revealed from [DATE] to [DATE], the resident received 45 ml of Lactose four times daily. From [DATE] to [DATE], the resident received 30 ml of Lactose four times a day except for the 10:00 P.M. doses on [DATE] and [DATE] which were not given as the nurse questioned the duplicate orders and noted she was awaiting clarification. Review of Resident #64's progress note dated [DATE] authored by RN #902 revealed the resident's blood glucose was 91. The resident reported her stomach felt full and she had not been able to eat well for two days. Review of Resident #64's bowel record dated 06/2025 revealed the resident did not have a bowel movement (BM) on [DATE], one large, formed BM on [DATE] and [DATE] and one medium BM on [DATE]. Interview on [DATE] at 10:00 A.M., with LPN #135 revealed she had reached out to NP #200 to send his telehealth visit note as it was not contained in Resident #64's medical record. Interview on [DATE] at 3:14 P.M., with the Administrator, IDON #600, and Corporate Nurse #601 reported the NP visits were all telehealth visits, and the NPs were available 24/7 to verify/clarify all orders. They indicated they were not sure why the Lactulose order was not clarified on [DATE]. Interview on [DATE] at 11:50 A.M., via telephone with Corporate Nurse #601 confirmed NP #200 had increased the dose (of Lactulose) on [DATE], however his progress note was not in the medical record. The resident's ammonia level on [DATE] was 45 (normal range 9-33) and the prior ammonia level dated [DATE] was 114 in the hospital. A telephone interview on [DATE] at 12:05 P.M., with NP #200 revealed he did a telehealth visit on [DATE] which was not in the medical record due to a glitch in the system. NP #200 reported he added an order for an additional 30 ml of Lactulose due to Resident #64 not having two to three bowel movements a day, which was the goal. Resident #64 had just been re-admitted on [DATE] after being hospitalized from [DATE] to [DATE]. NP #200 could not recall how many bowel movements the resident was having prior to increasing the dose. NP #200 reported he did not consult with the resident's physician or specialist because he felt 75 ml was safe dose for a short period of time. The NP confirmed he did not put a stop date on the new order because he stated he knew Resident #64 would be seen again in a week for a follow-up. Interview on [DATE] at 12:30 P.M., via email with the Administrator confirmed NP #200 had added a late addendum, dated [DATE], to his progress note from [DATE] to include the Lactulose was increased due to Resident #64's lack of stools and the goal was two to three stools daily. Interview on [DATE] at 7:03 A.M., with Certified Nursing Aide (CNA) #113 reported Resident #64 toileted herself and reported the resident had three BM's daily. The CNA reported she had provided care to the resident the last few weeks before she had expired and she had intermittent confusion. Interview on [DATE] at 9:25 A.M., with CNA #190 revealed Resident #64 usually toileted herself, however the last few weeks she started [TRUNCATED]

Based on review of pest invoices, review of concerns submitted to the state survey agency complaint intake unit, interviews, observation, and review of facility policy revealed the facility failed to ensure an effective pest control program was maintained. This had the potential to affect all 63 residents residing in the facility. Findings include:1 a. Review of concerns submitted to the state survey agency complaint intake unit dated 06/13/25 and 07/10/25 revealed a concern with cockroaches in the kitchen. Review of the pest control invoice dated 06/10/25 revealed the building was inspected for services including all interior areas for possible pest entry ways and activity. All glue boards were replaced as needed. Open area of concern was noted in the kitchen. The wall covering was loose/peeling. Wall tile was cracked and there were gaps between baseboards and wall. These areas need repaired or replaced to help prevent pest entry and harbor sites. The kitchen door seal was not rodent proof. The seal needed repaired. There were German Cockroaches noted to be found on the devices. Concerns were discussed with Licensed Practical Nurse (LPN) #108. Review of the pest invoice dated 06/23/25 revealed there were still open concerns with the wall covering and door seal in the kitchen. Findings were discussed with the previous Maintenance Director (MD) #204.Observation on 07/08/25 at 7:34 A.M. of the kitchen with Dietary Manger (DM) #300 revealed there was several sticky bug traps with numerous bugs observed in the boxes. There were additional closed red boxes that contained pests but could not be observed. Dietary Manager (DM) #300 reported the facility had a few oriental roaches which come up through the drains, but they were mostly German roaches that come from the wooded area behind the building. The DM #300 and staff reported they had not seen any live roaches, but there had been some found in the traps. The DM #300 confirmed the back door seal was missing from the bottom door and the light from outside was coming through the bottom of the door. The DM #300 confirmed the observed findings and reported the pest control company had voiced concerns that the pests were coming from the back door. There were several broken floor tiles noted in front of the door. The DM #300 confirmed the seal had been missing for some time. The DM #300 reported the facility did not have a Maintenance Director (MD) at this time. Observation on 07/08/25 at 10:52 A.M. of the kitchen with the Administrator and DM #300 confirmed the areas of concern listed on the pest control invoices on 06/10/25 and 06/23/25 had not been repaired. The Administrator and DM #300 confirmed the tiles in the dishwasher area were pulled away from the wall, the back door seal on the bottom was missing, and the tile on the floor and wall near the back door were broken and tile was pulling away from the wall. Interview on 07/09/25 at 11:45 A.M., with the previous Director of Nursing (DON) confirmed staff had voiced concerns regarding roaches in the last monthly meeting, however she had never seen any live roaches. b. Interview on 07/08/25 at 1:22 P.M., with an Ombudsman representative via phone revealed she had received a call from a medical provider that was visiting Resident #20 and had noticed gnats in Resident #20's room. The resident had voiced concerns, and the medical provider was concerned due to the resident had a colostomy bag and was not able to get out of bed on his own. Observation on 07/09/25 at 8:19 A.M., of Resident #20's room revealed there were 12 gnats observed in the resident room. The gnats were observed on the resident pillow, bedside table, and wall by bed. The resident reported that the gnats had been a problem for the last two weeks and he was happy to see the surveyor so hopefully the surveyor could do something about it. Observation and interview on 07/09/25 at 8:21 A.M., with Housekeeper Manager (HM) #413 confirmed there was 12 gnats in Resident #20's room. The HM #413 reported she would have staff clean the room immediately. Interview on 07/10/25 at 7:07 A.M., with Certified Nurse Aide (CNA) #186 confirmed there were issues with gnats and roaches. CNA #186 reported Resident #20's room was really bad with gnats and the roaches were mostly in the kitchen area. Interview on 07/10/25 at 7:16 A.M., with CNA #113 confirmed there was issues with gnats and roaches in the building currently. The roaches were worse in the kitchen area. Interview and observation on 07/10/25 at 7:28 AM with Resident #20 revealed there were still gnats in his room, but he reported it was better than yesterday. There was one gnat observed flying near the resident's face. Review of the facility's policy and procedure titled Pest Control dated 09/15/21 revealed the pest control company would establish a regimented time each month for spraying and to eliminate pests in the center. If a problem should develop, the Environmental Service Director will contact the pest control company for an additional visit. The pest control company would report any problems or changes to the Environmental Service Director. This deficiency represents non-compliance investigated under Complaint Number OH00166698 (1284492) and OH00166292 (1284491).

Based on observation, interview, review of funds list, and policy review, the facility failed to ensure residents had access to personal funds after business hours and on weekends. This affected four residents (#4, #22, #30 and #36) of four residents reviewed for personal funds managed by the facility. The facility census was 63.Findings include:Review of the facility funds list dated 07/08/25 revealed Residents #4, #22, #30, and #36 each had a personal funds account with the facility. Observation and interview on 07/08/25 at 7:26 A.M., with HR #153 confirmed she was responsible for dispensing resident funds. The surveyor requested to observe the money box for resident funds. HR #153 confirmed she did not leave a money box for staff after she left Tuesday at 5:00 P.M. The HR reported she leaves the money box on the weekends in the medical room, however, could not recall which staff member she had given to the box to the week prior. HR #153 reported most of the resident know they need to get money out before she leaves at the end of the day. Interview on 07/08/25 at 7:30 A.M., with Registered Nurse (RN) #158 reported he did not have access to personal funds, and it was the responsibility of HR #153. Interview on 07/08/25 at 7:50 A.M., with Licensed Practical Nurse (LPN) #163 confirmed there was no money left on weekends or after 5:00 P.M. on weekdays for staff to have available for residents. Interview on 07/08/25 at 8:00 A.M., with LPN #187 confirmed HR #153 was the only staff member that distributed personal funds money. LPN #187 reported the nursing staff did not have access to the money.Interview on 07/08/25 at 8:10 A.M., with Certified Nurse's Aide (CNA) #101 confirmed residents had voiced concerns regarding funds and they get frustrated because the staff doesn't have access to their funds. Interview on 07/08/25 at 10:15 A.M., with anonymous staff member #106 confirmed residents have voiced concerns that they don't have access to their money, and at times have waited days to get money due to the facility didn't have money in the personal funds box. The anonymous staff member reported in the past, a box was left in the medication room after hours to ensure residents had access to their funds after hours. Interview on 07/09/25 at 10:36 A.M., with Resident #22 confirmed the facility had ran out of money for days. The resident reported there was always an excuse why she could not get her money out. Resident #22 confirmed she cannot get her money out of her account after 5:00 P.M. during the week or on the weekends. Interview on 07/09/25 at 10:51 A.M., with Resident #4 confirmed she doesn't have access to her personal funds after 5:00 P.M. during the week and on the weekends. Resident #4 reported if you don't get your money out before 5:00 P.M. during the week, then you are just out of luck. Interview on 07/09/25 at 10:56 A.M., with Resident #30 confirmed he doesn't have access to his personal funds after 5:00 P.M. during the week or on weekends. Interview on 07/09/25 at 11:02 A.M., with Resident #36 confirmed he doesn't have access to his personal funds on the weekends or after 5:00 P.M. on weekdays. Interview on 07/10/25 at 7:07 A.M. with CNA #186 confirmed residents had voiced concerns regarding not having access to their funds. Interview on 07/10/25 at 7:16 A.M., with CNA #113 confirmed residents get flustered with her because they don't have access to their funds after management leaves. Review of the facility's policy and procedure titled Resident Trust Fund dated 06/01/16 revealed the facility would comply with all Federal and State laws and regulation regarding the handling of resident's funds and personal needs allowance accounts. This deficiency represents non-compliance investigated under Complaint Number OH00166292 (1284491).

Based on closed medical record review, facility policy and procedure review, and interview, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #63. The facility failed to ensure changes in the residents' medical condition were comprehensively assessed, the resident change in condition, including abnormal vital signs, was communicated to the medical health provider, and individualized interventions were implemented for Resident #63 when the resident was identified by therapy staff to have a decline in health including tachycardia, hypoxemia, and excessive daytime sleepiness and lethargy. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE] at approximately 12:30 P.M. when Resident #63 had hypoxemia, increased sleepiness, lethargy, and tachycardia while sitting at rest in therapy without adequate intervention. On [DATE] following an inability to complete therapy, Resident #63 returned to his room with no evidence the resident was comprehensively assessed by nursing staff (including Assistant Director of Nursing (ADON) #164 who had been notified by therapy staff) or the on-site nurse practitioner related to the identified decline and change in condition. On [DATE] at 8:10 P.M. Resident #63 was found absent of vital signs. Staff initiated cardiopulmonary resuscitation (CPR) and called first responders from the local fire and rescue; however, the resident was subsequently pronounced deceased by first responder staff. On [DATE] at 12:01 P.M. the Administrator, Regional Director of Clinical Operations Registered Nurse (RN) #171, and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 12:30 P.M. when the therapy staff identified Resident #63 exhibited a decline and a change in condition which included hypoxemia, increased sleepiness/somnolence, lethargy, tachycardia with an inability to continue therapy without evidence of timely or adequate interventions/medical treatment being provided. Resident #63 remained in his room with increased somnolence, sleepiness, lethargy, and loud snoring that was not comprehensively addressed and without necessary and individualized interventions provided to the resident. On [DATE] at approximately 8:10 P.M. Resident #63 was found absent of vital signs when Licensed Practical Nurse (LPN) #86 entered the room to administer medication. Cardiopulmonary Resuscitation was initiated, 911 was called with local fire and rescue responding, and the resident was pronounced deceased at 8:40 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following actions: • On [DATE], audits were completed by Licensed Practical Nurse (LPN) #75 and LPN #169 for all 62 current residents from [DATE] to current to ensure timely identification and adequate and necessary medical care and intervention was provided following an acute change in condition. • On [DATE] LPN #65 reviewed the nursing notes and care plans for all 62 residents from [DATE] to current for change of condition. • From [DATE] to [DATE] all residents with a Brief Interview for Mental Status (BIMS) score of 12 or higher were interviewed during daily ambassador rounds, to see if they had any concerns that needed to be addressed health or otherwise. This was completed by all department heads and would be an ongoing process. • From [DATE] to [DATE] all residents who were not able to be interviewed had a skin assessment completed by the DON/Designee. • On [DATE] the DON, Unit manager LPN #169 and MDS LPN #75 reviewed the last two weeks of residents who had been transferred to the hospital and/or who had expired in the facility to ensure adequate medical interventions were provided. • On [DATE] at 10:00 A.M., Regional Director of Clinical Services RN #171 re-educated the Director of Nursing on the policies Clinical Documentation Standards and Notification of Change in Condition to include ensuring timely identification of a resident acute change in condition and adequate and necessary medical care and intervention were provided following an acute change in condition. • On [DATE] from 10:00 A.M. to 4:00 P.M. the Director of Nursing re-educated all nurses either in person or via phone (including 10 RNs and 12 LPNs) on the Policies Clinical Documentation Standards and Notification of Change in Condition which included: Verbal communication with attending nurses. Ensuring timely identification and adequate and necessary medical care and intervention following an acute change in condition. If at any time staff felt a resident needed a higher level of care, call 911. • On [DATE] the Director of Rehabilitation (DOR) #173 educated 16 therapists either in person or via phone on the Notification of Change policy which included: Verbal or written communication to the nursing department. Communication with the nurse responsible for the resident. • Beginning on [DATE], upon hire any new nurse practitioner (NP) would receive education on the facility Clinical Documentation Standards and Notification of Change in Condition policies by the DON/Designee. • On [DATE] at 5:00 P.M., the Administrator presented the facility Quality Assessment and Performance Improvement (QAPI) Team with investigation and all findings for discussion and review. Discussion included an abatement plan from incident regarding Resident #63, to ensure timely identification and adequate and necessary medical care and intervention is provided following an acute change in condition. Staff in attendance included the Administrator, DON, Infection Control Preventionist LPN #169, Medical Records Director #107, SSD #168, MDS # 75, HR Director #74 and Regional Director of Clinical Operations #171 and (RDCO) #172. Via phone included the Medical Director, Regional Director of Operations #174 (RDO), Diversional Director of Clinical Operations #175 (DDCO), and [NAME] President (VP) of Risk #176. • Beginning on [DATE], the facility implemented a plan for the Administrator and/or designee/DON to conduct an audit on three to five residents/week for four weeks, and randomly thereafter to ensure timely identification and adequate and necessary medical care and intervention was provided following an acute change in condition. All findings of concern would be immediately addressed and reported to the QAPI committee for further review and prompt response and resolution. In addition, nurse's notes would be reviewed daily in the clinical A.M. meeting Monday through Friday ongoing. Any concerns noted would be directed to the medical providers. Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #63 revealed an admission date of [DATE] with diagnoses of cellulitis, morbid severe obesity (410 pounds (lbs.) on [DATE]), cor pulmonale (right sided heart failure), congestive heart failure, sleep apnea, hypertension, respiratory failure, acute and chronic renal failure, adult failure to thrive, psychoactive substance abuse, Stage 3 chronic kidney disease, chronic venous insufficiency, iron deficiency anemia, and lymphedema. Review of the facility physician's order dated [DATE] revealed Resident #63 was admitted to the facility for skilled level of care with therapy and/or nursing services (including antibiotic use for cellulitis to right posterior lower leg). Review of Resident #63's medical record revealed the resident was a full code (advance directive status) indicating the resident wished to receive all possible life-saving measures in the event of a cardiac or respiratory arrest. Review of Resident #63's physician's orders dated [DATE] revealed an order for physical and occupational therapy to evaluate and treat. Review of the physician orders dated [DATE] revealed the resident would receive occupational therapy services five times a week for 30 days with treatment including therapeutic exercises, therapeutic activities, neurologic reeducation, activity of daily living (ADL) training, and group therapy. Additionally, there was an order for the resident to receive physical therapy five times a week for 30 days for therapy exercise, therapy activities, neurological re-education, gait training and group therapy. A plan of care dated [DATE] revealed the resident had Bilevel Positive Air-way Pressure (BiPAP) Therapy for Obstructive Sleep Apnea. (A breathing device that delivers pressurized air through a mask, helping to open the airways an assist with breathing; often used to sleep apnea, chronic obstructive pulmonary disease (COPD) or other respiratory problems). The goal was for the resident to adhere to BiPAP regimen. Interventions included to educate resident/representative on the importance of BiPAP Therapy and encourage resident's use of BiPAP. There was not a general respiratory or oxygen plan of care for Resident #63. Review of the admission Minimum Data Set Assessment (MDS) assessment dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score that reflected he was cognitively intact and independent for daily decision making. The resident exhibited no behaviors, and the assessment included the resident rejected care one to three days in the look back period. Review of a Functional assessment dated [DATE] revealed Resident #63 had no upper or lower body functional impairment. The resident used a walker and wheelchair, was (staff) dependent for toileting, shower, upper and lower body partial moderate assistance with dressing, and personal hygiene. The resident was receiving physical and occupational therapy. The assessment revealed the resident required partial/moderate (staff) assistance to move from sitting position to lying position, required substantial/maximal (staff) assistance to move from lying position to sitting on the side of the bed, and required substantial/maximal (staff) assistance to transfer from a bed to a wheelchair. On [DATE] a physician order included oxygen at three liters per minute via nasal cannula as needed for shortness of breath or sign and symptoms of hypoxia/respiratory failure. Review of Nurse Practitioner (NP) #163's note dated [DATE] at 1:00 A.M. revealed the resident denied any chest pain or shortness of breath and had no other complaints. Review of Nurse Practitioner (NP) #163's note dated [DATE] revealed Resident #63 had been seen in the emergency department (ED) for a wound infection on [DATE] but had not been admitted . Upon assessment, the resident was sleeping in his bed with his legs dependent off of the bed. The resident was not wearing his BiPAP and noted to have loud snoring respirations. The NP note revealed she was able to wake the resident easily and upon asking why he wasn't wearing his BiPAP the resident reported he wore it when he could. Staff had frequently reported the resident refused the BiPAP. While in the ED venous blood gas testing showed a PCO2 of 87 which compared to one year prior was 84 and noted to be associated with hypoventilation due to obesity. The NP note revealed the resident had a diagnosis of sleep apnea and was supposed to be wearing a BiPAP, however he had been noted to be sleeping often without the BiPAP. The resident's vital signs included pulse of 76 beats per minute (BPM), blood pressure 130/64 mm/Hg, and oxygen saturation 98 percent on room air. The note included recommend using BiPAP all night and even throughout the day. Recommend follow up with pulmonology. Monitor respiratory status and vitals. Record review revealed there was no evidence of an appointment made with a pulmonologist as recommended by NP #163. Review of a nurse's note dated [DATE] at 3:00 A.M. and completed by LPN #77 revealed Resident #63 was pleasant. The resident took all evening medications as ordered without difficulty and had been medicated for generalized pain. The note included the resident refused to use BiPAP and had refused dressing changes to bilateral lower legs for this nurse, stating he was too tired. Review of the nurse's note dated [DATE] at 11:25 A.M. and completed by LPN #78 revealed the resident was alert and oriented to person, place and time. Receiving Occupational Therapy, receiving Physical Therapy and psychiatric consults. The note included the resident makes poor decisions; cues/supervision required. Review of Resident #63's occupational therapy note completed by Occupational Therapist (OT) #83 dated [DATE] and signed 12:58 P.M. revealed Resident #63's oxygen saturation at resting fluctuated between 75 and 89 percent (%) with an inability to recover with purse lip breathing (PLB). The resident came to the therapy room on three liters of oxygen. Increasing oxygen to four liters per minute via nasal cannula resulted in the resident's oxygen saturation fluctuating 82% to 95% PLB with inability to maintain greater than 90% consistently. The resident's resting heart rate was fluctuating between 86 and 116 beats per minute. The note revealed consult with nursing regarding this resident inappropriate for therapy at this time. Review of Resident #63's physical therapy note by Physical Therapy Assistant (PTA) #147 dated [DATE] at 1:24 P.M. included the resident was seen supine in bed with wound nurse removing intravenous therapy. The note included the nurse stated she had put the resident's oxygen on him while he was sleeping. The resident woke up and sat on the edge of bed (with) minimum assist times one. The resident remained on the edge of bed for 10 minutes to dress sitting unsupported. Resident edge of bed transfer to wheelchair with moderate assist times one, with cueing for sequencing and safety. Unable to reposition in wheelchair without momentum and required therapy behind wheelchair or it would tip. The resident wheeled halfway down to therapy and then requested be pushed the rest of the way. Resident's oxygen saturation checked upon arrival to therapy room and was 77%. Resident cued to breathe properly to increase oxygen saturations. Resident's oxygen was unable to stabilize at three liters increased to four liters, nursing aware. The resident was not appropriate for treatment on this date and returned to his room. Encouraged to keep oxygen on. The resident was also encouraged to sleep with a C-PAP (Note: this documentation identified the resident was using a C-Pap but Resident #63 was ordered and was using a BiPAP machine) machine on to increase patients' alertness during the day. The note included the resident still continues to spontaneously fall asleep no matter what he is doing. Review of Resident #63's medical record revealed no evidence a comprehensive nursing assessment or individualized interventions were initiated following this identified decline and change in condition per therapy notes on [DATE] at 12:58 P.M. and 1:24 P.M. respectively. Record review revealed documentation on Resident #63's treatment administration record that the resident refused to have vital signs taken by LPN #78 on [DATE] at 4:50 P.M. On [DATE] at 5:08 P.M. LPN #78 documented completion of a wound treatment to the resident's bilateral lower extremities. Review of the local Fire and Rescue Patient Care Record revealed a call came in to dispatch on [DATE] at 8:11 P.M. for a resident (#63) in cardiac arrest. Emergency responders were dispatched to the facility, arriving onsite at 8:15 P.M. and to the resident at 8:16 P.M. Upon arrival, the resident was found lying supine on the floor with cardiopulmonary resuscitation (CPR) in progress by facility staff. Staff reported to responders the resident had been lying in bed at 7:00 P.M., sleeping and snoring. Making rounds at 8:10 P.M., they found Resident #63 pulseless and apneic. The resident was in asystole (the complete absence of electrical and mechanical activity in the heart). Resuscitation efforts continued for over 20 minutes with the resident's skin becoming colder, and his color becoming more pale and cyanotic with lividity noted to his back. The resident's pupils were non-reactive. The resident was pronounced deceased on [DATE] at 8:40 P.M. Review of a nurse's note dated [DATE] at 9:10 P.M. revealed Resident #63 was found at 8:10 P.M. by Licensed Practical Nurse #86 (LPN) with no pulse or respirations. The note included the resident was last talked to at 7:15 P.M. by Certified Nurse Aide (CNA) #105. Staff quickly got help from a Curriculum Practicum Training (CPT) Intern (a nurse licensed in another country waiting to take the Ohio State Nursing Boards) RN #140 and CPT Intern RN #138 to call 911. LPN #86 grabbed the crash cart, and Automatic External Defibrillator (AED). The resident was lowered to the floor being especially careful not to hit his head. After which chest compressions started. An oxygen bag was obtained. The AED was put on scanned and no shock was advised. After about two to three minutes of chest compression, the resident started foaming out of the mouth and had blood come out of his nose. Staff went to get a suction kit. CNA's #116 and #162 were in the room assisting. Ambulance staff arrived at 8:16 P.M. and after a quick briefing of the situation they took over chest compressions, hooked the resident to a monitor, put in an oral air way and pushed epinephrine. At 8:40 P.M. emergency medical staff pronounced the resident deceased after contacting their physician. Review of Resident #63's Certificate of Death revealed the immediate cause of death was acute hypoxic respiratory failure and hypercapnic respiratory failure leading to the immediate cause. Interview on [DATE] at 3:03 P.M. with Occupational Therapist (OT) #83 revealed she called Assistant Director of Nursing (ADON) #164 into the therapy room on [DATE] when Resident #63 was in therapy. PTA #147 was also in the therapy room. OT #83 revealed she was unable to increase Resident #63's oxygen saturations. She had ADON #164 come into the therapy room to see him. The ADON was told they were unable to get the resident's vital signs to stabilize and could not continue therapy. The resident would fall asleep and wake up. They had to constantly get his attention. The resident would keep the oxygen on for therapy, per nasal cannula. Nurse Practitioner (NP) #163 was in the hall outside the therapy. The ADON went out to inform the nurse practitioner of the Resident #63's condition. However, the nurse practitioner did not come into the therapy room to assess the resident. OT #83 revealed therapy staff were shocked nothing happened. She believed she recalled the resident wheeling himself out of the therapy room when they could not continue therapy due to his oxygen saturations being low and pulse elevated. OT #83 revealed she signed her documentation of the therapy session at 12:58 P.M. She indicated that it would have been close to the time she would have seen him. Interview [DATE] at 3:44 P.M. with Nurse Practitioner (NP) #163 revealed on [DATE] she was talking to Licensed Practical Nurse #169 at her door which was across the hall from the therapy room. ADON #164 walked down the hall and in general passing told her Resident #63 keeps falling asleep in therapy. She asked if he had a follow up scheduled with an infectious disease doctor and was informed it was the following day. NP #163 stated she told ADON #164 to have the resident go to his appointment and do a telehealth visit if he changed and if it was needed that day. NP #163 indicated she saw the back of the resident's head while he was in therapy on [DATE]; but denied actually assessing the resident on this date. The NP revealed she felt like the resident had been falling asleep easily and refusing his BiPAP since admission and did not think this was any type of change for the resident over the past week. Interview on [DATE] 4:43 P.M. with PTA #147 revealed she went to Resident #63's room on [DATE]. The wound nurse was in there and told her she put oxygen on him when he was sleeping because of his loud snoring. PTA #147 revealed on [DATE] she was monitoring his vital signs; his pulse was erratic, and his oxygen saturation would go low and high. ADON #164 was walking past the room, and she asked ADON #164 to come in. The ADON stood and watched Resident #63 in therapy; his pulse and oxygen were erratic all over the place. OT #83 and PTA #147 then saw ADON #164 talk to NP #163 thinking the NP would then come in and assess the resident, but she did not. PTA #147 left the therapy room and upon her return, the resident was not in the therapy room. She stated she did not know how he got back to his room and denied taking him to his room. PTA #147 revealed this was the first date the resident had been unable to participate in therapy and was deemed not appropriate for therapy. PTA #147 revealed Director of Rehabilitation #173 told therapy staff she had reported in morning meeting the day after the resident passed away that he had not been appropriate for therapy the morning prior. Interview on [DATE] at 5:14 P.M. with Director of Rehabilitation (DOR) #173 revealed she was not working on [DATE]. However, on [DATE] her staff mentioned to her Resident #63 passed away. They informed her his oxygen saturations were all over (up and down), his heart rate was high, and he was inappropriate for therapy the previous day. DOR #173 revealed her staff told her they notified nursing. She mentioned in morning meeting the therapy staff said the resident's oxygen saturations were up and down the day prior. They increased his oxygen a liter, his pulse was high, and he was not appropriate for therapy. Interview on [DATE] at 5:36 P.M. with ADON #164 revealed on [DATE] one of the therapy staff called her into the therapy room and said Resident #63 did not look well. ADON #164 stated she saw the resident was in the therapy room, and verified he did not look well. She stated she went to get the NP (#163) and the NP said the resident had an infectious disease appointment the next day and to keep it and to do a telehealth visit if needed. The ADON verified she did not complete a head-to-toe comprehensive assessment on the resident. She thought the resident wheeled himself to his bedroom. The ADON denied recalling anyone else reporting anything new the rest of that day related to Resident #63. The ADON said she did not remember if she told the floor nurse on his hall that day ([DATE]) what happened in therapy. She said she probably should have documented therapy calling her in to see Resident #63 and what she saw that day in therapy, but she did not. A subsequent interview on [DATE] at 9:11 A.M. with ADON #164 occurred when the ADON called with additional information. She said (on [DATE]) Resident #63 was tired in the therapy. She stated she did speak to LPN #78, the nurse on his hall, and LPN #78 said this was the resident's normal. The ADON revealed she did not recall what exactly she reported to LPN #78 regarding the resident and therapy on this date. ADON #164 revealed Resident #63 was not doing well on [DATE]; he was not chatty like a normal day. An additional interview on [DATE] at 2:10 P.M. with ADON #164 included Resident #63 was falling asleep in therapy and did not look well. His head was falling down, and he was supporting it by holding it up with hand. ADON #164 included the resident was nodding off but easily arousable. When he was sleeping, he looked sick like he didn't feel well. She included she went to NP #163 to decide if they should transfer the resident to the emergency room. ADON #164 indicated she asked the NP if she (the NP) could look at the resident. However, the NP told her the was going to see the infectious disease physician the next day and to have staff do a telehealth visit if needed. Interview on [DATE] at 9:47 A.M, with LPN #86 revealed he was the night nurse who came in at 7:00 P.M. on [DATE]. He stated Resident #63's call light was on during report, and he thought CNA #105 answered the call light but said the resident did not want anything that he had just bumped it. LPN #86 revealed during shift change report he was not told of any episode in therapy related to Resident #63. He was told the resident was extremely tired throughout the day. LPN #86 revealed the first time he saw the resident was when he took in his medications at 8:10 P.M. at which time he found the resident's skin cool to touch, and he was not breathing. The resident's oxygen was up by his head and not in his nose. LPN #86 stated he ran out of the room and grabbed the crash cart and had a nurse call 911. A nurse supported the resident's head, they lowered him to the floor, and they began cardiopulmonary resuscitation. Interview on [DATE] at 9:27 A.M. with CNA #110 revealed on [DATE] she was assigned to Resident #63's hall. The resident had been very lethargic, and his lips were cyanotic, but he did go to therapy. CNA #110 revealed she had not assisted the resident back to bed after therapy and was unsure who had helped him get into bed. The CNA revealed she was not real familiar with Resident #63 but indicated the resident had not eaten any breakfast, or just a bite or two, indicating he was not hungry. However, she did have another staff enter he had eaten 26-50 percent of breakfast (she did not have access to enter the documentation). The CNA denied collect the resident's lunch tray, so she stated she did not write down a percentage eaten down, but revealed it was entered that he had eaten 76-100 percent (the accuracy of this could not be verified). The resident did not eat any dinner; however, the TASK kiosk included the resident consumed 51-75 percent of the dinner meal. CNA #110 revealed she told the aide coming in during shift report the resident had been lethargic, had not eaten. The resident's lips looked bluish, and he was taking gasps of air laying on the bed. The CNA stated it looked like he was going septic. She said she told the nurse (LPN #78) what she was seeing. She said the nurse reporting checking the resident's vital signs after lunch and they were fine. Interview on [DATE] at 10:07 A.M. with LPN #78 revealed on [DATE] the resident was asleep every time she went in his room, but she was able to wake him up. She stated she did not recall Resident #63 eating breakfast on this date. At lunch she tried to wake him up to eat lunch and he said OK. The LPN didn't recall if the resident ate supper on this date. The LPN revealed residents were not required to have vital signs taken every day and denied obtaining vital signs for the resident on this date. The LPN denied recall of ADON #164 saying anything to her or therapy saying anything to her about Resident #63's condition on [DATE]. LPN #78 revealed if she knew the resident's oxygen saturations were low and pulse fast, she would have obtained a set of vital signs every 20 minutes, turned on his oxygen and made sure he wore it. LPN #78 stated she thought Resident #63's face was flushed that day ([DATE]). The LPN then indicated Resident #63 refused his vitals to be taken at 4:50 P.M. as part of his daily orders. Interview on [DATE] at 10:39 A.M. with RN #149 revealed on [DATE] Resident #63 was difficult to arouse; however, the RN did not believe this was uncommon for the resident. The RN indicated she had discontinued the resident's intravenous antibiotic this morning and did not feel there was anything off about him at that time. Interview on [DATE] at 11:39 A.M. with the Director of Nursing revealed on [DATE] she documented Resident #63's supper meal percentage as 51-75 percent. She included someone would have had to tell her that percentage for her to write it. Interview on [DATE] at 11:53 A.M. with CNA# 162 revealed when she came in for night shift on [DATE] Resident #63 was asleep on walking rounds. She went out to her car and when she came in, they (staff) had started a code (for Resident #63). Interview on [DATE] at 10:28 A.M. with NP #163 revealed she was not provided any vital signs by ADON #164 to review from [DATE] for Resident #63. The NP stated if she knew the resident's oxygen saturation was 76 percent, pulse 118 and he was unable to complete therapy, she would have had the nurses keep the resident's BiPAP on him and would have transferred him to the emergency room if he continued with the elevated pulse and lower oxygen saturation. She stated she would have assessed him if she would have been aware of the change in condition. Interview on [DATE] at 5:04 P.M. with CNA #105 revealed on [DATE] Resident #63's call light was on at 6:53 P.M. when she arrived to work on this date. She stated she clocked in and put her stuff behind the nurse's station and then started answering lights (there were five resident call lights on). Resident #63's call light was the second light she answered. The resident way laying sideways in bed with his feet hanging down off the side of the bed and his head touching the mattress and propped up just a little bit. The CNA stated she asked the resident if he was alright or needed anything. The CNA stated the resident sort of sat up partially and his eyes were opened but he did not say anything. The CNA stated she took this as him not needing anything and left the room. Review of the facility undated Notification of Change in Condition policy revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs, concerns of the residents. Changes may include but are not limited to changes in overall health status, significant medical changes and therapy services changes. The policy included the facility must inform the resident, consult with the resident's medical practitioner and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there was a change requiring such notification. Circumstances requiring notification included but were not limited to significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status including but not limited to life-threatening conditions or clinical complications. Review of the facility's Oxygen-Medical Gas Use policy (dated 2014) included a licensed nurse, or respiratory personnel would provide respiratory assessments as indicated. This deficiency represents non-compliance investigated under Complaint Number OH00165450.

Based on closed medical record review, review of hospital records, review of an emergency medical service (EMS) report and EMS staff statements, review of facility Self Reported Incidents, review of a facility investigation, review of the facility dialysis policy and procedure, review of the facility Abuse/Neglect policy and procedure and interviews with staff, the coroner, and resident, the facility failed to prevent an incident of neglect when Resident #72 did not receive timely and necessary care to prevent major blood loss from his hemodialysis fistula site. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE], when Resident #72, who had intact cognition and required hemodialysis, was seen by dialysis staff, picking at his fistula site. The resident was educated not to pick at it and the resident stated he was a picker. Dialysis staff submitted a communication to the nursing home staff regarding the picking incident. The night shift nurse noted the resident asked for a band aid to cover the scabbed areas and the area was covered with a two by two (2x2) dressing with no further assessment or intervention at that time. On [DATE] at 11:25 A.M. Resident #72 was found by staff unresponsive, hemorrhaging a large amount of blood from his hemodialysis fistula in his left upper arm. The resident's call light had been activated (for an undetermined period of time) at the time he was found unresponsive. Resident #72 subsequently passed away on [DATE]. On [DATE] at 11:20 A.M., the Administrator, Director of Nursing (DON) and Divisional Director of Risk #223 were notified Immediate Jeopardy began on [DATE] when dialysis staff notified nursing home staff Resident #72 was picking at his dialysis fistula site. Nursing home staff failed to implement adequate and effective measures and interventions after identifying the resident was picking at his fistula site to prevent complications. On [DATE] at 11:25 A.M., Resident #72 was found by Certified Nursing Assistant (CNA) #267 with his call light on (for an undetermined amount of time), hemorrhaging a large amount of blood from his hemodialysis fistula. Resident #72 was subsequently pronounced deceased on [DATE] at 12:09 P.M. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified when the facility failed to prevent staff to resident potential abuse when a staff member was identified engaging in an inappropriate romantic relationship with Resident #71. This affected two residents (#71 and #72) of three reviewed for abuse and neglect. The facility census was 71. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 11:45 A.M., the DON began collecting statements from all staff who worked on Resident #72's unit in last 24 hours. All statements were collected by [DATE]. On [DATE] at 1:00 P.M., the Director of Human Resources #260 gave the DON all cardiopulmonary resuscitation (CPR) cards of the nurses completing CPR. On [DATE], Licensed Practical Nurse (LPN) Unit Manager (UM) #208 completed assessments on residents who had dialysis ports or fistulas. The assessments included checking for any signs of infection, any bleeding, dry and intact dressings, and bruit and thrill for Resident #71's arteriovenous (AV) fistula and Resident #64's right upper cervical (RUC) hemodialysis (HD) port. On [DATE], the DON initiated education to all 24 licensed nurses which was completed by [DATE]. The education pertained to the policy titled Hemodialysis Care and Monitoring with emphasis on the assessment of ports and shunts, pre and post assessments on dialysis residents, all dialysis orders, and on dialysis monitoring orders. The education also included communication between the facility and dialysis center every dialysis day and to initiate immediate dialysis interventions. New licensed nurses would be educated by the DON or designee during new hire orientation. On [DATE] the DON initiated education of the facility's Abuse, Neglect, and Misappropriation Policy. The education was completed by [DATE] for all 24 licensed nurses and all 29 CNA's. New nurses and CNAs would be educated during new hire orientation. On [DATE], the DON initiated an audit on all dialysis residents to validate dialysis orders to monitor residents' dialysis sites. Orders were corrected for Resident #71's left upper arm fistula and added to the treatment record. A physician order to check Resident #71's dialysis graft site for bruit and thrill every shift was initiated on [DATE]. On [DATE], the DON reviewed and revised care plans for dialysis residents to ensure accuracy and Resident #71's was updated to ensure accuracy related to the type of fistula he had. On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, Regional Director of Operations (RDO) #217, Regional Director of Clinical Operations (RDCO) #218, Diversional Director of Clinical Operations (DDCO) #219, [NAME] President (VP) of Risk #220, VP of Operations #221, and VP of Clinical Operations #222. On [DATE], a Root Cause Analysis was completed by the DON, Administrator, Assistant Director of Nursing (ADON) #213, Divisional Director of Risk #223, and LPN UM #208. Licensed nurses CPR licenses were verified. The analysis determined the problem to be cardiac arrest secondary to hypovolemic shock due to hemorrhage from AV fistula per hospital documentation. Care plans, orders, and code statuses were reviewed for accuracy, dialysis patients were assessed, and nurses received education on Hemodialysis Care and Monitoring and medication administration. On [DATE], the facility initiated audits for neglect through Angel Rounds (monitoring completed by department heads Monday through Friday on the residents) through observation and interviews of three staff and three residents, five days a week for four weeks. Beginning on [DATE], the DON/designee would audit three dialysis residents, three times a week for four weeks then randomly thereafter to ensure dialysis orders were in place to monitor the shunt site with the schedule, pre/post dialysis forms were completed, and care plans and orders reflected dialysis recommendations, and any monitoring needed. The DON/designee will validate that the facility received communication forms from the dialysis center three days a week for four weeks then randomly thereafter. On [DATE], education to all staff on answering call lights in a timely fashion was completed by the DON/designee. New staff would be educated during new hire orientation. On [DATE], the ED/designee would initiate call light audits on three call lights, three days a week and interview five residents a week on call light response times for four weeks then randomly thereafter. The results of audits will be forwarded to the facility QAPI committee for further review and recommendations until substantial compliance is maintained. The Medical Director will give input into any data presented and plans proposed by the Committee. Although the Immediate Jeopardy was removed on [DATE] the deficiency remained at a Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Included: 1. Review of the closed medical record for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart, end stage renal disease with hemodialysis, diabetes, hypothyroidism, dementia, major depressive disorder, hydronephrosis, benign prostatic hyperplasia, and mood disorder. The resident was discharged to the hospital on [DATE] where he expired. Review of the physician order dated [DATE] revealed Resident #72 had an order for staff to check his dialysis graft site for bruit and thrill every shift. Review of the hemodialysis care plan dated [DATE] revealed Resident #72 was receiving hemodialysis therapy related to renal failure and he had an AV fistula to the left upper extremity. Interventions included to administer medications per medical provider's order, observe for side effects and effectiveness, on dialysis days administer medications before, during, or after dialysis according to the medical providers orders, report abnormal findings to the medical provider, nephrologist, dialysis center, resident, and resident representative, communicate with the dialysis center regarding medication, vital signs, weights, restrictions, diet orders, nutrition or fluid needs, laboratory results, and who to notify with concerns, coordinate resident care in collaboration with dialysis center, evaluate the AV fistula for bleeding and if bleeding occurred, apply continuous direct pressure to the site for at least five minutes, if unable to stop the bleeding call 911, evaluate the resident following dialysis treatment, fluid restriction per orders, do not complete blood draws/blood pressure in the same arm as AV fistula, listen for bruit and thrill, do not remove dressing applied by dialysis center, and evaluate the AV fistula for bleeding. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had intact cognition and received dialysis. The assessment revealed the resident required (staff) set-up assistance or supervision for all activities of daily living (ADL) and mobility. Review of the [DATE] and February 2025 Medication Administration Records (MAR) and Treatment Administration Records (TAR) revealed no documented evidence of staff checking the dialysis graft site for bruit and thrill every shift for Resident #72 as ordered. Review of a Dialysis Hand Off Communication Report document dated [DATE] revealed Resident #72 had been picking at scabs on his fistula and the plan was to try to keep a band aide on the sites. The communication was signed by Dialysis Registered Nurse (RN) #225. Further review of the report revealed Facility Registered Nurse #261 signed the form indicating she checked Resident #72's bruit and thrill. She documented the resident's dialysis catheter dressing was dry and intact and the resident had no signs or symptoms of infection at that time. Review of a nurse's note dated [DATE] at 11:25 A.M. revealed the nursing assistant notified the nurse that Resident #72 was bleeding. Upon entering the room, Resident #72 was unresponsive with a large amount of blood noted. 911 was called immediately and a code blue (a universal emergency code indicative of a medical emergency, usually cardiac or respiratory arrest) for the staff was called. CPR was initiated at 11:26 A.M. with the arrival of other clinical staff. An intravenous (IV) access line was unable to be obtained. Resident #72's physician and family were notified. The ambulance arrived at 11:33 A.M. and the resident was transferred to the emergency room (ER). Review of an Emergency Medical Service (EMS) report dated [DATE] revealed at 11:23 A.M. EMS was called for an emergency at the facility. The primary impression was Resident #72 had a cardiac arrest and the secondary (impression) was hemorrhage. The report included barriers of care that the resident was left unattended or unsupervised and he had a sharp object penetrating injury or a cut laceration at the nursing home on [DATE]. EMS was dispatched to the facility for a hemorrhage from an unknown origin and the resident was lethargic. Upon arrival, and after applying standard precautions, the staff were found at the door, holding the doors open, and reported the resident's fistula was bleeding and he was bleeding out. A large stack of four-by-four gauze along with a pressure dressing was gathered from the truck and the crew reported to the resident's bedroom. The resident was found supine in bed with active CPR being performed. The staff did not report active CPR to EMS until the crew was at the bedroom door. A crew member was sent to the truck to obtain supplies for the updated situation. Additional resources were immediately requested with one staff member reporting they did not know what happened because Resident #72 was not their resident. When asked for the patient's information and history they stated, Why don't you go get your paperwork, and another staff member provided his first and last name however, no birth date was given. Another staff member stated, talk to her (indicating to the staff member preforming CPR) she would know more. This staff member reported, He was just fine a moment ago when I checked on him and then I came in and he was bleeding. Upon assessment, there was a large amount of blood loss and the (resident's) dialysis fistula, located in the anterior portion of the upper left arm, was no longer bleeding. The assumed site where the hemorrhage occurred was clotted and mostly hardened at the site. The site was closely monitored so as not to disrupt the clot. The site appeared to have been self-controlled for a considerable time as there was a large amount of dried blood to the area and no signs of active hemorrhaging. There were pools of cold blood under the resident as well as on the floor and next to the bed he was in. There was blood splatter on the headboard of the bed. There were many clots of varying size and in various stages of forming, including bright red arterial blood that was coagulating with pools of dark dried blood clots. Estimation was difficult, but total blood loss appeared to be around two to four liters. The resident had no easily visible veins including the jugular veins and his dialysis fistula was flattened. The resident's pupils were non-reactive, round and equal. He did not show signs of rigor mortis, dependent lividity, or an injury incompatible with life. The resident's skin displayed pallor and was dry to the touch. The resident had signs of cyanosis around the mouth and slight mottling of the skin in various areas. Resident #72 also did not have a Do Not Resuscitate (DNR) order, the decision to continue attempted resuscitation was made. The automated external defibrillator (AED) was attached by nursing home staff, when prompted for analysis it provided no shock advised, and CPR was resumed. While CPR was continuing, the resident's shirt was cut to allow for access to the chest. At the next pulse check the resident was moved to allow for the [NAME] University Cardiopulmonary Assist System (LUCAS) back plate (an automated chest compression machine) to be applied. Due to the size of the resident and the conditions of the bed, the LUCAS was not able to be attached to the back plate. The resident was moved to the cot and secured to the cot. CPR continued with the LUCAS device now applied. When the resident was moved to the cot, a large amount of additional blood and blood clots were found underneath the resident on the bed including a singular mass of coagulated/clotted blood that was several inches wide in diameter. The now revealed blood and blood clots had also varied stages of clotting and drying. This increased the suspicion of a prolonged down time due to the different dryness of blood and changes in color across the collective fluid, however the approximate downtime was not-clear due to history gathering and findings on scene. Once loaded into the ambulance, intraosseous (IO) (bone marrow) access was obtained via 25 millimeter (mm) IO needle which gave positive bone marrow return. Endotracheal intubation was successfully achieved with a 7.5 tube and stylet. Direct visualization was achieved and the endotracheal tube (ETT) was placed at 22 centimeters (cm) at the teeth line. ETT was secured with a [NAME] (a device used to secure an ETT tube). Upon arrival at the hospital the resident was transferred to the bed and care was transferred to the hospital staff with a full report given to the nurse and physician on duty. Due to the nature of the call and the circumstances that occurred, a police report was filed with the local police department and adult protective services were contacted after the call. Review of a hospital ER report dated [DATE] revealed Resident #72 presented to the ER in cardiac arrest and they noted a large amount of blood on the sheets. It noted that the resident came from the nursing facility after an unwitnessed cardiac arrest with concerns of a fistula rupture and an unknown downtime. The note also stated upon arrival, the resident had no active bleeding from the fistula and [the fistula] was flat with overlying scabs with no palpable pulsation or hum. Resident #72 arrived at the ER at 11:57 A.M. with a diagnosis of cardiac arrest and hypovolemic shock due to hemorrhage from AV fistula. The residents time of death was 12:09 P.M. Review of a handwritten Police Department Statement from Paramedic #216 dated [DATE] revealed upon arrival to the scene, Resident #72 was found lying in a pool of his own blood and the blood was beginning to clot. The resident was bleeding from his fistula. Paramedic #216 noted that once they arrived on scene staff had begun CPR. The statement revealed they were originally dispatched for a resident bleeding and lethargic. The staff stated the resident's downtime was unknown and they did not have any idea when the bleeding started. The fire department took over CPR efforts and moved the resident to the ambulance. The resident was transported to the hospital where the resident was pronounced deceased . Paramedic #216's statement included staff stated they were going to lose their jobs because of this, but the statement did not elaborate as to why the staff made the statement. Review of a handwritten Police Department Statement from Paramedic #215 dated [DATE] revealed when responding to an emergency call, Resident #72 was found supine in bed with an obvious injury to his dialysis fistula. The wound appeared to have been self-controlled for a significant amount of time. The wound had bleeding in various stages of clotting, there was dried blood found in significant amounts on the wound and arterial blood was found all around the resident in bed and on the headboard of the bed. There were large clots found under the resident and around various areas such as the floor and the bed sheets. Paramedic #215 noted there were no first aid supplies, such as dressings or a tourniquet found in the room, and the staff members could not provide an account of the events. No staff members could provide a name or birth date for the resident. Paramedic #215 further revealed that most of the blood found was either cool or cold and had begun to darken, and this was a cause for concern as it appeared the resident had been deceased for a substantial amount of time, and that the blood hemorrhaging had occurred as a substantial amount of time had passed prior to the nursing home calling and reporting. The resident appeared to have been bleeding to death and laid in a pool of his own blood unnoticed for an abnormally long time. Review of the facility investigation revealed the only documents present pertaining to an investigation into the incident related to Resident #72 from [DATE] included 31 different staff members' statements about the last time they saw Resident #72 and if he was picking at his fistula site. The statements revealed the last staff to see Resident #72 alive was RN #204 on [DATE] at 9:00 A.M. The statements revealed no facility staff observed the resident picking at his fistula site, besides Dialysis RN #225. The facility also conducted a timeline of the code blue for Resident #72 stating who was present and the sequence of events after the resident was found unresponsive. On [DATE] at 11:53 A.M. an interview with Dialysis RN #225 revealed on [DATE] Resident #72 had numerous small scabs on his fistula and he was picking at them. She stated there was no active bleeding when she saw him and she told him to stop, but he stated he was sorry and that he was a picker. She stated he did not have a dressing or band aid on prior to dialysis. She stated there were no concerns with his fistula and it was assessed and accessed fine for her that day. She stated she placed a pressure dressing over his fistula prior to him leaving the dialysis center. On [DATE] at 12:15 P.M. an interview with Visitor #226 revealed she had been visiting her family member on [DATE] and stated the call light for Resident #72 had been on for a long period of time that morning when she was in the facility. On [DATE] at 1:00 P.M. an interview with the Director of Nursing confirmed Resident #72 had an order for his dialysis fistula bruit and thrill to be checked every shift. However, there was no documentation this was completed. On [DATE] at 2:31 P.M. an interview with the DON confirmed an aide did leave at 8:00 A.M. on [DATE], leaving three aides and one restorative aide for four halls. No additional information was provided related to the activation of Resident #72's call light or the length of time it had been on before the resident had been found unresponsive. On [DATE] at 2:32 P.M. an interview with the Administrator revealed she did not know what they facility could have done differently regarding the circumstances of in the incident with Resident #72 on [DATE]. On [DATE] at 9:20 A.M. an interview with CNA #241 revealed she was in the dining room when the code blue was called for Resident #72. She revealed the staff had been working short on the units on [DATE] because they had an aide go home sick. On [DATE] at 9:46 A.M. an interview with CNA #286 revealed she had been working the day Resident #72 coded (indicating when the code blue was called), but stated she was not working his hall. She stated they had an aide go home sick, so they had three aides for four units. She stated CNA #241 did not help on the floor or help answer call lights, she only completed her restorative programs. She stated she did not know how long Resident #72 had his call light on, but confirmed the resident's call light was on when she went into the room to help with the code. On [DATE] at 9:55 A.M. an interview with CNA #244 revealed she was not working on Resident #72's unit on [DATE], however when they called the code she ran into the resident's room. She stated she did not notice the call light on when she went into the room, but it was on when she came out of the room. She stated she saw Resident #72 at breakfast when she took his tray to him at around 7:30 A.M., but you could not see his fistula because it was higher up on his arm and his gown covered it but she stated she did not see any blood on his gown at that time. She stated she also heard him talking to Director of Public Relations #249 when she (Director of Public Relations #249) picked up his breakfast tray (at approximately 8:10 A.M.), but she (CNA #244) did not see him at that time. On [DATE] at 12:16 P.M. an interview with CNA #267 revealed he was the only aide working on Resident #72's unit. He stated he was in the shower room giving a shower to a different resident. After the shower, he took that resident back to her room to get her dressed and then took her down to the dining room. When he came back to the unit, the lunch cart was sitting in the hallway outside Resident #72's room. He stated he got Resident #72's tray off the meal cart, went to take it in the room, saw all of the blood, immediately put the tray down, and went to get help. He stated Resident #72's call light was on when he went into the room. He stated he had not been in Resident #72's room for a little while and he indicated no other staff were on the unit when he was in the shower room. On [DATE] at 7:25 A.M. an interview with RN #261 revealed on [DATE] Resident #72 had a couple scabbed areas to his fistula site and she applied a dressing to it. However, the RN revealed she did not document this or write any new orders because the dialysis sheet (from the treatment on this date) already indicated they placed a band aide on it earlier. She stated she did not see any concerns with his fistula site at that time and she did not personally see the resident picking at his fistula site, but stated he had been picking at his forehead. There was no evidence any new interventions were implemented at that time to prevent the resident from picking or to prevent complications with the resident's dialysis fistula site. On [DATE] at 12:10 P.M. an interview with Coroner #214 revealed she knew about Resident #72. She stated she did not handle the resident's body and she did not know what the resident's official cause of death was on the death certificate, but she remembered the nurses in the ER calling her to tell her about Resident #72. The nurses told her the resident had been bleeding profusely from his left upper arm fistula as it had ruptured. She stated the nurses explained the resident had passed away from cardiac arrest, but Coroner #214 stated that would have been considered cardiac arrest secondary to hypovolemic shock secondary to a ruptured fistula based on the circumstances. She further revealed the nurses told her there was so much blood that they had to clean the resident up completely before they allowed the family in to see him. Review of the undated facility policy titled, Ohio Abuse, Neglect and Misappropriation, revealed neglect occurred when the facility was aware of, or should have been aware of, goods or services a resident required but the facility failed to provide them to the resident resulting in, or which may result in, physical harm, pain, mental anguish, or emotional distress. Review of the undated facility policy titled, Hemodialysis Care and Monitoring, revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents and that safety was the primary concern for the residents, staff and visitors. It noted that resident may require hemodialysis in the event of critically low kidney function, usually ,d+[DATE] percent to less, that allowed the buildup of lethal toxins in the blood. Hemodialysis may be required due to renal damage attributable to long term uncontrolled diabetes and/or hypertension or for acute episodes due to physical or chemical injury to the kidney. Residents would be individually evaluated by a nephrologist or physician for hemodialysis and would have a vascular access device placed specific to their needs. It was important that the nurse understand the type of venous access device each resident had, signs and symptoms to monitor, was pruritus or itchy skin present and if lotion could relieve, aneurysm which may rupture, bleeding, lack of bruit and thrill palpated at the site. General care was to monitored for infection, thrill and bruit. 2. Review of the medical record for Resident #71 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, diabetes, neuropathy, hepatitis C, hypertension, anxiety disorder, major depressive disorder, complete traumatic amputation between the elbow and wrist of the left arm and phantom limb syndrome. Resident #71 was his own responsible party. Review of the plan of care dated [DATE] revealed no documentation of inappropriate sexual behaviors being exhibited by the resident. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #71 had intact cognition and had no behaviors. Review of the signed handwritten statement from Certified Nursing Assistant (CNA) #287 dated [DATE] revealed she had called the Director of Human Resources #260 on [DATE] to let her know about an incident that occurred on Tuesday ([DATE]) morning in the parking lot, directly after working. Resident #71 walked to her (CNA #287's) car with CNA #227. CNA #227 got into the car and Resident #71 leaned down and thanked her (CNA #287) for giving CNA #227 a ride home, they both giggled then Resident #71 leaned in and kissed CNA #227. CNA #287 stated she turned her head away because she did not want to see it. Resident #71 then walked away. Review of the signed, typed statement for Director of Human Resources #260 revealed she had received a call from CNA #241 stating she spoke to a coworker and the coworker reported to her that CNA #227 and Resident #71 kissed in the parking lot after CNA #227's shift on the morning of [DATE]. CNA #241 stated to her that she received a call from CNA #287 stating she was taking CNA #227 home the morning after her scheduled shift on [DATE]. She stated Resident #71 walked to her [CNA #287's] car with a crutch and kissed CNA #227 in the car in the parking lot. Review of the facility Self Reported Incident (SRI) investigation dated [DATE] revealed a State surveyor called the facility Administrator and asked if she was aware of an allegation of sexual activity between a resident and staff. The investigation noted that the facility had been working on an investigation regarding a staff member and resident and possible romantic involvement that did not include allegations of sexual activity. Both the resident and staff member had previously denied the allegations of romantic involvement. The investigation further revealed CNA #227 was previously suspended upon arrival to work [DATE], pending the investigation of a suspected kiss with Resident #71. CNA #287 reported to the Director of Human Resources #260 on [DATE] that in the evening, she had driven CNA #227 home and Resident #71 walked them to the car and kissed CNA #227. CNA #227 denied that the resident kissed her. CNA #287's interview and statement indicated that CNA #227 was in the car, Resident #71 leaned in the window, and CNA #287 assumed the resident was going to kiss CNA #227, and CNA #287 looked away. Resident #71 was interviewed and stated he did not kiss CNA #227 but only walked her to the car. CNA #227 was interviewed via phone on [DATE] and she denied any sexual interactions with Resident #71. Resident #71 was interviewed on [DATE] and he denied any sexual interactions with CNA #227. The investigation noted Resident #71's psychosocial care plan was updated with new interventions and he would continue to see the facility psychiatric nurse practitioner and the facility counselor. Review of the facility investigation revealed the following text message exchange between CNA #227 and CNA #287 on [DATE]: CNA #287 stated, Did you find a ride home? CNA #227 replied, Nope CNA #227 then stated, Mister man says he loves you But not the way he loves me CNA #287 replied, Lol I hope not CNA #227 stated, Girl . maybe I should just find a different job CNA #287 replied, Oh [expletive] what happened now? CNA #227 stated, I miss my boyfriend CNA #287 replied, Lol just be careful. CNA #227 stated, I'm just meaning this drama [expletive] won't be for me lol CNA #287 replied, Ya I know all this crap is [expletive] and [Resident #28] is the root. The text messages jump to another unknown date revealing following text message exchange between CNA #227 and CNA #287: CNA #227 stated, Hey. CNA #287 replied, What's up. CNA #227 stated, I got suspended. (she was suspended on [DATE]) CNA #287 replied, For? CNA #227 stated, You work tonight? CNA #287 replied, Yes What for? CNA #227 stated, They think we was making out in the parking lot Tues morning. I told her he [Resident #71] walked me out to the car, and thanked you for having my back and getting me home CNA #287 replied, Oh someone saw you guys kiss? . girl that's why I told you to stay away from him . CNA #227 stated, [NAME] all I know is it's not true Is it? CNA #287 replied, What? Yes you did . girl don't bring me into this . and now bc I was in that car I'll probably get in trouble too bc I didn't report it. [Expletive]. CNA #227 stated, I'm not wantin [TRUNCATED]

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, emergency room record review, review of a facility Self-Reported Incident (SRI), review of the facility investigation, review of the news broadcast at https://wtov9.com/news, employee code of conduct review, staff interviews, resident interview and review of facility policy, the facility failed to prevent staff to resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm on 08/08/24 at approximately 11:10 A.M. when Hospitality Aide (HA) #286 witnessed an incident of potential sexual abuse between Maintenance Director (MD) #300 and Resident #1, a resident with a court appointed legal guardian due to mental incapacity with a known history of hypersexual tendencies. On 08/08/24 HA #286 observed Resident #1 sitting in her room on the floor, with the door closed and Maintenance Director (MD) #300 standing in front of the resident. Upon entry to the room, HA #286 observed MD #300 pulling down his shirt and his pants appeared to have been unbuttoned. The incident was reported to nursing staff and the Administrator and MD #300 was suspended pending an investigation of alleged sexual abuse. The local police department was notified of the alleged incident. On 08/08/24 at 3:45 P.M. Police Chief (PC) #306 contacted the facility Administrator and reported MD #300 confessed to receiving oral sex from Resident #1 on 08/08/24 when discovered in the resident's room. The PC also reported MD #300 confessed to having sexual interactions with Resident #1 for the last nine to 12 months (while he was employed at the facility). MD #300 was arrested and charged with sexual assault of Resident #1. This affected one resident (#1) of two residents reviewed for abuse. The facility census was 75. On 08/15/24 at 4:30 P.M. the Administrator and Regional Director of Clinical Operations (RDCO) #304 were notified Immediate Jeopardy began on 08/08/24 when Resident #1 was observed on the floor in her room with MD #300 standing in front of her. MD #300 was adjusting his shirt, and his pants appeared to be unbuttoned when discovered by HA #286. MD #300 was suspended pending an investigation and later confessed to receiving oral sex from Resident #1 and being in a sexual relationship with Resident #1 for the past nine to 12 months (while employed at the facility). The MD was arrested by police and charged with the sexual assault of Resident #1. Based on Resident #1's diagnoses and mental incapacity, there was no evidence Resident #1 was able to consent to this relationship. The deficient practice was corrected on 08/10/24 when the facility implemented the following corrective actions: On 08/08/24 between 11:10 A.M. and 11:20 A.M., Hospitality Aide (HA) #286 entered Resident #1's room (the door was closed) and observed Resident #1 sitting on the floor and Maintenance Director (MD) #300 standing in front of her, adjusting his clothing. HA #286 ensured the resident's safety by instructing MD #300 to immediately leave the room and reported the incident to Licensed Practical Nurse (LPN) #238. On 08/08/24 at 11:30 A.M. LPN #238 reported the incident to the Administrator. On 08/08/24 at 11:33 A.M. LPN #238 completed a head to toe and pain assessment on Resident #1. On 08/08/24 at 11:34 A.M. the Administrator interviewed MD #300, who initially denied anything sexual was occurring and stated he was helping Resident #1 up off the floor. MD #300 was suspended pending the results of the investigation for suspicion of sexual abuse and escorted out of the facility by Human Resource Manager (HRC) #256. MD #300's timecard reflected an 11:45 A.M. time punch to end his shift MD #300's employment was subsequently terminated on 08/08/24. On 08/08/24 at 11:40 A.M. the Administrator notified Regional Director of Operations (RDO) #308 of the suspicion of sexual abuse by MD #300. On 08/08/24 at 11:45 A.M. the Administrator interviewed HA #286 regarding her observations. HA #286 remained with Human Resource Manager (HRM) #256 to provide a statement and then went home at 12:30 P.M. per her request. On 08/08/24 at 12:06 P.M. the Director of Nursing was notified of the incident by the Administrator. On 08/08/24 at 12:25 P.M. the Administrator notified the local police department of the incident HA #286 had reported involving MD #300. On 08/08/24 at 12:30 P.M. the Administrator asked Social Service Designee (SSD) #225 to speak with Resident #1 to determine if the resident would share any information. The resident was unable to provide meaningful information at that time, indicating MD #300 had been fixing her television. On 08/08/24 at 12:40 P.M. Police Chief #306 arrived at the facility and interviewed Resident #1. The Police Chief asked Resident #1 if she would like to go to the hospital and get checked out. Resident #1 declined at first but then stated it may be nice to get out for a little bit. The Police Chief explained to Resident #1 the hospital may complete a rape kit. Resident #1 stated she was familiar with rape kits. The resident returned to the facility on [DATE] at 5:57 P.M. No rape kit had been completed due to the resident's refusal at that time. On 08/08/24 at 1:30 P.M. Resident #1 was transported to the emergency room (ER). On 08/08/24 at 3:45 P.M. Police Chief #306 called the Administrator and reported during the interview with MD #300, MD #300 admitted to receiving oral sex from Resident #1. MD #300 was being arrested and taken to jail. On 08/08/24 at 5:12 P.M. the Administrator initiated a self-reported incident to report the incident of sexual abuse to the State agency. On 08/08/24 at 8:30 P.M. the DON/Designee interviewed 26 female residents (Resident #1, #2, #4, #5, #7, #8, #17, #21, #25, #26, #27, #33, #35, #38, #45, #46, #54, #58, #59, #62, #65, #68, #70, #71, #74 and #75) with a Brief Interview of Mental Status (BIMS) score of nine or higher (results range from 0-15) regarding MD #300. Skin sweeps were completed for 12 female residents (#3, #6, #20, #24, #32, #36, #37, #39, #40, #53, #69 and #74). unable to be interviewed Three residents (#16, #31 and #34) received both a skin sweep and interview due to their questionable BIMS score. On 08/09/24 at 9:00 A.M. the DON/Designee interviewed 28 male residents (#10, #11, #12, #14, #15, #16, #18, #19, #28, #29, #30, #41, #42, #43, #44, #47, #48, #49, #50, #55, #56, #57, #61, #64, #66, #67, #72 and #73) and skin sweeps were completed for eight non-interviewable residents (#9, #13, #22, #23, #51, #52, #60 and #63) to identify any additional sexual abuse concerns. On 08/09/24 by 1:00 P.M. the DON/Designee interviewed all 52 interviewable residents regarding abuse. Questioned asked included: Has staff, a resident or anyone else here abused you-this includes verbal, physical or sexual abuse? On 08/09/24 by 1:00 P.M. the DON/Designee interviewed 97 staff (five housekeeping staff, 35 STNAs, eight dietary staff, seven registered nurses (RN), 16 licensed practical nurses (LPN), 15 therapy staff, seven administration staff, two activity staff, one maintenance staff, and one hospitality aide) regarding MD #300 and inappropriate activity with residents. Employees were interviewed either by phone or in person. STNA #200, #219, #220, and #250 were interviewed in-person or by phone by 08/13/24 due to approved leave, leave of absence (LOA) or beginning employment. STNA #230 remained on LOA and will be interviewed on her first shift upon her return. Questions asked included: Have you witnessed or heard any inappropriateness between MD #300 and a resident? If yes, what did you hear and when? HA #286 stated she had observed Resident #1 naked in her bathroom with MD #300 present a few months prior, but this was not reported. On 08/09/24 at 3:13 P.M. Resident #1 was evaluated by Psychiatric Nurse Practitioner #307. On 08/09/24 by 2:00 P.M. the Administrator/Designee completed education with 97 staff (five housekeeping staff, 35 STNAs, eight dietary staff, seven registered nurses (RN), 16 licensed practical nurses (LPN), 15 therapy staff, seven administration staff, two activity staff, one maintenance staff, and one hospitality aide). Employees were educated either by phone or in person regarding facility's abuse policy as well as identifying residents at risk for boundary violations and recognizing warning signs of inappropriate behavior. In addition, employees were also educated via text through On-Shift. STNA #200, #219, #220, and #250 were educated in-person or by phone by 08/13/24 due to approved leave, leave of absence or beginning employment. STNA #230 remains on LOA and will be educated on her first shift upon her return. Education was related to the facility abuse policy, identification of potential/actual abuse situations and abuse reporting. On 08/09/24 at 11:30 A.M. an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held. Members of the meeting included the Administrator, DON, Regional Director of Operations (RDO) #308, RDCO #304, Divisional [NAME] President of Risk #309, Medical Director #301, and Divisional President #310. As a result of the meeting, the facility-initiated interventions to have no male caregivers for Resident #1, no male staff in the resident's room without a witness and to encourage Resident #1 to leave the door open. Beginning on 08/10/24, the DON/Designee began interviewing all interviewable residents, then implemented a plan to interview five residents weekly for four weeks regarding any abuse concerns. After four weeks, random interviews would be conducted. Beginning on 08/10/24 the Administrator/Designee began interviewing five staff members which would be done weekly for four weeks regarding any abuse concerns. Beginning on 08/10/24 Social Services and in-house counseling services would continue offering support to Resident #1 as needed. Additional residents would be identified as needed in morning clinical meeting by reviewing resident nurse's notes, discussion of grand rounds prior to morning meeting, recap from resident meetings from the therapeutic behavior specialist and psych services. On 08/10/24 the facility implemented a plan for all self-reported incidents to be reviewed by the DON/Designee within 24 hours to ensure no other residents were affected. The DON/Designee would address issues with reported incidents immediately upon identification. The facility implemented a plan for any additional staff training/re-education to be completed by the DON/Designee as needed on the facility Abuse and Neglect policy. The facility also implemented a plan for the DON/Designee to educate all new staff on the abuse policy. This would be ongoing as part of new hire orientation. Beginning in September 2024, the Administrator or DON would monitor compliance in the facility monthly QAPI meetings for three months. Then as needed for one year. The facility identified Regional Director of Clinical Operations would monitor compliance during monthly visits times beginning 08/09/2024 for three months then on an as needed basis. Findings include: Review of the Final Decree of Adjudication of Incapacity and Appointment of Plenary Guardian of the Person and Estate document dated January 15, 2003, revealed Resident #1 was adjudged and decreed an incapacitated person and her parents were appointed as guardians. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses including schizophrenia, adjustment disorder, anxiety, unspecified psychosis not due to a substance or known physiologic condition, depression, unspecified lack of coordination, difficulty walking and sleep disorder. Record review revealed the facility developed a care plan (initiated 03/09/22 and revised 04/22/24) for Resident #1 related to behaviors. The care plan noted the resident had diagnoses of schizophrenia, adjustment disorder, anxiety, and psychosis as evidenced by verbal outbursts, physical outbursts, hallucinations, restlessness, irritability, disturbance in sleep patterns, inappropriate/false statements, sexual behaviors/ comments (i.e. father), taking others belongings, yells loudly throughout the building, prefers to sleep on the floor at times stating its cooler. Interventions included administer medications as ordered; Observe and document signs and symptoms of effectiveness and side effects; Educate resident/resident representative to medication effectiveness and side effects; Assist with cosmetic routine; Behavioral health consults as needed; Communicate with resident/resident representative regarding behaviors and treatment; Consult with pastoral care, Psych services and/or support groups; Encourage active support by family/resident representative; Encourage resident to express feelings; Encourage resident to participate in activities of choice; Encourage to maintain as much independence and control/decision making as possible; Intervene as necessary to protect the rights and safety of others; Minimize potential for disruptive behaviors by offering tasks that divert attention; Monitor behavioral episodes and attempt to determine underlying causes; Music of resident's choice; Offer activity of choice, offer chocolate or pop (caffeine free when possible); Notify medical provider of increase in behaviors; observe and anticipate resident's needs: thirst, food, body positioning, pain and toileting needs; Offer TV or PlayStation; Praise any indication of progress in behaviors; Send for psych evaluation if unable to redirect. A plan of care, initiated on 03/09/22 revealed Resident #1 experienced hallucinations at times related to schizophrenia as she would not answer questions appropriately at these times and might appear to have cognitive decline related to this. Interventions included administer medications as ordered, assess whether the behaviors endanger her and/or others and intervene as necessary and obtain psych consult/psychosocial therapy as needed. A plan of care, initiated on 03/09/22 revealed Resident #1 had impaired temporal orientation and recall, hallucination, disorganized thinking and poor decision-making skills related to schizophrenia. Interventions included administer medication as ordered; Discuss concerns about confusion, disease process, nursing home placement with resident/family /care giver; Keep routine as consistent as possible in order to decrease confusion; Observe/document /report to medical provider any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status; Offer two to three step instructions when competing basic tasks. Review of the resident's current physician orders revealed medications included Geodon 80 milligrams (mg) one tablet two times daily for schizophrenia, Sertraline 200 mg in the morning for depression, Wellbutrin SR 150 mg daily for depression, Amitriptyline 50 mg at bedtime for insomnia, Divalproex 500 mg in the A.M. and 1000 mg at night for schizophrenia, and Junel 1/20 daily for birth control (which had been ordered since August 2021). Review of the annual Minimum Data Set (MDS) 3.0 Assessment, dated 07/05/24, revealed a Brief Interview of Mental Status (BIMS) score of 13 (a level of 13-15 indicates intact cognition). Further review revealed the resident had delusions and indicated the resident had verbal behaviors directed toward others which occurred one to three days in the seven-day assessment period. Review of Resident #1's nurse's note, authored by the DON, dated 08/08/24 at 12:31 P.M. revealed staff reported an alleged allegation regarding Resident #1. The staff immediately had Resident #1 separated from harm and made to feel safe. The note included a head-to-toe assessment was completed with no abnormalities noted. Review of Resident #1's nurse's note, authored by the DON, dated 08/08/24 at 1:30 P.M. revealed the facility nurse practitioner (NP), NP #312 was notified, and an order was given to send Resident #1 to the emergency room . Resident #1's father was notified. Review of Resident #1's nurse's note, authored by the DON, dated 08/08/24 at 1:45 P.M. revealed Resident #1 was transported to the emergency room per (name of transport company). Review of a facility self-reported incident (SRI), tracking number 250577 revealed an initial report, dated 08/08/24 at 4:21 P.M. related to an incident of sexual abuse involving Resident #1 (victim). The SRI listed the perpetrator as MD #300. HA #286 was identified to be a witness of the incident. HA #286 reported she walked into Resident #1's room and the resident was sitting on the floor and MD #300 was standing in front of her, adjusting his clothing; pulling his shirt down and it appeared to her that, under his shirt, his pants were unfastened. HA #286 remained in the room and called for help. State tested Nursing Assistant (STNA) #285 came in the room and assisted in standing Resident #1 up. HA #286 reported the incident because the positioning (of those involved) and the clothing adjustment when she walked into the room seemed suspicious to her. The investigation of the incident revealed on 08/08/24 between 11:10 A.M. and 11:20 A.M. HA #286 entered Resident #1's room and saw Resident #1 sitting on the floor and MD #300 standing in front of her adjusting his clothing. HA #286 ensured Resident #1's safety by asking MD #300 to immediately leave the room and reported the incident to LPN #238. At 11:30 A.M. LPN #238 reported the incident to the Administrator. At 11:33 A.M. LPN #238 assessed the resident which included a head-to-toe and pain assessment. At 11:34 A.M. the Administrator immediately met and interviewed MD #300. MD #300 denied anything sexual was going on. MD #300 stated he was helping Resident #1 up off the floor. MD #300 was sent home pending investigation. At 11:45 A.M. the Administrator interviewed HA #286. HA #286 remained with Human Resource Director #256 to complete a statement and went home after. At 12:06 P.M. the DON was notified and at 12:25 P.M. the Administrator notified the police and described the scenario as HA #286 explained. PC #306 stated he would be out. At 12:30 P.M. the Administrator asked social service staff to speak with Resident #1 and see if she would share any information. At 12:40 P.M. PC #306 arrived and interviewed Resident #1. PC #306 asked Resident #1 if she would like to go to the hospital and get checked out. Resident #1 declined at first but then stated it may be nice to get out for a little bit. PC #306 explained that the hospital may complete a rape kit. Resident #1 stated she was familiar with them (rape kits). At 1:30 P.M. Resident #1 went out to the emergency room (ER) and at 3:45 P.M. PC #306 called the administrator. PC #306 reported during their interview with MD #300, MD #300 admitted to receiving oral sex from Resident #1. MD #300 was arrested and taken to jail. At 5:57 P.M. Resident #1 returned from the ER but no rape kit was performed (resident refused). A skin check was completed upon the resident's return with no issues noted. On 08/15/24 at 4:59 P.M. the facility SRI was completed. As a result of this investigation the facility substantiated the incident of sexual abuse. Review of Resident #1's nurse's note, authored by the DON, dated 08/08/24 at 5:57 P.M. revealed Resident #1 returned from the emergency department. A head-to-toe assessment was completed with no new findings. Review of the emergency room Hospital discharge date d 08/08/24 revealed the resident was seen for vaginal discharge and indicated the resident was to follow up with her primary provider. No other information relevant to the visit was provided. As part of the facility investigation, a statement was obtained from HA #286. The handwritten statement dated 08/08/24 at 12:00 P.M. revealed HA #286 was going to pick up Resident #1's lunch tray. She opened the door and Resident #1 was sitting on the floor with her back to the sink. MD #300 was facing the resident. MD #300 hurried up and pulled his untucked shirt down over the front of his pants. Resident #1 was licking her lips. MD #300 wouldn't move. He said he was trying to help Resident #1 up. MD #300 wouldn't move and kept standing in front of Resident #1. HA #286 moved over a little bit and yelled out the door that they needed help. When HA #286 looked back, MD #300 was messing with the front of his pants while his shirt was still over his pants. Through his shirt, you could see that his pants were not buttoned. STNA #285 came in to help get Resident #1 up. HA #286 stated she did not leave the room. MD #300 asked, What else do you need fixed? But MD #300 did not have any tools with him. MD #300 left the room but stood in the hallway while HA #286 was in the room. MD #300 eventually left the hall. By the time MD #300 left the room, the staff had Resident #1 off the floor. Resident #1 did not admit to anything. HA #286 tried to ask Resident #1 if MD #300 made her do something and she said no. HA #286 documented she told Resident #1 we are all human, but we are supposed to protect her. Review of a police report dated 08/08/24 and completed by Police Chief (PC) #306, incident #24-08-000247 revealed the police were contacted by the facility related to an incident of sexual abuse involving Resident #1. During the initial police investigation, MD #300 admitted to receiving oral sex from Resident #1. MD #300 stated to PC #306 sexual relations with Resident #1 had been going on for nine months to a year. The prosecutor was contacted, and MD #300 was transported to a local county jail. MD #300 was charged with sexual assault. Review of the news broadcast at https://wtov9.com/news/local/[NAME]-healthcare-worker-charged-with-sexual-assault-of-a-resident on 08/13/24 at 5:08 P.M. revealed a maintenance worker employed by [NAME] Healthcare Center had been charged with sexual assault after an incident last week at the facility. MD #300 was arrested after an investigation and had since bonded out. The PC involved with the case stated he received a call from the facility Administrator on 08/08/24 that an incident was reported to her regarding a staff member that may have sexually assaulted a resident. Allegedly, another employee witnessed MD #300 engaging in sexual activity with a patient. On 08/15/24 at 8:18 A.M. an interview with PC #306 revealed MD #300 was arrested and charged related to the above incident with Resident #1 as the result of a police investigation. PC #306 indicated Resident #1 lacked the cognitive ability to report accurately what had or was occurring (with MD #300) due to her diagnoses. PC #306 stated based on their investigation, witness, suspect confession- the incident of sexual abuse had occurred. Further interview revealed the PC was aware of some rumors that MD #300 had been engaging in sexual activity for a number of years, but stated none of the staff felt had enough evidence or had witnessed anything specific prior to this incident on 08/08/24. On 08/15/24 at 9:35 A.M. an attempted interview with Resident #1 revealed the resident was unable to describe any physical interactions with MD #300. On 08/15/24 at 11:56 A.M. an interview with the Administrator revealed she was notified of the incident involving Resident #1 and MD #300 on 08/08/24 at 11:30 A.M. The Administrator stated she immediately brought MD #300 to the office, and he was notified at that time of a suspension pending investigation (into an allegation of sexual abuse). The Administrator stated she asked MD #300 if anything sexual had occurred with Resident #1 to which MD #300 denied. At that point MD #300 became angry and threw his keys on the desk. MD #300 was escorted out of the building. During the interview, the Administrator shared about a year ago, there was report of MD #300 coming to the building at off hours frequently however, she stated the incident was investigated without findings. On 08/15/24 at 12:21 P.M. an interview with HA #286 revealed on 08/08/24 between 11:10 A.M. and 11:20 A.M. she walked into Resident #1's room. The main door to the room was closed and Resident #1 only closed the door when looking for clothing or when she was sleeping. HA stated MD #300 was in Resident #1's bathroom and Resident #1 was sitting on the bathroom floor. HA #286 stated after she entered the room, MD #300 pulled down his shirt to cover the front of himself. HA #286 stated she asked MD #300 what he was doing in the room, and he told her he was helping Resident #1 get off the floor. HA #286 shared MD #300 would never assist a resident off the floor prior to this incident but would ask staff to assist a resident. HA #286 stated, at that point, MD #300 was told to leave the room and she stated she called for help. HA #286 stated MD #300 turned away from her and adjusted his pants and left the room but stayed in the hallway outside of the door. HA #286 further revealed there was an incident with MD #300 within the last year where he was in Resident #1's bathroom with Resident #1 and the resident was without clothing. HA #286 stated she did not report the incident because she did not think anyone would do anything about her observation. HA #286 also stated Resident #1 would often call out MD #300's name. On 08/15/24 at 12:55 P.M. interview with STNA #294 revealed she was working on a different hall on 08/08/24 and HA #286 had reported concerns involving Resident #1 directly to her. STNA #294 stated HA #286 was distraught and looked like she had just seen a ghost. STNA #294 stated HA #286 told her she walked into Resident #1's room for a food tray and Resident #1 was on the floor with her back up against the sink. HA #286 described MD #300 was standing over Resident #1 and had his shirt untucked. STNA #294 was told by HA #286 MD #300 then pulled down his shirt to cover his front. STNA #294 stated this was unusual for MD #300 as he always had his shirt tucked in with a belt on. At that point they were approached by LPN #238 and HA #286 was removed from the area to talk privately with LPN #238. Further interview with STNA #294 revealed MD #300 spent a lot of time with Resident #1 behind closed doors. STNA #294 also shared Resident #1 would call out MD #300 by name in a sweet manner but would call out to other staff with anger and would curse. STNA #294 indicated in her opinion, the facility failed Resident #1 by not reporting feelings staff had that MD #300 gave a creepy vibe regarding Resident #1. On 08/15/24 at 1:52 P.M. interview with LPN # 238 revealed on 08/08/24, HA #286 pulled her into a private area and informed her of an incident between Resident #1 and MD #300. LPN #238 stated she then reported the incident to the Administrator and HRM #256. After reporting the incident, LPN #238 stated she completed an assessment of Resident #1 for injury and there were no physical or mental issues. When asked what was meant by that, LPN #238 stated Resident #1 was confused at times with delusions. LPN #238 further revealed Resident #1 could not make safe decisions which all staff were aware of. LPN #238 shared Resident #1 would call out MD #300's name but stated this did not seem suspicious to her. LPN #238 stated she had not witnessed any unusual behaviors with MD #300 prior to this incident. LPN #238 stated there was a time MD #300 was reported to be coming in early (for work) but she stated this had been investigated, and nothing was found out of the ordinary. Lastly, LPN #238 stated Resident #1 was not capable of consenting to a sexual relationship with MD #300 due to her cognition. On 08/15/24 at 2:50 P.M. an interview with Physician #301 (also the facility medical director) revealed he was Resident #1's primary care physician. Physician #301 stated Resident #1 could not make safe decisions. Physician #301 further stated Resident #1 could say something sensible at one minute then something nonsensical the next. Physician #301 stated he was aware of the incident involving MD #300 that had occurred on 08/08/24 and had participated in the facility corrective plan following the incident. On 08/15/24 at 3:52 P.M. an interview with Resident #1's mother, who was a named guardian for the resident, revealed Resident #1 could, in no way make safe decisions. Resident #1's mother further stated Resident #1 often fixated on sex and would not stop fixating. Resident #1's mother revealed she had been notified of the incident that had occurred with MD #300 on 08/08/24. On 08/15/24 at 3:52 P.M. an interview with Ombudsman #303 revealed knowledge of the incident that occurred on 08/08/24. Ombudsman #303 stated she saw Resident #1 on 08/09/24 and at that time Resident #1 had denied the incident. Ombudsman #303 further stated she interviewed staff, and many were creeped out by MD #300 and advances he had made toward staff in the past. On 08/15/24 at 3:57 P.M. an interview with Nurse Practitioner (NP) #302 revealed she saw all residents in the building for psychiatric care except for Resident #65. NP #302 stated she was made aware of the incident that occurred on 08/08/24 on the day it happened and gave the order to send Resident #1 to the emergency room to have a rape kit completed. NP #302 stated Resident #1 was unable to make safe, informed decisions. The NP stated she felt MD #300 knew the status (cognitive and behavioral) of Resident #1 (he attended morning clinical meetings) including the resident being fixated on sex, her mental status, that she was on birth control and believed MD #300 likely felt no one would believe the resident if she reported sexual incidents. The NP stated the resident was on birth control as an intervention to prevent pregnancy if she was sexually active. She described it as the perfect storm. On 08/19/24 at 12:48 P.M. an interview with Social Service Designee (SSD) #225 revealed she was notified of the incident between Resident #1 and MD #300 on 08/08/24 and attempted to speak to Resident #1 about the incident. SSD #225 revealed Resident #1 was unable to tell her what MD #300 had done or why MD #300 was in the room. SSD #225 stated during the interview, Resident #1 denied any incidents regarding MD #300. On 08/22/24 at 11:20 A.M. an attempt to reach MD #300 via phone was made. The phone number was not in service. An interview with the Administrator revealed she was told MD #300's phone was confiscated by the police. On 08/22/24 at 11:30 A.M. an interview with STNA #285 revealed she was the STNA who assisted HA #286 to get Resident #1 off of the floor on 08/08/24. STNA #285 stated she went to Resident #1's room because she heard HA #286 call for help. STNA #285 stated she witnessed Resident #1 on the floor in the bathroom with her back against the wall. STNA #285 stated Resident #1 was clothed. STNA #285 revealed MD #300 (who was present in the room) stated he was helping Resident #1 get off the floor. STNA #285 stated she thought that was odd because MD #300 never assisted with any resident needs before. STNA #285 stated that in the past if any resident expressed a need to MD #300, he would tell the resident he would get someone. STNA stated she did not personally witness MD #300's pants being undone nor, did she see MD #300 adjust his clothing. STNA #285 stated after she and HA #286 assisted Resident #1 off the floor and walked out of the room. HA #286 stated to her, I think I just saw something bad. Review of MD #300's personnel file revealed the employee was hired on 10/13/17. An Employee Corrective Action Form dated 08/08/24 revealed MD #300 was terminated from employment on 08/08/24. The reason for termination included performance/policy violation and abuse. The document was signed by the Administrator and HRM #256. Review of the facility's undated Code of Conduct for Contract with Attestation revealed the company was committed to maintaining the highest professional and et [TRUNCATED]

Based on record review, observation and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure the accurate identification of pressure ulcers, on-going assessment and monitoring, adequate treatment and effective interventions to timely identify and treat pressure ulcers for Resident #4. Actual Harm occurred on 11/24/23 when Resident #4, who was cognitively intact, paraplegic, required partial to moderate assistance with bed mobility and was identified by the facility as having systolic congestive heart failure placing him at high risk for developing pressure ulcers, was assessed by the Wound Nurse Practitioner (NP) #500 to have a new unstageable (full thickness loss of tissue completely covered by dead tissue) pressure ulcer to the left posterior thigh measuring 4.0 centimeters (cm) by 5.0 cm by 0.1 cm with 100 percent eschar (dead tissue). No further measurements were obtained of the left posterior thigh pressure ulcer until 01/02/24 by Licensed Practical Nurse (LPN) #501 who identified the pressure ulcer as larger by measurements of 6.0 cm by 7.0 cm with eschar and noting the pressure ulcer had declined. This affected one resident (#4) of three residents reviewed for pressure ulcers. The facility census was 71. Findings include: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including systolic congestive heart failure (CHF), cocaine abuse, hyperlipidemia, hypertension, arteriosclerotic heart disease and paraplegia. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/31/23, revealed Resident #4 had intact cognition, did not reject care, had impaired movement in the bilateral lower extremities, needed partial to moderate assistance with bed mobility and transfers from bed to chair or toilet and used a manual wheelchair for ambulation. The assessment revealed Resident #4 was always incontinent of urine and frequently incontinent of bowel. Resident #4 had occasional pain at a level of five on a scale of one being the least pain to 10 being the worst pain. Resident #4 was admitted to the facility with one Stage II (partial thickness loss of tissue with a red or pink wound bed) pressure ulcer, four Stage III (full thickness tissue loss with no bone, tendon or muscle exposure) pressure ulcers, three unstageable pressure ulcers and three venous ulcers. Review of the Nursing Admission Evaluation V2 dated 10/25/23, and Skin and Wound note dated 10/27/23 completed by Nurse Practitioner #500 revealed Resident #4 was admitted to the facility with 11 wounds of both pressure and arterial etiology. The wounds included three unstageable pressure ulcers to the left inferior medial lower leg measuring 5.0 cm by 2.5 cm by 0.1 cm and had a moderate amount of serosanguinous (thin, bloody) drainage no odor, the right hip measuring 7.0 cm by 5.0 cm by 0.1 cm with scant drainage no odor, and the left hip measuring 6.0 cm by 8.0 cm by 1.0 cm with heavy seropurulent (thin, watery, cloudy and yellow to tan in color) drainage malodorous (foul smelling) after cleansing; four Stage III pressure ulcers to the left buttock measuring 1.0 centimeters (cm) by 1.0 cm by 0.1 cm and scant serosanguinous drainage nor odor, the left posterior knee measuring 4.0 cm by 8.0 cm by 0.1 cm with moderate serosanguinous drainage no odor , the right lower leg measuring 1.0 cm by 1.0 cm by 0.1 cm and scant drainage no odor, and the left lower leg measuring 2.0 cm by 2.0 cm by 0.1 cm and scant drainage no odor ; one Stage II pressure ulcer to the left superior medial lower leg measuring 1.5 cm by 1.5 cm and scant drainage no odor; three arterial wounds to the left fifth toe, left lateral foot and left lateral foot proximal without drainage or odor. Resident #4 had multiple musculoskeletal contractures and diminished pedal (foot) pulses. Review of an encounter note, dated 10/26/23 and authored by primary NP #505, revealed Resident #4 had congestive heart failure with an ejection fraction of 25 percent (normal is 55 to 70 percent), paraplegia and his pedal (foot) pulses were diminished at plus (+) two bilaterally (the scale for pedal pulse is zero being no pedal pulse and three being normal). Resident #4's pressure ulcers and arterial wounds were not assessed at the time of the visit. Review of the physician orders dated 10/26/23 to 11/03/23 revealed no treatment orders written for the unstageable right hip pressure ulcer until 11/03/23. Timely treatment orders were written on 10/26/23 for the remaining 10 pressure ulcers and arterial wounds, as well as orders for daily wound assessments of the dressings to see if dry and intact, any pain, drainage, signs of infection, presence of necrotic tissue, odor and assessment of the tissue surrounding the wounds. Review of the plan of care for Resident #4, dated initiated 10/29/23, revealed Resident #4 had behaviors of refusing incontinence care, refusing dressing changes and making false statements and accusations. Interventions included approach and speak in a calm manner, allow the resident as much control and independence for decision making as possible, attempt to determine underlying cause for behaviors, offer tasks that divert attention and intervene as necessary to protect the rights and safety of others. Review of the plan of care, dated 11/06/23, revealed Resident #4 had impaired skin integrity and was at risk for further risk of altered skin integrity. Interventions included complete weekly skin checks, complete skin at risk assessment upon admission, quarterly and as needed, and encourage the resident to turn and reposition or assist as needed as resident allows. The plan of care was updated on 11/15/23 to add interventions including administer treatments as ordered by medical provider, apply barrier cream post incontinent episodes, low air loss (LAL) mattress to the bed as ordered, provide appropriate off-loading cushion to chair, offer dietary supplements and diet per orders, notify resident and provider of any skin breakdown and nutrition consult on admission, quarterly and as needed. Review of the October 2023 Treatment Administration Record (TAR) revealed there was no documentation wound treatments or the daily wound assessments were completed on 10/26/23, 10/28/23 or 10/31/23. Treatments and assessments for the unstageable right hip pressure ulcer were not on the October 2023 TAR at all resulting in nothing being documented/recorded for the right hip. Review of the progress notes revealed no written evidence Resident #4 refused wound treatments on 10/26/23, 10/28/23 or 10/31/23. Resident #4 was documented as noncompliant with offloading and/or incontinence care on only 10/29/23 and 10/30/23 with no evidence to support education to the resident or additional compliance attempts at that time. Review of the Skin and Wound note dated 11/03/23 authored by NP #500 revealed all pressure ulcers and arterial ulcers were noted to be stable or improving without odor except for the unstageable pressure ulcer to the left hip continued to be malodorous after cleansing with heavy seropurulent drainage and measured 6.5 cm by 7.5 cm by 1.0 cm. and was noted to be improving. Review of progress notes dated 11/05/23 to 11/07/23 revealed Resident #4 had been sent to the hospital with complaints of chest pain on 11/05/23 and returned to the facility on [DATE]. Review of the Nursing Admission Evaluation V2 dated 11/07/23 revealed Resident #4 was readmitted to the facility with three unstageable pressure ulcers to the left inferior medial lower leg measuring 5.0 cm by 2.5 cm by 0.1 cm, the right hip measuring 5.0 cm by 4.5 cm by 0.1 cm, and to the left hip measuring 6.5 cm by 7.5 cm by 1.0 cm; four Stage III pressure ulcers to the left buttock measuring 1.0 cm by 1.0 cm by 0.1 cm, the left posterior knee measuring 4.0 cm by 8.0 cm by 0.1 cm, the right lower leg measuring 1.0 cm by 1.0 cm by 0.1 cm and the left lower leg measuring 2.0 cm by 1.0 cm by 0.1cm; one Stage II pressure ulcer to the left superior medial lower leg measuring 1.5 cm by 1.5 cm, and three arterial wounds to the left fifth toe, left lateral foot and left lateral foot proximal. Review of the physician orders dated 11/07/23 revealed daily wound treatment orders in place for the pressure ulcers and arterial wounds, as well as orders for daily wound assessments of the dressings to see if dry and intact, any pain, drainage, signs of infection, presence of necrotic tissue, odor and assessment of the tissue surrounding the wounds. Review of the Braden Scale risk assessment dated [DATE] revealed Resident #4 was low risk for developing pressure ulcers. Review of the Braden Scale risk assessment dated [DATE] revealed Resident #4 was low risk for developing pressure ulcers. Review of the Braden Scale risk assessment dated [DATE] revealed Resident #4 was low risk for developing pressure ulcers. Further review of the medical record revealed no wound measurements were obtained by nursing staff or NP #500 between 11/07/23 to 11/23/23, and no thorough assessment of the appearance of the wound base, level of any tissue type exposure, appearance of the wound edges or and no documentation on the type and amount of any exudate from any of the wounds until NP #500 assessed Resident #4's wounds on 11/24/23. The only assessments on the wounds being completed by nursing staff from 11/08/23 to 11/23/23 included answering yes/no questions regarding if the dressing was dry and intact, was there drainage, any signs of infection, any odor, dead tissue, pain and was the surrounding skin normal or abnormal. Review of the Skin and Wound note dated 11/24/23 by NP #500 revealed Resident #4 developed a new unstageable pressure wound to the left posterior thigh measuring 4.0 cm by 5.0 cm by 0.1 cm with 100 percent eschar and peri wound erythema (redness). The treatment ordered included cleanse with wound cleanser, apply betadine to wound base and secure with bordered gauze every day. It was noted Resident #4's review of systems indicated he had faint pedal pulses and multiple contractures. Documentation of the other pressure ulcers revealed the Stage III pressure ulcer to the left buttock and the Stage II pressure ulcer to the left superior medial lower leg were both healed. The unstageable pressure ulcer to the left inferior medial lower leg measuring 9.0 cm by 5.0 cm by 0.1 cm with 75 to 99 percent eschar was marked as stable although larger from the previous measurement on 11/07/23. The Stage III pressure ulcer to the left posterior knee measuring 5.0 cm by 10.0 cm by 0.1 cm with 50 to 74 percent slough was marked as improving although measuring larger from the previous measurements on 11/07/23. Additional measurements included an improving unstageable pressure ulcer to the right hip measuring 3.0 cm by 3.0 cm by 0.1 cm with 25 to 49 percent slough, an improving Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer to the left hip measuring 6.5 cm by 7.5 cm by 1.0 cm with 3.0 cm undermining at 5 o'clock to 7 o'clock, a stable Stage III pressure ulcer to the right lower leg measuring 1.0 cm by 1.0 cm by 0.1 cm with 50 to 74 percent slough , and a stable Stage III pressure ulcer to the left lower leg measuring 2.0 cm by 1.0 cm by 0.1cm with 50 to 74 percent slough. NP #500 performed a debridement (removal of dead tissue using a curette) on the left lower leg Stage III and the right hip unstageable pressure ulcers. Review of the November 2023 TAR revealed there was no written evidence of wound treatments or the daily wound assessments being completed on any of the pressure ulcers on 11/08/23, 11/21/23, 11/25/23 or 11/27/23. Review of the progress notes from 11/09/23 through 11/30/23 revealed Resident #4 refused to see the wound NP on 11/14/23 and 11/28/23, refused wound treatments and wound assessments by nursing on 11/09/23, 11/12/23 and 11/29/23, and was noncompliant with offloading and/or incontinence care on 11/01/23, 11/05/23, 11/26/23 and 11/28/23. Review of the December 2023 TAR and progress notes dated 12/01/23 through 12/30/23 revealed there was no evidence the physician ordered wound treatments were implemented on 12/01/23, 12/23/23 or 12/25/23 and daily wound assessments were not completed on 12/01/23, 12/07/23, 12/16/23, 12/22/23, 12/23/23 or 12/25/23. There was documentation Resident #4 had refused to have his wound treatment done on 12/14/23, 12/21/23, and 12/27/23 with no evidence to support education to the resident or additional compliance attempts were made on 12/27/23. Review of the Wound NP note dated 12/05/23 revealed Resident #4 had refused the visit. Review of the primary NP #505 note dated 12/06/23 at 1:00 A.M. revealed Resident #4 was upset because his pain was out of control. He reported he was having severe burning in his bilateral hips. The note indicated although he was a paraplegic, he did experience severe neuropathic pain in his legs intermittently. He was having increased foul-smelling drainage to his right and left hip. The plan was to obtain x-rays of the right and left hip, wound culture the right and left hip. Review of the progress note dated 12/06/23 at 11:25 A.M. revealed wound care was done per order; wound cultures were ordered for both hips and posterior left knee and x-rays of both hips. Review of the physician orders dated December 2023 revealed orders for wound cultures of the left and right hip to be sent out on 12/07/23, x-rays to bilateral hips to rule out osteomyelitis, Imipenem-cilastatin (antibiotic) intravenous 500 milligrams (mg) every six hours for wound infection for seven days, Levofloxacin (antibiotic) 500 mg once daily for infection for 10 days and Doxycycline hyclate (antibiotic) 100 mg twice daily for wound infection for 10 days. All orders for daily wound assessments and treatments continued. Review of the wound culture results dated 12/06/23 and reported on 12/13/23 revealed Resident #4 had heavy growth of the organisms klebsiella pneumoniae extended- spectrum beta-lactamases (ESBLS), organisms pseudomonas aeruginosa and enterococcus raffinosus. Review of the wound culture results dated 12/07/23 and reported on 12/13/23 revealed Resident #4 had light growth of the organisms klebsiella pneumoniae EBSL and providencia stuartii. Review of the wound culture results dated 12/07/23 and reported on 12/13/23 revealed Resident #4 had heavy growth of the organism's pseudomonas aeruginosa and heavy growth of Acinetobacter baumannii Carbapenem Resistant Acinetobacter baumannii. Review of the primary NP #505 note dated 12/07/23 at 1:00 A.M. revealed x-rays were negative for osteomyelitis. The plan at that time indicated to refer to the wound clinic and pain clinic. Review of the progress note dated 12/11/23 at 3:08 P.M. revealed Resident #4 was referred to infectious disease physician due to infected wounds. Review of the physician's orders dated 12/11/23 revealed Resident #4 had an order for Imipenem-Cilastation 500 mg intravenous every six hours for wound infection for seven days. Review of the physician's order dated 12/13/23 revealed Resident #4 had an order for Doxycycline hyclate 100 mg twice daily for wound infection for 10 days. Review of the physician's order dated 12/15/23 revealed Resident #4 had an order for Levofloxacin 500 mg daily for infection for 10 days. Further review of the medical record revealed no assessment measurements of Resident #4's pressure ulcers were obtained from 11/25/23 through 01/02/23 when Licensed Practical Nurse (LPN) #501 obtained the measurements. Review of the Skin Grid Pressure V9 document, dated 01/02/24 and completed by LPN #501, revealed Resident #4 had a deteriorating unstageable pressure ulcer to the left rear thigh measuring 6.0 cm by 7.0 cm with eschar, a deteriorating Stage III pressure ulcer to the left posterior knee measuring 5.2cm x 10.3 cm by 0.1 with slough, a stable unstageable pressure ulcer to the right hip measuring 3.1 cm by 3.2 cm, a stable Stage III pressure ulcer to the right lower leg measuring 1.0 cm by 1.0 cm by 0.1 cm with slough, a stable Stage II pressure ulcer to the left lower leg measuring 2.0 cm by 1.0 cm by 0.1 cm with slough, a stable unstageable pressure ulcer to the left lower leg front measuring 9.3 cm by 5.1 cm with slough and eschar, and a stable Stage IV pressure ulcer to the left hip measuring 6.7 cm by 7.2 cm by 1.0. On 12/28/23 at 12:17 P.M. interview with Resident #4 revealed he did not refuse to have his wound treatments and assessments done by the nurses. The resident stated his concern was that the nurses come at the dumbest times so he would tell them to come back later not refuse. Resident #4 stated he did not like the wound nurse practitioner, NP #500, so he would not often let her do his assessments, but he would let LPN #501. Resident #4 was observed sitting in a wheelchair but was unable to put his feet onto the footrests as his legs bent at the knee due to contracture positioning his lower leg towards the underneath of the wheelchair seat but not touching the floor. Additional intermittent observations of Resident #4 on 12/28/23 revealed while he laid in bed, Resident #4 could not straighten out his legs resulting in the legs being bent at the knee without the lower leg making contact with the thigh. On 01/02/24 at 9:00 A.M. an interview with the Director of Nursing (DON) revealed the only thorough skin assessments and wound measurement the facility had prior to 01/02/23 were from Wound NP #500 on 10/27/23, 11/03/23, and 11/24/23 and his two admission assessments from 10/25/23 and 11/07/23. The DON indicated Resident #4 refused most weeks to allow Wound NP #500 to do the assessments and measurements. The DON verified his treatments were being done regularly by the facility nurses and the facility nurses could have measured his wounds when they were completing his treatments. On 01/02/24 at 12:10 P.M. an interview with Wound NP #500 revealed it was her expectation for the staff nurses to obtain wound measurement every seven days. She stated this was the only facility she did rounds in that did not get the measurement weekly if she was unable to get measurements. NP #500 explained she did not do wound care treatments when she rounded (saw residents), but stated she did look at the wounds, took measurements and pictures. NP #500 stated she had only seen Resident #4's pressure ulcers four times since he had been at the facility. There was no evidence this was communicated to the physician, or the resident was offered other options for wound care. On 01/02/24 at 12:24 P.M. an interview with Registered Nurse (RN) #502 revealed she often worked the unit Resident #4 resided on and provided his wound care. RN #502 stated she was not aware NP #500 expected the nurses to get wound measurements if a resident refused NP #500, and RN #502 was not asked to get measurement of Resident #4's wounds. On 01/02/24 at 4:35 P.M. an interview and record review with the DON of the October, November and December 2023 TARs revealed on 12/28/23 she had filled in the dates previously not signed off as completed by nursing on 12/01/23, 12/23/23 and 12/25/23. The DON indicated the treatments were done just not recorded on the TAR, so she filled it in. The DON also verified there was no documentation of wound care provided to Resident #4 on 10/26/23, 10/28/23, 10/31/23, 11/09/23, 11/14/23 or 11/28/23. On 01/04/24 at 10:15 A.M. an interview with primary NP #505 revealed she had a visit with Resident #4 due to the staff stating he was refusing to allow them to do his treatments. NP #505 stated Resident #4 told her he was not refusing to allow them to do his treatments. NP #505 said Resident #4 stated to her his wounds had increased drainage, were foul smelling and hurting him more. NP #505 explained to him she would get some x-rays and do some wound cultures. The x-rays were negative for osteomyelitis, but he had several different organisms growing which was why he was ordered different antibiotics. NP #505 indicated she would question why the facility staff found a new pressure ulcer at an unstageable with 100 percent eschar but stated for Resident #4 she felt the resident had co-morbidities placing him at increased risk for such development. When asked if she agreed with the Braden scores indicating the resident was low risk for developing pressure ulcers, NP #505 stated she did not agree because Resident #4 was definitely high risk for pressure ulcers, and stated it was the DON's responsibility to ensure all treatments were being provided to Resident #4. On 01/04/24 at 11:30 A.M. an interview with DON revealed Wound NP #500 had discovered the new left posterior thigh pressure ulcer on Resident #4 when she was doing her wound rounds on 11/24/23. The DON verified it was not normal to find a wound that was unstageable with 100 % eschar. The DON verified the resident's left lower leg wound, left posterior knee, and left hip were measuring larger on 11/24/23 and there were no wound grids or wound measurements for December 2023. The DON stated Resident #4 had refused a cushion in his chair at first because he stated he had one at home which was not brought to the facility so he then started to use the cushion provided by the facility. The DON stated Resident #4 refused an air mattress at first, but staff were able to talk him into the air mattress without the over lay. When asked why the Braden scores indicated he was low risk for developing pressure ulcers, the DON stated she did not know why his Braden scores assessed the resident to be at low risk and stated he should have scored as high risk so she would need to have him re-assessed. The DON verified the resident's left inferior lower leg, right hip, left posterior knee and the left rear thigh were all measuring larger or deteriorating on the 01/02/24 skin grid done by LPN #501 compared to the last documented wound assessment on 11/24/23 done by Wound NP #500. On 01/04/24 at 1:00 P.M. an interview with LPN #501 revealed she had just taken over as wound nurse for the facility about two weeks ago. LPN #501 stated Resident #4 had complained to her (exact dates unknown) about not wanting his treatments done in the morning and the nurses were coming in to do his treatments in the early morning. LPN #501 said Resident #4 told her he did not like to be woken up that early. LPN #501 said after she realized this about him, she decided she would do the treatments later in the evening and he was agreeable. LPN #501 verified his preference of not wanting treatments done in the morning was not added to the care plan. On 01/04/24 at 4:10 P.M. an interview with the DON confirmed there was no documentation that an order was obtained, or a treatment was completed for the right hip of Resident #4 from admission until 11/03/23. Review of the undated facility policy titled, Skin Care and Wound Management, revealed the facility staff strived to prevent resident skin impairment and promoted the healing of existing wounds. Each resident would be evaluated on admission and weekly thereafter for changes in skin condition. Residents should be re-evaluated with a change in clinical condition. Care plans should have individualized interventions. This citation represents non-compliance identified during the investigation of Complaint Number OH00149046.

Based on record review and interview the facility failed to administer a pneumococcal vaccination to Resident #13 after receiving consent from the resident to receive the vaccination to decrease the resident's risk of developing pneumonia. Actual harm occurred on 09/15/19 when the resident experienced increased shortness of breath and a low oxygen saturation level resulting in the resident being transported to the hospital where she was admitted with a [DIAGNOSES REDACTED]. This affected one resident (#13) of five residents reviewed for immunizations. Findings include: Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's Pneumonia Vaccine consent, dated 08/06/19 revealed the resident gave her permission to the facility to administer the pneumonia vaccine. Review of Resident #13's physician's orders from 8/06/19 through 09/15/19 revealed no evidence the resident received a pneumonia vaccine during this time period. Review of Resident #13's immunization history record revealed no evidence the resident received a pneumonia vaccine between 08/06/19 and 09/15/19. Review of Resident #13's nursing progress notes revealed a note dated 09/14/19 at 2:13 P.M. that indicated the resident was complaining of shortness of breath. Upon assessment, the resident was noted to have wheezing (abnormal lung sounds) to the right upper lobe. The physician was notified and an order was obtained for a mobile chest x-ray. A nursing progress note, dated 09/15/19 at 12:56 [NAME]M. revealed the resident complained of not being able to breath and was administered an aerosol treatment that she indicated did not work. The resident had oxygen at three liters nasal cannula, was wearing a [MEDICAL CONDITION] (continuous positive airway pressure machine) and continued to complain of not being able to breathe. The physician was notified and stated to give the resident an aerosol treatment and [MEDICATION NAME] (pain medication). The next entry in the nursing progress notes, dated 09/15/19 at 2:46 [NAME]M. revealed the resident continued to complain of not being able to breathe. Her oxygen saturation was 70% with the [MEDICAL CONDITION] and oxygen at three liters via nasal cannula. The resident's blood pressure was elevated at 241/149. 911 was called and the resident was transported to the emergency room . Review of Resident #13's hospital paperwork revealed the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #13 physicians' progress note dated 09/26/19 also revealed the resident returned from the hospital after being admitted with pneumonia. Interview on 12/18/19 at 1:35 P.M. with Licensed Practical Nurse (LPN) #115 revealed the facility had information in (YEAR) Resident #13 received a pneumococcal vaccine. The LPN was unsure if it was the Prevnar 13 (PVC13) or [MEDICATION NAME] (PPSV23) that had been received. LPN #115 further revealed she was unable to obtain records regarding the vaccination. LPN #13 verified Resident #13 signed the consent on 08/06/19 to receive a pneumonia vaccine, but the facility did not obtain an order for [REDACTED]. Review of the facility policy titled, Pneumococcal Vaccine Administration, dated 11/11/18 revealed the facility would follow the criteria set forth by the Centers of Disease Control and Prevention (CDC). The facility would provide education to the resident on the importance of pneumococcal vaccinations and would have methods for tracking when the second vaccinations were due. The nurse would obtain a history of previous pneumonia vaccines with dates or appropriate dates, and if the dates were unknown or unavailable the facility would select the appropriate vaccination schedule. Review of the CDC guidelines revealed pneumococcal vaccines were recommended for people who have long-term health conditions, like [MEDICAL CONDITION] or asthma. The PCV13 vaccine was recommended for people age two years and older who had certain health conditions. The PPSV23 vaccine was recommended for people age 2 years and older who have certain health conditions. The CDC also provided information which stated for residents who had not received any pneumococcal vaccines or the vaccination history was unknown and were between the ages of 19 and 64, an initial dose of PCV13 should be given with a dose of PPSV23 given at least eight weeks later. A second dose of PPSV23 should be administered at least five years after the previous dose and a final dose of PPSV23 should be administered after the age of 65 and at least five years after the most recent dose of PPSV23.

Based on observations, review of the medical record, Unit Supervision policy and procedure, staffing records, resident council meeting minutes, resident and staff interviews and interview with Physician #305, the facility failed to provide sufficient nursing staff resulting in one unit not having any staff on duty to provide for resident safety and personal needs. The lack of sufficient staff resulted in one resident (Resident #50) not being provided transfer assistance as care planned to prevent a fall with injury. This resulted in Immediate Jeopardy on 01/28/19 at approximately 10:25 A.M. when no staff were able to be located to assist Resident #50 back to bed resulting in the resident attempting to transfer himself. Resident #50 had a history of [REDACTED]. Actual Harm occurred when Resident #50 fell during the self-transfer and sustained multiple facial fractures and a subdural hematoma. The resident was subsequently hospitalized in the intensive care unit at a tertiary hospital. The facility also failed to deploy adequate direct care staff to provide timely activities of daily living care to residents, answer resident call lights timely and provide restorative nursing services to residents on the night (7:00 P.M. to 7:00 A.M.) shift. This affected eight residents (Resident #50, #4, #21, #22, #30, #39, #49 and #54) and had the potential to affect all 57 residents residing in the facility. On 02/07/19 at 5:55 P.M. the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 01/28/19 at approximately 10:25 A.M. when no staff were available to assist Resident #50, who was assessed to be at risk for falls and had care plan interventions to be assisted by staff to bed after meals, attempted to transfer himself back to bed after repeatedly asking Housekeeper #100 to assist him to bed. The resident sustained [REDACTED]. The Immediate Jeopardy was removed on 02/11/19 when the facility implemented the following corrective action: · On 02/08/19 Regional Director of Operations #305 educated the Administrator, DON and Human Resource Manager (HRM) #210 on daily staffing review and ensuring adequate staffing levels were scheduled to meet residents needs per the facility assessment. · On 02/08/19 the DON reassessed Resident #50's fall risk and the resident's plan of care was updated to ensure appropriate fall interventions were in place. · On 02/08/19 the Administrator provided one-to-one education to State tested Nurse Aide (STNA) #105, the STNA assigned to care for Resident #50 on 01/28/19, and Housekeeper #100 with an emphasis on ensuring all residents, including Resident #50 received timely care and care based on their identified needs. · On 02/08/19 the Administrator conducted a resident council meeting with Resident #21, #49 and #26 present. During the meeting, Resident #21 suggested the facility needed more STNAs for night turn. The Administrator discussed with the residents the plan to ensure staff were hired included going to local schools, job fairs, bonuses for staff at the facility and advertising online and in the newspapers. · On 02/08/19 Social Service Designee (SSD) #200 conducted interviews with five residents (Resident #16, #49, #21, #55 and #56) identified to be interviewable. Four of the five residents (Resident #16, #49, #21, and #55) indicated they did not think there was adequate staff for the facility. There was no evidence of any follow up to these residents identified staffing concerns at that time. · Beginning on 02/08/19 a plan for the Administrator, DON, Scheduler #205 and Human Resource Manager (HRM) #210 to complete a daily staffing review to ensure staffing levels were maintained at 2.50 hours per resident per day (ppd) and the current acuity was implemented. The plan for staffing included five nurses (three scheduled on the 7:00 A.M. to 7:00 P.M. shift and two scheduled on the 7:00 P.M. to 7:00 A.M.) and six STNAs (three scheduled on the 7:00 A.M. to 7:00 P.M shift and three scheduled on the 7:00 P.M. to 7:00 A.M. shift) for an average daily census of 55 residents. If staffing levels were determined to be inadequate, the plan was to call all current employees who were not scheduled for shift pick up. If no coverage could be obtained the nurse manager on-call would be responsible to provide coverage. · On 02/08/19 the Administrator implemented an on-call nurse manager schedule which included the DON, ADON, Restorative Licensed Practical Nurse (LPN) #215, Registered Nurse (RN) Assessment Nurse #218, Nursing Supervisor (LPN) #220 and RN (EHR Coordinator) #225. The schedule required the nurse manager to assist with providing staffing coverage 24 hours a day/7 days per week due to census fluctuations, report offs or acuity changes to ensure staffing levels were maintained based on the facility assessment. · Beginning on 02/08/19 a plan for the Administrator to review night shift staffing levels daily at approximately 7:00 P.M. to ensure sufficient staffing according to the facility assessment and initiate the nurse manager on call support if indicated. · On 02/08/19 and 02/09/19 HRM #210, the DON and ADON provided education to all licensed nursing staff and direct care STNA staff regarding the Federal requirements for staffing and notification to the Administrator when staffing assignments changed from the daily staffing assignment sheet and the initiation of the on-call Nurse Manager schedule. As of 02/09/19 all 41 licensed nurse's and STNAs had received the education. · Beginning on 02/08/19 the facility initiated a shift pick up bonus program as an incentive to add additional support to direct care staff. · On 02/08/19 Senior Administrator #405 created a memo which was provided to the Administrator and DON indicating it was the practice of the facility that residents who were on one-to-one would not be calculated into the staffing calculations for the entire facility (and this staff person would be assigned in addition to the staff scheduled). · Beginning on 02/08/19 Corporate Recruiter #300 was designated to assist the facility Human Resource Manager, HRM #210 with a recruitment campaign including the use of Facebook, Zip Recruiter and Indeed. · On 02/08/19 the facility identified three LPNs and one STNA who had been hired to start with additional interviews set up for STNA staff over the next seven days. · Beginning on 02/08/19 the Administrator implemented a Manager on Duty schedule to ensure a manager was in the facility seven days per week with rounds to be completed to review resident care. Any identified concerns were to be reported to the Administrator. · Beginning on 02/08/19 a plan for the Administrator to review daily staffing minutes weekly for three months during weekly Quality Assurance meetings was implemented. · Beginning 02/08/19 a plan for Regional Director of Operations #305, to review the projected staffing schedule weekly for three months to ensure continued compliance with staffing per the facility assessment was implemented. · On 02/08/19 SSD #200 conducted interviews with five facility staff, Hospitality Aide #199, LPN #700, LPN #101, STNA #600 and Human Resource Manager #210 and asked if there was adequate staff for the facility. LPN #700 and STNA #600 indicated there was not enough staff. Beginning on 02/11/19 RN #400 implemented a plan for all 41 nursing staff to be interviewed regarding staffing and for follow up to be conducted with LPN #700 and STNA #600. · On 02/10/10 SSD #200 conducted resident interviews with all 21 of 23 residents identified to be interviewable. Five residents, Resident #4, #16, #21, #49 and #55 indicated they did not feel there was enough staff available to make sure care and assistance was provided without having to wait a long time. · On 02/11/19 SSD #200 initiated follow up with Resident #4, #16, #21, #49 and #55 to determine why the residents did not feel there was enough staff and to determine what care needs were not being met based on a lack of staff. · Beginning 02/11/19 RN #400 provided a plan for the facility to conduct call light audits on an ongoing basis. · On 02/10/19 and 02/11/19 interviews with LPN #122, #507 and #508, STNA #110, #111 and #112 revealed they had received facility education and were knowledgeable of the facility staffing requirements and call off procedures. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care was initiated on 09/11/18 reflecting the resident was at risk for falls related to incontinence, cognition and medications. Interventions dated 12/06/18 included anticipate and meet the resident's needs, ensure call light was within reach and encourage resident to use it for assistance as needed. On 09/11/18 an intervention was added to provide prompt response to all requests for assistance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/07/18 revealed Resident #50 had severe cognitive impairment and required extensive assistance from one staff member for bed mobility, transfers, walking in his room and corridor, dressing, toilet use and personal hygiene. The resident was assessed to require supervision from staff with mobility on and off the unit. The resident was assessed to be frequently incontinent of bowel and bladder. Record review revealed Resident #50 sustained falls 01/14/19 while ambulating unassisted, and on 01/17/19 and 01/19/19 while attempting to self-transfer from his wheelchair to bed. Record review revealed the resident's plan of care was updated on 01/16/19 to reflect actual fall with no injury related to poor balance and unsteady gait. On 01/18/19 the care plan was updated for staff to offer resident to lay down after supper. On 01/21/19 the care plan was updated for staff to offer and assist resident to lay down after all meals. Review of the fall risk observation tool, dated 01/19/19 revealed Resident #50 had balance problems with standing, falls within the last 30 days and was incontinent. Documentation on the tool revealed staff were to offer and assist the resident to bed after meals. Review of a nursing progress note, dated 01/28/19 revealed a late entry was made at 5:53 P.M. indicating Resident #50 was observed by the therapy department lying on the floor in his room. The resident was lying on his right side with visible blood from the right side of his head. The resident was assisted back to bed and 911 was called for transport to the hospital. Review of the facility investigation revealed a root cause of the fall was not identified. The resident was transferred to the emergency room for evaluation and admitted for multiple facial fractures including the anterior and lateral maxillary buttress, posterior orbital wall, the right orbital floor, infraorbital foramen and the right zygomatic arch; and a subdural hematoma. Review of the POS [REDACTED].M. revealed Resident #50 was last seen at 10:25 A.M. by Housekeeper (HK) #100 in his room, seated in his wheelchair. The resident told HK #100 he wanted to go to bed. As part of the facility investigation, staff statements were obtained which revealed the following: LPN #101 observed the resident lying on his right side, on the floor. Blood was noted from a right eye laceration and his right eyebrow was ecchymotic (bruised) and [MEDICAL CONDITION] (swollen) and unable to open. The resident's right nares was actively bleeding. The resident was restless and wanting into bed. The resident was non-compliant with laying still and was assisted back to bed. Review of HK #100's statement revealed the resident was sitting in his wheelchair next to his bed. HK #100 went to the resident's room to clean and the resident asked her several times if she could put him in his bed and she politely told him no because she was housekeeping. HK #100 left Resident #50's room and continued down the hall. The next thing the housekeeper heard was the resident was on the floor because he had fallen out of his chair. Review of Physical Therapy Assistant #102's statement dated 01/28/19 revealed she was informed the resident was possibly on the floor. She went into the resident's room and observed the resident laying on his stomach and right side with visible blood around the head area and on the floor. The resident was asking to go to bed and requesting help. Nursing arrived at the room shortly after. The resident was not incontinent and was wearing non-skid socks. On 02/07/19 at 10:01 A.M. an interview with HK #100 revealed she was working on the 100 hall on the day Resident #50 fell . HK #100 stated STNA #105, who was assigned to provide care to Resident #50, was not on the unit and had not been seen for approximately 30 minutes. HK #100 was in the resident's room cleaning and the resident kept asking her to put him to bed. The housekeeper said she told the resident she was unable to put him to bed. HK #100 stated Resident #50 always wanted to go to bed after meals and she was aware that nursing staff were to assist him to bed after meals. HK #100 revealed after she was done cleaning Resident #50's room, she went to find someone to help the resident into bed but, despite looking for 10-15 minutes on the other halls and the dining room, no nursing staff could be found to help the resident. She stated she began to hear yelling and went to the resident's room. Resident #50 was lying face down on the floor. She stated his roommate, Resident #14 had also gone to get help and therapy staff arrived. On 02/07/19 at 11:00 A.M. interview with the facility medical director, Physician #350 revealed his expectation would be for the facility to maintain adequate staffing levels to meet the needs of all residents and resident care needs were to be addressed timely. On 02/07/19 at 11:27 A.M. interview with STNA #105 revealed she was the STNA assigned to care for Resident #50 the day he fell and was sent to the hospital. The STNA stated the resident usually laid down after breakfast but the resident didn't say anything to her that morning about wanting to lay down. STNA #105 states she was unable to recall the number of STNAs working on shift that day but stated the morning was always a very busy time for the direct care staff and she had not had the chance to offer or assist the resident to lay down after breakfast. (Breakfast was at approximately 8:00 A.M. and the resident sustained [REDACTED].M.) The STNA also stated she was not on the hall because she was on another hall assisting another staff member with resident care. During the interview the STNA stated if the facility had enough staff helping during the busy morning time, she would have been able to assist Resident #50 to bed that morning and prevented the resident from trying to transfer himself to bed. Review of the Staff Schedule for 01/28/19 revealed there four STNAs scheduled for the 7:00 A.M. to 7:00 P.M. shift. STNA #105 was assigned to care for 26 Residents. On 02/07/19 at 4:30 P.M. interview with the DON revealed the facility had not identified the root cause of the fall on 01/28/19 but verified the resident was not assisted to bed per the plan of care and STNA #105 was assisting other staff on another unit with care instead of assisting Resident #50 to bed. During the interview, the concern was shared that HK #100 attempted to find staff to assist Resident #50 but was unsuccessful and STNA #105 who was the STNA assigned to care for the resident was off the unit assisting other staff. The DON was unable to provide any evidence to determine these two staffing factors did not contribute to the resident's fall. Review of the Fall Investigation, with a revision date of 02/08/19 for Resident #50 revealed the facility determined the resident fell due to STNA #105 not implementing fall interventions and HK #100 not notifying direct care staff of the resident's request to be assisted to bed. 2. On 02/05/19 at 8:50 P.M. LPNs #122 and #124, and STNAs #110, #115 and #120, were observed on duty and providing care for the 55 residents who were currently in the facility. Further clarification of the staffing revealed STNA #115 was assigned to provide one-to-one care to Resident #52, which resulted in two STNAs, STNA #110 and #120 to provide care for the remaining 54 residents. On 02/06/19 at 12:10 A.M. during an interview with STNA #110, STNA #115 and STNA #120, they revealed there were five residents, Resident #4, #22, #30, #49 and #54 who did not receive their showers as scheduled on 02/05/19 because there were not enough staff working to assist with the showers. Further interview revealed STNA #115 was assigned to provide 1:1 supervision for Resident #52 until approximately 9:30 P.M. when a hospitality aide was called in to sit with the resident after the surveyor arrived. The STNAs voiced concerns that it was too difficult to take the 11 residents (identified to be smokers) out to smoke, provide resident care including written restorative nursing programs and activities of daily living when an STNA was pulled to provide 1:1 with Resident #52 and the facility did not replace the staff member. During the interview, STNA #120 revealed concerns that Resident #54 had an odor when she assisted her to the bathroom earlier in the shift and attributed the odor to a lack of showering. On 02/06/19 at 3:00 P.M. interview with Resident #49 revealed he did not receive his shower on 02/05/19 because the facility did not have enough staff. Further interview revealed he wished the facility had adequate staffing to make sure the residents got their scheduled showers. On 02/07/19 at 1:25 P.M. interview with Resident #54 revealed she did not receive her shower on 02/05/19. The resident revealed staff had informed her they didn't have enough help to give her a shower on that day. Resident #54 stated she did not like to be dirty and would prefer to get her showers as scheduled. Review of the shower schedule revealed there were ten residents scheduled to receive showers on 02/05/19 during the 7:00 P.M. to 7:00 A.M. shift. Review of the bathing/shower documentation for 02/05/19 revealed five of the ten residents, Residents #4, #22, #30, #49 and #54 did not receive showers as scheduled on this date. On 02/06/19 at 3:00 P.M. Resident #30 was observed lying in bed. Resident #30 was noted to have a strong body odor. On 02/07/19 at 1:30 P.M. interview with STNA #130 revealed night shift often had staffing issues and residents did not always get assistance with their activities of daily living (ADL). On 02/07/19 at 4:20 P.M. interview with LPN #135 revealed there were mornings it was evident night shift staff were unable to provide all care to all residents due to a lack of staff. The LPN further revealed the lack of staff resulted in residents not getting checked and changed timely and as needed. LPN #135 stated she sometimes would work during a night shift and she would tell the STNAs when there were only two STNAs working to concentrate on the heavy wetters so they could get their work completed. LPN #135 stated heavy wetters were the residents who generally voided large amounts or voided often. On 02/08/19 at 9:25 A.M. interview with Resident #21 revealed she was independent with her personal care however, she had much concern about the residents who needed help or required the use of a wheelchair. Resident #21 revealed evening/night shift had the least amount of help and residents frequently did not get showers. Further interview revealed call lights often go unanswered on the night shift, especially around bedtime, because the staff were stretched so thin providing care to the residents. Resident #21 also stated it would be very difficult for the staff to provide adequate supervision to the residents due to the lack of staff. 3. On 02/07/19 at 6:37 P.M. interview with the restorative nurse, LPN #215, revealed the facility began to implement a restorative nursing program approximately six months ago. The LPN revealed prior to six months ago, there had been no program in place. LPN #215 stated since implementation the program relied on the direct care STNA staff to provide functional maintenance programs to the residents who had programs planned and there were no dedicated direct care staff for the delivery of restorative nursing programs. LPN #215 revealed there were currently 23 residents who had planned restorative nursing programs. Review of the program documentation revealed Resident #39 had a plan for programming to be provided during the night (7:00 P.M. to 7:00 A.M) shift. Record review revealed Resident #39 had a restorative program for self-care bathing/dressing/oral care five to seven days a week for 15 minutes a day. Record review revealed the program was only provided as written, on 01/26/19 and 01/31/19 during a 14-day review period. On 02/10/19 at 12:30 A.M. interview with STNA #330 revealed there was not enough staff working during the 7:00 P.M. to 7:00 A.M. shift to provide restorative nursing programs to residents, including Resident #39 as written. 4. Review of the facility resident council meeting minutes revealed during the meetings held on 11/27/18 and 12/26/18 the residents present at the council meeting voiced concerns related to call lights not being answered mostly on night shift. On 02/11/19 at 7:29 A.M. an interview with Resident #49 revealed he was also the Resident Council President. Resident #49 stated call lights not being answered timely was a monthly resident council concern and it was not unusual to wait 45 minutes to have your call light answered on night shift. Further interview revealed management's response to the call light concern was always we are going to try to be better. Resident #49 stated the facility had a council meeting on 02/08/19 (in the evening) to discuss the facility plan related to being short staffed but did not mention adding additional staff to ensure resident care needs were met. Resident #49 stated resident council was used for the residents to share their concerns and needs for the facility to address. Resident #49 stated the monthly meetings routinely voiced concerns regarding lack of staff, showers not being provided and call lights not being answered timely in addition to other resident concerns. Review of minutes from a resident council meeting, held by the Administrator on 02/08/19 revealed Resident #21, #49 and #26 were present. During the meeting, Resident #21 suggested the facility needed more STNA staff for night turn. The Administrator discussed with the residents the plan to ensure staff were hired including going to local schools, job fairs, bonuses for staff at the facility and advertising online and in the newspapers. 5. Review of the facility assessment dated [DATE] revealed based on the facility resident population and their needs for care and support, the facility approach to staffing was to ensure that each of the facility residents had the minimum direct care staff to meet the needs of the residents at any given time. The assessment revealed the facility strived to achieve staffing with six (6) to nine (9) State tested nursing assistants per day (24-hour period) based on staff working 12-hour shifts (7:00 A.M. to 7:00 P.M.). Review of the STNA schedule from 01/28/19 to 02/05/19 revealed the following: A) On 01/28/19 there were four STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 58 residents. B) On 01/29/19 there were three STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 57 residents. C) On 01/30/19 there were four STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 59 residents. D) On 01/31/19 there were three STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 60 residents. E) On 02/01/19 there were three STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 59 residents. F) On 02/02/19 there were three STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 60 residents. G) On 02/03/19 there were three STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 61 residents. H) On 02/04/19 there were three STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 58 residents. I) On 02/05/19 there were three STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 57 residents. An interview on 02/07/19 at 10:11 A.M. with the Administrator revealed the facility had pulled an STNA to provide 1:1 care to a resident during the dates reviewed above. This STNA was originally figured into the staffing numbers and was not replaced, leaving only two STNA's to provide care for the remaining facility residents. The Administrator revealed the facility had a higher population of residents with behaviors. Review of the staffing assignments revealed the facility was counting the staff member providing the 1:1 supervision in the total amount of direct care staff hours for the entire facility and did identify this was not an accurate reflection of the staffing being provided. On 02/07/19 at 4:30 P.M. interview with Scheduler #205 verified the schedule did not reflect that one staff member was providing only 1:1 supervision and indicated the facility did not meet the facility assessed staffing levels for all residents in the facility on the dates noted above. On 02/11/19 at 7:38 A.M. interview with Scheduler #205 revealed she generally tried to schedule three to four STNAs for 7:00 A.M. to 7:00 P.M. and two to three STNAs on 7:00 P.M. to 7:00 A.M. Further interview revealed once Resident #52 began 1:1 on 01/28/19, management staff were used during the week from 7:00 A.M. to 7:00 P.M. Scheduler #205 stated she attempted to call additional staff in to be 1:1 with Resident #52, but if no one would pick up the shift, the 1:1 staff member for Resident #52 would be pulled from the direct care staff providing care to the other residents in the facility. During the onsite investigation, from 02/05/19 through 02/08/19 the surveyor requested to review facility staffing policies and procedures. No policies were provided to review. On 02/08/19 at 10:11 A.M interview with the Administrator revealed the facility did not have any type of staffing policies or protocol for 1:1 staffing. On 02/11/19 at 10:54 A.M. interview with RN #400 revealed although the facility had not implemented any type of policy and procedure for staffing related to residents who required 1:1 supervision, a memo was written, dated 02/08/19 by Senior Administrator #405 and training was provided to the Administrator and DON which indicated it was the practice of the facility that staff assigned to 1:1 supervision would not be counted into the staffing calculations. On 02/11/19 at 11:05 A.M. RN #400 provided a policy and procedure, revised 05/22/18 and titled Unit Supervision indicating this was one of two facility staffing policies. Review of the document revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for our residents, staff and visitors. The Unit Supervisor was a licensed nurse with the skills and competencies to safely and appropriately monitor and delegate tasks to others and perform duties consistent with safe and effective care and treatment of [REDACTED]. On 02/11/9 at 12:05 P.M. interview with the DON revealed the facility did not have a designated unit supervisor but rather all nurses were responsible to monitor and delegate tasks and if any concerns with staffing were identified, they were to be communicated to her as the DON for follow up. The DON stated when only two STNAs were scheduled or working, then all attempts would be made to call someone in who was off and if that was unsuccessful then management and licensed nurses should be assigned to provide direct resident care. There was no additional information provided as to why this did not occur during the night shifts reviewed from 01/28/19 to 02/05/19. Review of the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, QSO-19-02-NH Memo, dated 11/30/18 related to Payroll Based Journal (PBJ) revealed while CMS was encouraged by facilities' efforts to improve staffing, they were also concerned about some of the findings from the new PBJ data. For example, some facilities were reporting several days in a quarter without an RN onsite and/or significantly low nurse staffing levels on weekends. Review of the PBJ data for (MONTH) (YEAR) revealed the facility had reported low levels of weekend staffing. Review of the facility State agency survey history revealed concerns were identified related to the facility staffing levels and lack of staff to meet the total care needs of all residents during the surveys completed in the facility on 09/26/17, 09/19/18 and 11/08/18. Based on the onsite survey investigation, beginning on 02/05/19 review of the facility staffing revealed continued concerns related to staffing. The facility failed to provide adequate evidence and ensure sustainable corrective actions were developed and implemented to ensure staffing levels were being maintained to meet the total care needs of all residents. This deficiency substantiates Complaint Number OH 325.

Based on record reviews, survey history review, facility plan of correction review, review of the Quality Assurance Performance Improvement Plan (QAPI) policy review and interviews with staff and Physician #305 the facility failed develop and implement an effective QAPI program to correct quality concerns with respect to staffing levels to ensure resident safety and provision of care. This resulted in Immediate Jeopardy when one unit was left unattended by staff resulting in Resident #50 attempting to self-transfer himself to bed. Actual harm occurred on 01/28/19 at approximately 10:25 A.M. when no staff were available to assist Resident #50 back to bed after the breakfast meal and the resident attempted to self-transfer himself sustaining a fall which resulted in multiple facial fractures and a subdural hematoma which required a hospital stay in the Intensive Care Unit. In addition, based on resident and staff interviews, the lack of staffing resulted in personal care, including showers, restorative nursing care and toileting not being provided timely for all residents. This had the potential to affect the resident population of 57 residents. On 02/07/19 at 5:55 P.M. the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 01/28/19 at approximately 10:25 A.M. when no staff were available to assist Resident #50, who was assessed to be at risk for falls and had care plan interventions to be assisted by staff to bed after meals, attempted to transfer himself back to bed after repeatedly asking Housekeeper #100 to assist him to bed. The resident sustained [REDACTED]. The facility also failed to maintain adequate staffing levels to meet the needs of all residents and failed to identify systemic failures related to staffing and accidents with effective and sustainable resolution during the QAPI process. The Immediate Jeopardy was removed on 02/11/19 when the facility implemented the following corrective action: · On 02/08/19 Regional Director of Operations #305 educated the Administrator, DON and Human Resource Manager (HRM) #210 on daily staffing review and ensuring adequate staffing levels were scheduled to meet residents needs per the facility assessment. · On 02/08/19 the Administrator provided one-to-one education to STNA #105 (the STNA assigned to care for Resident #50 on 01/28/19) and Housekeeper #100 with an emphasis on ensuring all residents, including Resident #50 received timely care and care based on their identified needs. · On 02/08/19 the Administrator conducted a resident council meeting, as part of the facility plan of correction, with Resident #21, #49 and #26 present. During the meeting, Resident #21 suggested the facility needed more STNA staff for night turn. The Administrator discussed with the residents the plan to ensure staff were hired including going to local schools, job fairs, bonuses for staff at the facility and advertising online and in the newspapers. · An Ad-H[NAME] Quality Assurance (QA) meeting was held on 02/08/19 at 3:00 P.M. which included the Administrator, DON, ADON, Registered Nurse (RN) #218, RN #225, Licensed Practical Nurse (LPN) #101, LPN #215, Business Office Manager #77, Maintenance Director #800, Social Services Director #80 and Human Resource Manager (HRM) #210 to review fall prevention, staffing levels required to meet the care needs of the residents per the facility assessment and the facility QAPI plan. · Beginning on 02/08/19 a plan for the facility to conduct weekly QAPI meetings for three months to review the facility fall prevention program, staffing levels to meet care needs of residents per the facility assessment and continued compliance of the QAPI Plan was implemented. Beginning the week of 02/18/19 the facility planned to include a direct care licensed nurse and direct care STNA to the meetings, in addition to the QA committee members noted above. · On 02/08/19 Regional Director of Operations #305 provided education to the facility QAPI committee consisting of the Administrator, DON, ADON, RN #218, #225, LPN #101, LPN #215, BOM #77, Maintenance Director #800, SSD #80 and HRM #210 regarding the QAPI Plan. On 02/08/19 the members of the QAPI Committee provided education to all facility staff regarding how to bring an issue to QAPI. As of 02/09/19 all 67 facility employees had received the education. · Beginning on 02/08/19 a plan for Regional Director of Operations #305 and RN #400 to review weekly QA meeting content for three months and monthly thereafter to ensure continued compliance was implemented. · On 02/08/19 SSD #200 conducted interviews with five facility staff, Hospitality Aide #199, LPN #700, LPN #101, STNA #600 and Human Resource Manager #210 and asked if there was adequate staff for the facility. LPN #700 and STNA #600 indicated there was not enough staff. Beginning on 02/11/19 RN #400 implemented a plan for all 41 nursing staff to be interviewed regarding staffing and for follow up to be conducted with LPN #700 and STNA #600. · On 02/10/10 SSD #200 conducted resident interviews with 21 of 23 residents identified to be interviewable. Five residents, Resident #4, #16, #21, #49 and #55 indicated they did not feel there was enough staff available to make sure care and assistance was provided without having to wait a long time. · On 02/11/19 SSD #200 initiated follow up with Resident #4, #16, #21, #49 and #55 to determine why the residents did not feel there was enough staff and to determine what care needs were not being met based on a lack of staff. · Beginning on 02/11/19 RN #400 provided a plan for the facility to conduct call light audits on an ongoing basis. · Beginning on 02/11/19 a plan for the QA committee members to complete 10 resident interviews per week for four weeks and then monthly for three months for residents assessed to be interviewable to ensure resident needs were being met. The results of these interviews will be reviewed during weekly QAPI meeting and appropriate facility adjustments made as determined by issues identified in interviews. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance. Findings include: 1. Review of the facility survey history revealed the following previously identified concerns related to facility staffing and accident hazards: During the annual survey completed on 09/26/17 a deficiency was issued related to inadequate staffing levels to ensure all residents received the care and services necessary to maintain their highest practicable well-being related to restorative services and resident supervision. The facility alleged compliance on 11/02/17, utilizing QAPI to review audits and determine if further monitoring would be needed. During a complaint survey completed on 09/19/18 a deficiency was issued related to insufficient levels of nursing staff to ensure all residents received adequate and timely care. The facility alleged compliance on 10/19/18 utilizing QAPI to review audits of medication administration and daily staffing meeting to ensure the needs of the residents were met. During the annual survey completed on 11/08/18 a deficiency was issued related to insufficient nursing and direct care staff to ensure all residents received the necessary care and services to attain the residents highest level of well-being. The facility alleged compliance on 12/18/18 utilizing a daily staffing meeting, a nurse manager on-call schedule and five resident interviews per week to ensure resident care needs were being met. The results of the interviews were to be reviewed with the QAPI committee. In addition, during the annual survey completed on 11/08/18 a deficiency was issued related to accident hazards/falls at Data Tag F689. Concerns identified included new fall interventions not being implemented after a fall. The facility alleged compliance on 12/18/18. Falls were to be audited during the morning clinical meeting weekly for four weeks and then monthly to ensure new fall interventions were implemented and root cause of the fall was completed with the fall investigations. The results of the audits would be reviewed in the QAPI committee. During a complaint survey completed on 01/09/19 a deficiency was issued related to accident hazards at Data Tag F689 related to the facility's failure to provide adequate supervision to prevent a resident elopement. The facility alleged compliance on 02/05/19. The facility was to audit resident documentation weekly and report the audit results to be reviewed with the facility QAPI committee. Review of the facility assessment dated [DATE] revealed based on the facility resident population and their needs for care and support, the facility approach to staffing was to ensure that each of the facility residents had the minimum direct care staff to meet the needs of the residents at any given time. The assessment revealed the facility strived to achieve staffing with six (6) to nine (9) state tested nursing assistants per day (24-hour period) based on staff working 12-hour shifts (7:00 A.M. to 7:00 P.M.). Review of the staffing meeting minutes for 02/05/19 (completed as part of the facility plan of correction from the 11/08/18 annual survey) revealed staffing was reviewed and determined three STNAs were working on the night shift (7:00 P.M. to 7:00 A.M.). However, this review did not account for one of the three assigned STNAs was providing one-to-one supervision for Resident #52, therefore leaving only two STNAs to provide care for the remaining 54 residents residing in the facility, a staffing ratio of 27:1 for the STNAs. Review of the staffing patterns revealed the following: A) On 01/28/19 there were four STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 58 residents. B) On 01/29/19 there were three STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 57 residents. C) On 01/30/19 there were four STNAs who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 59 residents. D) On 01/31/19 there were three STNA who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 60 residents. E) On 02/01/19 there were three STNA who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 59 residents. F) On 02/02/19 there were three STNA who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 60 residents. G) On 02/03/19 there were three STNA who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 61 residents. H) On 02/04/19 there were three STNA who worked from 7:00 A.M. to 7:00 P.M. and two STNAs who worked from 7:00 P.M. to 7:00 A.M. to care for 58 residents. Based on the above review of staffing, not only did the facility fail to meet the minimum staffing requirements based on the facility assessment, the facility QAPI process failed to identify and correct this staffing issue. Resident #52 required one-to- one supervision beginning on 01/28/19 and the most recent facility QA meeting occurred on 01/31/19. On 02/11/19 at 5:15 P.M. interview with HRM #210 revealed there were three STNA staff scheduled on the night shift upon review of the staffing but she was unable to recall if, upon review of the staffing, the team identified that one of the three was required to provide one on-to-care to Resident #52. HRM #210 revealed she attended the monthly QA meetings and the facility discussed open positions. HRM #210 provided no evidence the QA team discussed topics identified as part of previous facility plans of correction including a daily staffing meeting to ensure the needs of the residents were met, a nurse manager on-call schedule and five resident interviews per week to ensure resident care needs were being met. During the interview with HRM #210, the HRM revealed the facility has had open positions on night shift since the (MONTH) (YEAR) QAPI meeting and recently had two STNA resignations as well as a nurse resignation on night shift (in (MONTH) 2019). 2. The facility failed to ensure Resident #50, who was assessed to be at risk for falls and had care planned interventions for staff to assist the resident to lay down after meals, was provided timely care to prevent a fall with injury. This resulted in Immediate Jeopardy on 01/28/19 at approximately 10:25 A.M. when no staff were present on the unit to assist Resident #50 back to bed resulting in the resident attempting to transfer himself. Resident #50 had a history of [REDACTED]. Actual Harm occurred when after repeatedly asking Housekeeper #100 to help him to bed, Resident #50 fell during the self-transfer and sustained multiple facial fractures and a subdural hematoma. The resident was subsequently hospitalized in the intensive care unit at a tertiary hospital. (See findings at F689). 3. The facility failed to provide sufficient and adequate nursing staff to ensure all residents received appropriate car with activities of daily living resulting in showers not being completed, incontinence care not being delivered and restorative nursing programs not being implemented. The lack of sufficient and adequate staff resulted in Resident #50 not being provided timely fall interventions to prevent a fall with injury and additional residents not receiving timely personal care, including showers. (See findings at F725) On 02/07/19 at 11:00 A.M. interview with the facility Medical Director, Physician #350 revealed his expectation would be for the facility to maintain adequate staffing levels to meet the needs of all residents and resident care needs were to be addressed timely. During the interview, Physician #350 revealed he was unaware of any staffing concerns because the facility had not reported to him or informed him of any concerns. Review of the QAPI attendance record dated 01/31/19 revealed the medical director did not attend the meeting but was contacted via telephone. Review of meeting documentation revealed, topics of discussion included ways to identify residents at risk for falls, reviewing falls and staff retention and turnover. In addition, review of the (MONTH) (YEAR) QAPI meeting minutes revealed no evidence the medical director was part of the meeting. On 02/11/19 at 5:10 P.M. telephone interview with the Administrator revealed his employment with the facility began in mid-December (YEAR) (exact date not provided). In regards to the QAPI meeting held on 01/31/19, he stated the medical director was not present or part of the meeting but he called him and left a message with the physician's answering service regarding the resident elopement that was cited during the complaint investigation on 01/09/19. The Administrator denied discussing any additional information related to facility staffing or falls. In addition, there was no evidence the Administrator discussed comprehensive or sustainable action plans related to falls and/or staffing as noted during the above surveys with the medical director or during the QAPI meetings held in (MONTH) (YEAR) or (MONTH) 2019. The Administrator also indicated the Medical Director was not present for the (MONTH) (YEAR) QAPI meeting. Review of the facility QAPI Plan policy, dated 10/01/17 revealed QA was the process of meeting quality standards and assuring the care reaches an acceptable level. The facility would identify standards of quality based on meeting regulations and would also create standards that go beyond regulation. QA was a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities did improve quality, but efforts could end once the standard was met. Performance improvement (PI), also called quality improvement was a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying persistent/systemic problems. PI aimed to improve processes involved in health care delivery and resident quality of life. PI could improve quality. QAPI was identified to be data driven and was a proactive approach to improving quality of life, care and services. The activities of QAPI involved members at all levels of the organization to: identify opportunities for improvement, address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions. The policy included QAPI data was not only to identify quality and safety problems, but to also identify other opportunities for improvement, and then setting priorities for action. QAPI focused on identifying and undertaking systemic change to eliminate problems after the root cause is determined. The QAPI committee was to include the Executive Director (Administrator), DON, Medical Director, three other staff and other state required attendees. The facility policy indicated a QAPI meeting would be held every month and the required members would be present. Members would review any trends or other facility data that required additional review. On 02/11/19 at 5:30 P.M. interview with Regional Director of Operations #305 and RN #400 revealed concerns were identified related to the repeat deficiencies issued regarding facility staffing during the (YEAR) and (YEAR) annual surveys as well as a complaint survey in 09/2018. Concerns were also shared regarding the repeat deficiencies issued related to accident hazards/falls as noted above. The concern was shared that the lack of effective and sustainable corrective actions taken via a QAPI process contributed to the ongoing concerns with staffing and accident hazards identified during the current complaint investigation, that began on 02/05/19. Regional Director of Operations #305 and RN #400 were unable to provide any additional information to determine the facility had an effective QAPI process in place to correct quality deficiencies and maintain compliance with the regulatory requirements for staffing and accident hazards. This deficiency is an incidental finding to Complaint Number OH 325.

Based on observation, review of the medical record review, fall investigation, fall policy, hospital records, staff and resident interview, interview with Physician #350, review of staff assignment sheets and schedule review the facility failed to ensure Resident #50, who was assessed to be at risk for falls and had care planned interventions for staff to assist the resident to lay down after meals, was provided timely care to prevent a fall with injury. This resulted in Immediate Jeopardy on 01/28/19 at approximately 10:25 A.M. when staff were not available to assist Resident #50 back to bed resulting in the resident attempting to transfer himself. Actual Harm occurred when after repeatedly asking Housekeeper #100 to help him to bed, Resident #50 fell during a self-transfer and sustained multiple facial fractures and a subdural hematoma. The resident was subsequently hospitalized in the intensive care unit at a tertiary hospital. This affected one (#50) of three residents reviewed for falls. The facility census was 57. On 02/07/19 at 5:55 P.M. the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 01/28/19 at approximately 10:25 A.M. when, due to a lack of available staff, Resident #50 attempted to self-transfer himself to bed, over two hours following the breakfast meal. During the transfer, the resident fell , resulting in an admission to the hospital intensive care unit for treatment of [REDACTED]. The Immediate Jeopardy was removed on 02/09/19 when the facility implemented the following corrective action: · On 02/08/19 the DON reassessed Resident #50's fall risk and the residents plan of care was updated to ensure appropriate fall interventions were in place. · On 02/08/19 the Administrator provided one-to-one education to State tested Nurse Aide (STNA) #105 (the STNA assigned to care for Resident #50 on 01/28/19) and Housekeeper #100 with an emphasis on ensuring all residents, including Resident #50 received timely care and care based on their identified needs. · Beginning on 02/08/19 the DON, ADON, Registered Nurse (RN) #225, RN #218, Licensed Practical Nurse (LPN) #101 and LPN #215 reassessed all current residents residing in the facility utilizing the Fall Observation Tool to ensure risk factors, safety measures and resident specific fall interventions were in place and reflected on the resident ' s plan of care and STNA Kardex information. · On 02/08/19 the Regional Clinical Team, RN #700, RN #701 and LPN #702 reviewed all falls that had occurred in the facility for the previous 90 days to determine the root cause of the falls and to ensure appropriate interventions had been determined and care planned. · On 02/08/19 Regional Director of Operations #305 provided education to the Administrator, DON and Human Resource Manager #210 related to the daily staffing review and to ensure adequate staffing levels were scheduled to meet the residents' needs per the facility assessment for staffing to prevent resident falls. · On 02/08/19 the DON provided education to facility STNA staff to review all Kardex information at the beginning of each shift to ensure STNA staff were aware of resident care needs. As of 02/09/19 all 20 STNAs employed by the facility had been educated. · Beginning on 02/08/19 the DON, ADON, RN #225, RN #218, LPN #101 and LPN #215 provided education for all facility nursing staff regarding the Fall Prevention Program guidelines. As of 02/09/19, 41 of 41 nursing staff had received the education. Beginning on 02/08/19 non-nursing staff were educated on all risk factors and safety measures. As of 02/09/19, 26 of 26 non-nursing facility employees had received the education. · Beginning on 02/08/19 a plan for the DON, ADON and LPN #101 to audit all new admissions, no later than the next working day following admission for three months to ensure the Fall Observation Tool was completed on admission and to ensure risk factors, safety measures and resident specific fall interventions were in place. · Beginning on 02/08/19 a plan for the DON/designee to review all falls during the daily clinical meeting for three months to ensure appropriate fall interventions were implemented and the residents plan of care was reviewed and revised. · Beginning on 02/08/19 a plan for a review of the above fall information during weekly Quality Assessment Performance Improvement (QAPI) meetings was implemented for an indefinite period of time. · Beginning on 02/08/19 a plan for the Administrator to review daily staffing minutes weekly for three months during weekly QAPI meetings was implemented. · Beginning on 02/08/19 a plan for Regional Director of Operations #305 to review the projected staffing schedule weekly for three months to ensure compliance with staffing was implemented. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance. Findings include: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care was initiated on 09/11/18 reflecting the resident was at risk for falls related to incontinence, cognition and medications. On 09/11/18 an intervention was added to provide prompt response to all requests for assistance. Interventions dated 12/06/18 included anticipate and meet the resident ' s needs, ensure call light was within reach and encourage resident to use it for assistance as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/07/18 revealed Resident #50 had severe cognitive impairment and required extensive assistance from one staff member for bed mobility, transfers, walking in his room and corridor, dressing, toilet use and personal hygiene. The resident was assessed to require supervision from staff with mobility on and off the unit. The resident was assessed to be frequently incontinent of bowel and bladder. Record review revealed Resident #50 sustained falls on 01/14/19 while ambulating unassisted, and on 01/17/19 and 01/19/19 while attempting to self-transfer from his wheelchair to the bed. Record review revealed the resident ' s plan of care was updated on 01/16/19 to reflect actual fall with no injury related to poor balance and unsteady gait. Interventions included to continue the interventions on the at risk for fall care plan. On 01/18/19 the care plan was updated for staff to offer resident to lay down after supper. On 01/21/19 the care plan was updated for staff to offer and assist Resident #50 to lay down after meals. Review of the fall risk observation tool, dated 01/19/19 revealed Resident #50 had balance problems with standing, falls within the last 30 days and was incontinent. Documentation on the tool revealed staff were to offer and assist the resident to bed after meals. Review of a late entry nursing progress note, dated 01/28/19 at 5:53 P.M., revealed Resident #50 was observed by the therapy department lying on the floor in his room. The resident was lying on his right side with visible blood from the right side of his head. The resident was assisted back to bed and 911 was called for transport to the hospital. Review of the facility investigation revealed a root cause of the fall was not identified. The resident was transferred to the emergency room for evaluation and admitted for multiple facial fractures including the anterior and lateral maxillary buttress, posterior orbital wall, the right orbital floor, infraorbital foramen and the right zygomatic arch; and a subdural hematoma. Review of the POS [REDACTED].M. revealed the resident was last seen at 10:25 A.M. by Housekeeper #100 in his room, seated in his wheelchair. The resident told Housekeeper #100 he wanted to go to bed. Review of the hospital records dated 01/28/19 to 01/31/19 revealed Resident #50 was admitted to a tertiary hospital intensive care unit on 01/28/19 status [REDACTED]. The resident returned to the facility on [DATE] with sutures to the right temporal area and appointments to follow with plastic surgery, neurosurgery and have a computed tomography scan (CT) scan of his head after discharge. As part of the facility investigation, staff statements were obtained which revealed the following: Licensed Practical Nurse (LPN) #101 observed the resident lying on his right side, on the floor. Blood was noted from a right eye laceration and his right eyebrow was ecchymotic (bruised) and [MEDICAL CONDITION] (swollen) and unable to open eye. The resident ' s right nares was actively bleeding. The resident was restless and wanting into bed. The resident was non-compliant with laying still and was assisted back to bed. Review of Housekeeper (HK) #100's statement revealed the resident was sitting in his wheelchair next to his bed. HK #100 went to the resident ' s room to clean and the resident asked her several times if she could put him in his bed and she politely told him no because she was housekeeping. HK #100 left Resident #50's room and continued down the hall. The next thing the housekeeper heard was the resident was on the floor because he had fallen out of his chair. Review of Physical Therapy Assistant #102's statement dated 01/28/19 revealed she was informed the resident was possibly on the floor. She went into the resident's room and observed the resident laying on his stomach and right side with visible blood around the head area and on the floor. The resident was asking to go to bed and requesting help. Nursing arrived at the room shortly after. The resident was not incontinent and was wearing non-skid socks. On 02/06/18 at 3:05 P.M. Resident #50 was observed lying in bed, awake. The resident had an ecchymotic area to the outer his right eye approximately two inches in width. He also had had a fading ecchymotic area to the right cheek, jaw area and extending into the right side of the neck. At the time of the observation an attempt to interview the resident revealed he could not provide information related to the fall that occurred on 01/28/19 but did say I ' m afraid to fall. On 02/07/19 10:01 A.M. interview with HK #100 revealed she was working on the 100 hall on the day Resident #50 fell . HK #100 stated State tested Nursing Assistant (STNA) #105, who was assigned to provide care to Resident #50, was not on the unit and had not been for approximately 30 minutes. HK #100 was in the resident ' s room cleaning and the resident kept asking her to put him to bed. The housekeeper said she told the resident she was unable to put him to bed. HK #100 stated the resident always wanted to go to bed after meals and she was aware that nursing staff were to assist him to bed after meals. HK #100 revealed after she was done cleaning Resident #50 ' s room, she went to find someone to help the resident in bed but, despite looking for 10-15 minutes on the other halls and the dining room, no nursing staff could be found to help the resident. She stated she began to hear yelling and went to the resident ' s room. Resident #50 was lying face down on the floor. She stated his roommate, Resident #14 had also gone to get help and therapy staff arrived. On 02/07/19 at 11:00 A.M. interview with the facility medical director, Physician #350 revealed his expectation would be for the facility to maintain adequate staffing levels to meet the needs of all residents and resident care needs were to be addressed timely. On 02/07/19 at 11:27 A.M. interview with STNA #105 revealed she was the STNA assigned to care for Resident #50 the day he fell and was sent to the hospital. The STNA stated the resident usually laid down after breakfast but the resident didn ' t say anything to her that morning about wanting to lay down. STNA #105 states she was unable to recall the number of STNAs working on shift that day but stated the morning was always a very busy time for the direct care staff and she had not had the chance to offer or assist the resident to lay down after breakfast. (Breakfast was at approximately 8:00 A.M. and the resident sustained [REDACTED].M.) The STNA also stated she was not on the hall because she was on another hall assisting another staff member with resident care. During the interview STNA #105 stated if the facility had enough staff helping during the busy morning time, she would have been able to assist Resident #50 to bed that morning and prevented the resident from trying to transfer himself to bed. Review of the Staff Schedule for 01/28/19 revealed there four STNAs scheduled for the 7:00 A.M. to 7:00 P.M. shift. STNA #105 was assigned to care for 26 Residents. On 02/07/19 at 4:30 P.M. interview with the DON revealed the facility had not identified the root cause of the fall on 01/28/19 but verified the resident was not assisted to bed per the plan of care and STNA #105 was assisting other staff on another unit with care instead of assisting Resident #50 to bed. During the interview, the concern was shared that HK #100 attempted to find staff to assist Resident #50 but was unsuccessful and STNA #105, who was the STNA assigned to care for the resident, was off the unit assisting other staff. The DON was unable to provide any evidence to determine these two staffing factors did not contribute to the resident's fall. Review of the Fall Investigation revision dated 02/08/19 for Resident #50 revealed the facility determined the resident fell due to STNA #105 not implementing fall interventions and HK #100 not notifying direct care staff of the resident ' s request to be assisted to bed. On 02/08/19 at 12:10 P.M. Resident #50 was observed attempting to push himself away from the table in the dining room and stated he wanted to go back to his room. Hospitality Aide (HA) #199 and Certified Occupational Therapy Assistant (COTA) #333 were observed in the dining room. COTA #333 told HA #199 she was going to see if Resident #50 would eat more lunch if assisted with the meal. HA #199 told COTA #333 that Resident #50 could not go back to his room alone after the meal. On 02/08/19 at 1:23 P.M. interview with STNA #599 revealed Resident #50 was afraid of falling since his return from the hospital and spent more time in bed as well. On 02/08/19 at 5:10 P.M. interview with STNA #600 revealed she provided care to Resident #50 before and after the fall that occurred on 01/28/19. The STNA indicated the resident was more tired since his return from the hospital and was afraid of falling. On 02/08/19 at 5:12 P.M. interview with STNA #603 revealed Resident #50 spent more time in bed since his return from the hospital. Review of the facility Fall Risk Observation Policy, dated 10/17/13 and revised 08/10/18 revealed a fall was defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. It was the policy of the facility to promote resident centered care by providing a fall risk observation on admission, quarterly and following any fall that occurs. The policy included to institute appropriate precautions that were individualized to the resident needs. This deficiency substantiates Complaint Number OH 325. This deficiency is also an example of continued non-compliance from the survey dated 01/09/19.

Based on medical record review, incident management log review, policy review and interview the facility failed to prevent a significant medication error from occurring involving Resident #70. This affected one resident (Resident #70) of six residents reviewed for unnecessary medication use. Actual harm occurred when Resident #70 was administered 50 units of [MEDICATION NAME] (fast-acting) insulin instead of 50 units of [MEDICATION NAME] (long-acting) insulin requiring the insertion of a peripheral intravenous (IV) line, a liter of IV [MEDICATION NAME] (an intravenous sugar solution) and an overnight hospital observation. Findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact for daily decision-making and received insulin daily. Review of the monthly physician orders [REDACTED].#70 was to be administered [MEDICATION NAME]50 units daily in the morning, and [MEDICATION NAME]before meals and at bedtime for blood sugar levels over 150. Review of the Incident Management Log dated 2017 revealed a medication error had occurred involving Resident #70 on 08/25/17. Review of Resident #70's nursing progress notes, dated 08/25/17 revealed at 9:40 A.M., Resident #70's physician was notified of a [MEDICATION NAME]administration error and ordered to start IV [MEDICATION NAME] 50 milliliters per hour (ml/hr), and to offer food and fluids. The IV [MEDICATION NAME] was to be increased to 100 ml/hr if the resident's blood glucose continued to drop. The resident was to be sent to the emergency room (ER) if the blood glucose level dropped below 150. At 9:55 A.M., Resident #70's blood glucose was 474 and she was given two glasses of orange juice with added sugar, a cereal bar and a Pepsi. At 10:30 A.M., the resident's glucose was noted to drop from 172 to 155 and the IV [MEDICATION NAME] was increased to 100 ml/hr. At 11:30 A.M., the resident's glucose level was 115 and Resident #70 complained of feeling a little shaky. At that time, emergency medical service (EMS) was called and the resident was sent to the hospital for evaluation. Review of the EMS Report dated 08/25/17 revealed the resident's blood glucose level was 88 at 11:48 A.M Review of the hospital Discharge Summary dated 08/26/17 revealed resident was diagnosed with [REDACTED]. On 09/19/17 at 12:09 P.M., interview with Resident #70 revealed a nurse gave her the wrong dose of insulin resulting in her having to receive IV fluids and an overnight stay at the hospital. On 09/20/17 at 9:16 A.M. interview with Licensed Practical Nurse (LPN) #57 revealed on 08/25/17 she had to work over due to a call-off and she was tired. LPN #57 stated after completing the morning accu-checks (glucose monitoring), she went to the medication cart to prepare the resident's sliding scale insulin; however, the [MEDICATION NAME] flex pen bag was empty. LPN #57 stated she borrowed a vial of [MEDICATION NAME] from another resident, drew up 12 units and administered the insulin to Resident #70. At approximately 9:40 A.M., LPN #57 began preparing the resident's morning medications including an order for [REDACTED].#57 stated there was a pharmacy bag labeled [MEDICATION NAME] insulin, she pulled the flex pen out of the bag, set the pen to 50 units, and administered the insulin. After giving the dose she returned the pen into the bag and that's when she realized that it was a [MEDICATION NAME] pen inside the [MEDICATION NAME] pharmacy bag. She double checked the cart and then immediately went to the Director of Nursing and reported the medication error. At the time of the medication error, the residents glucose level was 474. The LPN stated she called the physician and spoke to the nurse practitioner who ordered [MEDICATION NAME] 0.9% 50 ml/hr and the resident was also given two cups of orange juice with four packets of regular sugar, a cereal bar and a Pepsi. LPN #57 stated the resident's glucose was monitored every 15 minutes and a drop in the glucose was noted. Once the resident's glucose dropped to 115, the resident was sent out to the ER for evaluation. The resident was admitted to the hospital with [REDACTED]. Review of the policy: General Dose Preparation and Medication Administration revised 01/01/13 revealed facility staff were to verify each time a medication was administered that it was the correct medication at the correct dose, route, rate, time and person. Staff were to verify that the medication name and dose were correct and should inspect the medication.

Based on closed medical record review, policy review and staff interview, the facility failed to ensure preventative measures were in place to prevent the deterioration of a pressure ulcer for Resident #79. This resulted in actual harm when Resident #79 experienced a decline in the stage of a pressure ulcer from a Stage I pressure ulcer to a Stage III pressure ulcer. This affected one resident (Resident #79) of two residents reviewed for pressure ulcers. The facility identified four residents currently with pressure ulcers. The facility census was 57. Findings include: Review of Resident #79's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of nurse's notes upon admission identified the skin to resident's coccyx was red/purplish in color with no open areas. Review of the Weekly Pressure Ulcer Progress Report, dated 01/13/15 identified a wound to the coccyx as a Stage I pressure ulcer (defined area of persistent redness) measuring eight centimeters (cm) by six cm. Relief device interventions identified on the Weekly Pressure Ulcer Progress Report indicated only a pressure relief mattress. There was no evidence of a pressure relief cushion for use when up in a chair or wheelchair. Review of the Weekly Pressure Ulcer Progress Report revealed a decline in the wound when the coccyx wound declined to a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) on 01/21/15. Relief device interventions identified on the Weekly Pressure Ulcer Progress Report indicated only a flow mattress with pump (pressure relief mattress). There was no evidence of a pressure relief cushion for use when up in a chair or wheelchair. On 02/09/15 the wound further deteriorated to a Stage III pressure ulcer (full thickness skin loss) per the Weekly Pressure Ulcer Progress Report. Relief device interventions identified on the Weekly Pressure Ulcer Progress Report indicated only a flow mattress with pump (pressure relief mattress). There was no evidence of a pressure relief cushion for use when up in a chair or wheelchair. Review of physician's orders revealed no evidence of any orders for the use of a pressure relief cushion when up in a chair. Review of the plan of care for Resident #79 identified the Stage I pressure ulcer to the coccyx. Interventions included the use of a cushion for pressure reduction when resident was in a chair as needed. Review of the facility policy and procedure Pressure Ulcer Prevention Protocols/Risk Assessment with a revision date of 01/08 indicated resident's will automatically be high risk when admitted with any pressure ulcers. Review of the facility policy and procedure Care Standards for Pressure Ulcer Prevention/Supportive Precautions for High Risk with a revision date of 01/08 indicated to utilize pressure reduction cushion when resident is in chair. Review of the Minimum Data Set (MDS) 3.0 assessment with a reference date of 01/20/15 identified the resident as at risk for development of pressure ulcer and currently having a Stage one pressure ulcer. No pressure reducing device for a chair was identified. Review of an additional MDS assessment dated [DATE], again, identified no pressure reducing device in use when in a chair. Additional review of nurse's notes identified that the resident was frequently up in a wheelchair throughout the day. No evidence was found of any use of a pressure reducing cushion when up in a chair. Review of the treatment administration record (TAR) also revealed no indication of the use of a pressure reducing cushion when up in a chair. Interview with the Director of Nursing (DON) on 05/20/15 at 11:20 A.M. verified no evidence of a pressure reduction cushion being in place for Resident #79. The DON verified the pressure ulcer to the resident's coccyx was assessed to have deteriorated while the resident resided in the facility. The pressure ulcer went from a Stage I pressure ulcer on 01/13/15 to a Stage III pressure ulcer on 02/09/15.