Every finding on record at Eastland Rehabilitation and Nursing Center

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure that vital signs were monitored as ordered prior to the administration of medication. This affected one (Resident #70) of eight residents reviewed for medications. The facility census was 92 residents. Findings include: Review of the medical record for Resident #70 revealed an admission date of 07/12/25 with diagnoses including cerebral palsy, chronic diastolic (congestive) heart failure, and cardiomyopathy. Review of the care plan for Resident #70 revealed the resident had a diagnosis of diastolic heart failure with interventions including to monitor vital signs and to notify the physician of significant abnormalities. Review of the physician's orders for Resident #70 revealed an order dated 07/12/25 for Entresto 24-26 milligrams (mg) twice a day and to hold if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 80. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 06/30/26 revealed the resident had severe cognitive impairment. Review of the Medication Administration Record (MAR) for Resident #70 dated 07/07/26 revealed there was no documentation of a blood pressure reading prior to Entresto administration. Observation of medication administration on 07/07/2026 at 7:43 A.M. revealed Registered Nurse (RN) #344 did not obtain or attempt to obtain a blood pressure prior to administration of Entresto. Interview 07/07/26 at 9:35 A.M. with RN #344 confirmed Resident #70's Entresto had parameters for administration, but the nurse did not take the resident's blood pressure prior to administration. Review of the facility policy titled Administering Medications dated December 2012 revealed if ordered vital signs must be checked/verified for each resident prior to administering medications. This deficiency represents noncompliance investigated under Complaint Number 3021579.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were stored appropriately. This affected one (Resident #13) of eight residents reviewed for medications. The facility census was 92 residents.Findings include:Review of medical record for Resident #13 revealed an admission date of 02/13/25 with diagnoses including bipolar disorder, emphysema, peripheral vascular disease, and gastro-esophageal reflux disease (GERD.) Reviewed the care plan for Resident #13 dated 02/13/25 revealed the resident had impaired cognitive function, impaired thought processes related to bipolar disorder, delusional disorder, paranoid schizophrenia with an intervention to include administer medications as ordered. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 05/09/26 revealed the resident had moderate cognitive impairment and required supervision for activities of daily living (ADLs) Review of the physician's orders for Resident #13 revealed an order dated 05/13/26 for omeprazole oral capsule delayed release 40 milligrams (mg) one capsule by mouth once daily for GERD and order dated 06/17/26 for magnesium oxide 400 mg one tablet by mouth once daily. Observation on 07/07/26 at 9:57 A.M. revealed there was a medication cup with two tablets left sitting on Resident #13's bedside table. Interview on 07/07/26 at 9:57 A.M. with RN #346 confirmed the medications on Resident #13's bedside table were omeprazole and magnesium oxide. RN #346 stated she gave the medications to Resident #13 but did not observe her taking the medication. Interview on 07/07/26 at 2:20 P.M. with the Administrator #108 confirmed if Resident #13 was allowed to self-administer her medications, then she would have an order to self-administer medications. If there was no order to self-administrator medications, then Resident #13 would not be allowed to self-administer her own medications. Interview on 07/07/26 at 2:57 P.M. with the Director of Nursing (DON) verified Resident #13 did not have an order to self-administer medications. Review of the facility policy titled Administering Medications dated December 2012 revealed medications should be administered in a safe and timely manner, and as prescribed. This deficiency represents noncompliance investigated under Complaint Number 3021579.

Based on review of the medical record, review of hospital records, staff interviews, and review of facility policies, the facility failed to ensure accuracy of the medical record related to residents neurological assessments. This affected two Residents (#54 and #78) of three reviewed for falls. The facility census was 76. Findings include: 1. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] and had diagnoses that included encephalopathy, chronic obstructive pulmonary disorder (COPD), and psychotic disturbance. Review of Resident #78's Minimum Data Set (MDS) 3.0 assessment completed 03/01/26 indicated the resident had severe cognitive impairment. Further review of the medical record for Resident #78 revealed the resident suffered an unwitnessed fall that was discovered about 2:00 A.M. on 4/12/26 in which the resident suffered swelling and bruising to the left upper and lower eyelids in addition to a laceration (near) the left eye. As a result of the fall, Resident #78 was placed on neurological checks per facility protocol; checks every 15 minutes for one hour, every hour for 4 hours, then every 4 hours for 19 hours. Review of the Neurological Assessment Flow Sheet for Resident #78 revealed the facility checks were conducted on 04/12/26 at 2:00 A.M., 2:15 A.M., 2:30 A.M., 2:45 A.M., 3:00 A.M., 4:00 A.M., 5:00 A.M., 6:00 A.M., 7:00 A.M. and 11:00 A.M. Review of the 11:00 A.M. neurological assessment documentation noted the resident had a blood pressure of 122/78, a temperature of 97.8 degrees Fahrenheit, a pulse of 72 beats per minute and respirations of 18 breaths per minute. The assessment also noted the resident was alert, had an appropriate pain response, was able to move all extremities, and the residents pupils were equal and reactive to light. Review of the hospital record for Resident #78 stated the resident was admitted to the hospital at 9:54 A.M. on 04/12/26 for a fall (traumatic event). During the hospital stay, Resident #78 was diagnosed with subarachnoid hemorrhage, closed fracture of the left orbit, closed fracture of the zygomatic arch (cheek bone), and closed fracture of the maxillary sinus. Resident #78 was present at the hospital at 11:00 A.M. on 04/12/26, indicating a neurological check at the facility at 11:00 A.M. on 04/12/26 would not be possible. Interview with Administrator #81 on 05/19/26 at 1:35 P.M. confirmed there was documentation on the facility's Neurological Assessment Flow Sheet at 11:00 A.M. on 04/12/26. Administrator #81 also confirmed that the time of admission according to hospital records was 9:54 A.M. on 04/12/26. Review of facility policy titled Falls – Clinical Protocol (revised September 2012) states that staff, with physician guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as subdural hematoma have been ruled out or resolved. Review of facility policy titled Neurological Assessment (revised October 2010) revealed the neurological assessments are indicated following an unwitnessed fall. The policy states that the date and time of the (assessment) should be documented in the resident's medical record. Review of facility policy titled Charting Errors and/or Omissions (revised December 2006) states an accurate medical record shall be maintained by the facility. The policy states if an error is made while recording data in the medical record, staff are to line through the error with a single line and correct the error. 2. Review of the medical record for Resident #54 revealed an admission date of 01/13/22. Diagnoses included metabolic encephalopathy, diabetes, emphysema, dysphagia, and vascular disease. Review of the plan of care dated 06/21/22 revealed resident was at risk for falls with interventions to anticipate needs, ensure the call light was in reach, call for assistance, ensure the bed was in the lowest position, ensure resident wore appropriate footwear when ambulating, obtain laboratory services as ordered, remove bed remote, provide a reacher, and evaluate and treat. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively impaired and required substantial/maximum assistance from staff for activities of daily living and mobility. Review progress notes dated 04/25/26 at 9:30 P.M. revealed the resident was heard yelling for help. Staff observed the resident to be lying on his side on the floor and complained of pain to the right lower extremity and his head, and stated the pain had a rating of seven out of 10 (zero being no pain and 10 being the worst pain). The resident was unable to perform range of motion exercises with the lower extremities due to pain. Emergency services were contacted and the resident was transported to the hospital for evaluation. A note dated 04/25/26 at 11:05 P.M. revealed MedOne (Physician group) was notified and the resident had requested to go to the hospital. A note dated 04/26/26 at 4:38 A.M. revealed the resident was at the hospital and a note at 7:30 A.M. revealed the resident returned from the hospital with a diagnosis of closed head injury. Neurological checks were to be initiated upon his return and the resident was to be monitored for increased confusion, vomiting and headache. Review of the hospital paperwork included the hospital timeline including an arrival to the emergency room on [DATE] at 10:23 P.M. and he was discharged from the emergency room on [DATE] at 6:46 A.M. During the hospital visit, a head computed tomography scan (CT) and x-ray of the knee were completed. Review of the Neurological assessment form revealed checks were to be completed every 15 minutes for one hour, every hour for 4 hours, then every 4 hours for 19 hours. Resident #54's form dated 04/25/26 revealed they were initiated then completed at 9:30 P.M., 9:45 P.M., 10:00 P.M., 10:15 P.M., and 11:15 P.M. and on 04/26/26 at 12:15 A.M., 1:15 A.M., 2:15 A.M., 3:15 A.M., 7:15 A.M., and 11:15 A.M. After the 11:15 A.M. entry, it was marked hospital and no other neurological checks were completed. Review of the 11:15 P.M. neurological assessment documentation noted the resident had a blood pressure of 122/70, a temperature of 98 degrees Fahrenheit, a pulse of 76 beats per minute and respirations of 18 breaths per minute. The 12:15 A.M. neurological assessment documentation noted the resident had a blood pressure of 124/82, a temperature of 98 degrees Fahrenheit, a pulse of 78 beats per minute and respirations of 18 breaths per minute. The 1:15 A.M. neurological assessment documentation noted the resident had a blood pressure of 126/78, a temperature of 98 degrees Fahrenheit, a pulse of 78 beats per minute and respirations of 18 breaths per minute. The 2:15 A.M. neurological assessment documentation noted the resident had a blood pressure of 126/72, a temperature of 98 degrees Fahrenheit, a pulse of 82 beats per minute and respirations of 18 breaths per minute. The 3:15 A.M. neurological assessment documentation noted the resident had a blood pressure of 132/74, a temperature of 98 degrees Fahrenheit, a pulse of 82 beats per minute and respirations of 18 breaths per minute. The assessments all also noted the resident was alert, had an appropriate pain response, was able to move his right and left upper extremities and his left lower extremity, and the residents pupils were equal and reactive to light. The assessments from 04/25/26 at 11:15 P.M. through 04/26/26 at 3:15 A.M. were all initialed with letters consistent with Registered Nurse (RN) #230's initials. Interview on 05/18/26 at 1:49 P.M. with RN #230 revealed she found Resident #54 on the ground after the fall. RN #230 reported she had assessed the resident for injuries and contacted 911 for emergency transport to the hospital. She reported she conducted an assessment which included a neurological assessment and confirmed she did not complete any additional neurological checks as the resident had then transferred to the hospital. Interview on 05/18/26 at 2:10 P.M. with Regional Nurse #250 confirmed the neurological assessments documented on the form did not match the times the resident was at the facility and confirmed he was hospitalized for several of the neurological checks that were documented as completed. Interview on 05/18/26 at 2:20 P.M. with RN #210 confirmed she did not do any neurological assessments when Resident #54 returned from the hospital. She confirmed she did not check his neurological status and denied filling out the neurological assessment form. Interview on 05/18/26 at 3:00 P.M. with the Administrator and Regional Director of Operations confirmed the neurological assessment form for Resident #54 had entries during the residents hospitalization and confirmed the form contained documentation errors. Review of facility policy titled Neurological Assessment (revised October 2010) revealed the neurological assessments are indicated following an unwitnessed fall. The policy states that the date and time of the (assessment) should be documented in the resident's medical record. Review of facility policy titled Charting Errors and/or Omissions (revised December 2006) states an accurate medical record shall be maintained by the facility. The policy states if an error is made while recording data in the medical record, staff are to line through the error with a single line and correct the error.

Based on closed medical record review and interview, the facility failed to timely report a change in condition to Resident #20's physician. This affected one resident (#20) of three residents reviewed for change in condition. The facility census was 83. Findings include:Review of the closed medical record for Resident #20 revealed an admission date of 04/11/25 with medical diagnoses including dementia, major depressive disorder, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, age-related osteoporosis, heart failure, and high blood pressure. Review of Resident #20's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 7 indicating severely impaired cognition. Resident #20 required assistance with activities of daily living tasks. Review of the nursing progress notes dated 09/29/25 at 12:00 A.M. revealed Resident #20 was seen by the Certified Nurse Practitioner (CNP) #225 due to pain and edema in her left knee. Resident #20 stated she was experiencing pain in her left knee and had noticed swelling in the area. The physician ordered an x-ray of the knee. A follow up note dated 09/30/25 at 12:00 A.M. authored by CNP #225 referenced Resident #20's knee with increased edema and pain. The x-ray results revealed an indication of distal fracture fragments. The note referenced the resident would be sent to a local hospital's emergency room (ER) for further evaluation and management. Interviews conducted on 10/09/25 between 2:00 P.M. and 5:45 P.M. with Certified Nursing Assistant (CNA) #101 and CNA #102 revealed Resident #20 had complained to the two CNAs on 09/24/25 and 09/25/25 about increased left knee pain which prevented her from engaging in activities of daily living. Both CNAs reported observing Resident #20's knee as swollen and both CNAs confirmed they had reported these findings to the (unspecified) nurse on duty. Interview with Registered Nurse (RN) #125 on 10/09/25 at 2:47 P.M. revealed she confirmed that CNA #101 had reported Resident #20's knee as swollen to her on 09/24/25. On this date, RN #125 assessed the knee and administered the resident her routine pain medications. RN #125 confirmed she did not report her assessment findings to the resident's physician because she believed the findings to be attributed to cellulitis, for which the resident was currently being treated. Interview with CNP #225 on 10/14/25 at 11:35 A.M. confirmed the cellulitis would not have impacted Resident #20's knee since the cellulitis was related to a wound on the resident's lower leg. CNP #225 confirmed that neither she nor the resident's physician was notified about Resident #20's increased reports of pain or swelling in her knee until 09/29/25. This deficiency represents non-compliance investigated under Complaint Numbers 2640272 and 2637095.

Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to prevent the development and/or worsening of pressure ulcers and to ensure adequate and appropriate interventions/treatments were in place as ordered and to promote healing. This affected two residents (#40 and #49) of two residents reviewed for pressure ulcers. The facility census was 76. Actual harm occurred beginning on 04/10/25 when Resident #49, who was cognitively impaired, rarely/never understood and dependent on staff for activities of daily living was assessed by Wound Certified Nurse Practitioner (CNP) #1200 to have a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) to the sacrum. The resident had been admitted to the facility on [DATE] with a Stage III pressure ulcer (An ulcer with full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) to the area with a lack of assessment, monitoring and/or intervention to prevent the decline. Following admission, the resident's sacral pressure ulcer continued to deteriorate and became infected with contributing factors including duplicate, inaccurate, and missed treatment applications as well as missed antibiotic medication doses and a lack of effective pressure ulcer reducing interventions. On 05/15/25 the resident was transferred to the hospital and admitted for treatment of a Stage IV pressure ulcer and osteomyelitis. Findings include: 1. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses including adult failure to thrive, Alzheimer's disease, anxiety disorder, metabolic encephalopathy, and difficulty walking. Resident #49 was transferred to the hospital on 05/15/25. The resident remained hospitalized at the time of the onsite survey. Review of Resident #49's orders from admission to the facility from a transferring skilled nursing facility dated 04/02/25 revealed an order for a left knee wound. The order indicated to apply calcium alginate, Santyl (ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas) with additional gauze island daily for 30 days. (The treatment had been initiated on 03/18/25). Review of Resident #49's orders from admission to the facility from a transferring skilled nursing facility dated 04/02/25 revealed the resident had a Stage III pressure ulcer to the coccyx. Orders included apply alginate calcium, secondary gauze island with border gauze every shift, and/or when soiled until resolved at bedtime. Review of the admission skin assessment dated [DATE] revealed Resident #49 had a coccyx Stage III pressure ulcer with no descriptions or measurements of the wound included in the assessment. The assessment also included the resident had a Stage IV pressure ulcer to the left knee with no descriptions and no measurements. Review of a physician order dated 04/03/25 at 6:16 P.M. revealed an order to cleanse wound on left knee with normal saline, pat dry, use calcium alginate and cover with dry dressing every night shift for 16 days. Review of the April 2025 TAR revealed the treatment was discontinued on 04/17/25; a treatment was not documented as completed on 04/07/25 or 04/10/25. A new treatment order was obtained on 04/17/25 as the wound was not healed as of this time. Review of a physician's order dated 04/03/25 at 6:30 P.M. revealed an order to cleanse wound on sacrum (identified to be the same area previously noted as coccyx) with normal saline, pat dry, apply Santyl and cover with dry dressing every night shift for 30 days. Review of the Braden Scale for Predicting Pressure Sore Risk dated 04/03/25 revealed a score of 7.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #49 was at high risk for skin breakdown. Review of the plan of care dated 04/03/25 revealed Resident #49 had impairment to skin integrity related to incontinence, moderate protein-calorie malnutrition and pressure ulcer to the coccyx with interventions including but not limited to monitor/document location, size and treatment of the skin injury and to follow facility protocols for treatment of injury. Review of an admission evaluation completed by Facility Certified Nurse Practitioner #1000 (CNP) dated 04/07/25 reflected Resident #49 had a wound to the sacrum and to follow with in house wound (care). Review of an admission evaluation by Facility Medical Director #2000 (MD) dated 04/08/25 revealed Resident #49 had a sacral pressure injury, wound team to follow. Further review of the medical record from 04/04/25 through 04/09/25 revealed no attempts to reassess and measure the sacral Stage III pressure ulcer or left medial knee Stage IV pressure ulcer during this time period. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was rarely/never understood. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility, and transfers. The assessment also noted the resident was always incontinent of bowel and bladder and had a Stage III pressure ulcer injury present on admission. Review of Wound Certified Nurse Practitioner (CNP) #1200's initial assessment dated [DATE] revealed Resident #49 had a Stage IV sacral pressure ulcer that measured 5.9 centimeters (cm) in length by 6.2 cm width with an undetermined depth. The ulcer was assessed to be a cluster wound with moderate serosanguinous drainage with 60% granulation, 30% slough, and10% tendon. The assessment note revealed to initiate Dakin's moistened gauze to minimize odor and decrease slough. A new order was written for Dakin's solution 0.125% cleanser, apply 0.125% Dakin's moistened gauze, and apply a clean dry dressing daily and as needed. Review of the physician order dated 04/10/25 at 4:44 P.M. revealed to cleanse wound on sacrum with 0.125% Dakin's solution, apply 0.125% Dakin's moistened gauze and apply a clean dry dressing daily and as needed. Review of Wound CNP #1200's assessment dated [DATE] revealed Resident #49's sacrum Stage IV pressure ulcer measured at 6.3 cm by 6.1 cm with an undetermined depth; a cluster wound with moderate serosanguineous drainage and 70% granulation, 20% slough and 10% tendon. The wound had less odor. Continue to cleanse wound on sacrum with 0.125% Dakin's solution, apply 0.125% Dakin's moistened gauze and apply a clean dry dressing daily and as needed. Review of Wound CNP #1200's assessment dated [DATE] revealed Resident #49's sacrum Stage IV pressure ulcer measured at 6.1 cm by 5.7 cm with 3.4 cm depth; a cluster wound with moderate serosanguinous and 80% granulation and 20% tendon and to continue to cleanse wound on sacrum with 0.125% Dakin's solution, apply 0.125% Dakin's moistened gauze and apply a clean dry dressing daily and as needed. Review of the April 2025 Treatment Administration Record (TAR) revealed the order to cleanse the wound on sacrum with normal saline pat dry and apply Santyl and cover with dry dressing was an active order through the entire month and the resident did not have the wound care treatment documented as completed on 04/07/25 and 04/10/25. The resident also had an order for 0.125% Dakins solution, apply 0.125% Dakins moistened gauze and apply a dry dressing daily and as needed initiated on 04/10/25. However, the TAR revealed the treatment was not documented as completed on 04/10/25, 04/19/25, 04/20/25, or 04/21/25. Review of the TAR from 04/18/25 to 04/24/25 revealed the ordered treatment to the wound on Resident #49's left lateral knee was not completed as ordered on 04/19/25. In addition, Resident #49 had orders to apply barrier cream to peri area and or buttock after each episode of incontinence every shift prevent/personal hygiene, and to turn and reposition every two hours as tolerated every shift not documented as completed on the day shift on 04/10/25, 04/11/25, 04/18/25, 04/19/25, 04/20/25,04/21/25 or on the evening shift on 04/07/25 and 04/10/25. Review of Wound CNP 1200's assessment dated [DATE] revealed Resident #49's sacrum Stage IV pressure ulcer measured 5.9 cm by 5.7 cm with 3.2 cm depth; a cluster wound with moderate serosanguinous drainage with 90% granulation and 10% tendon. Continue the treatment to cleanse wound on sacrum with 0.125% Dakin's solution, apply 0.125% Dakin's moistened gauze and apply a clean dry dressing daily and as needed. Review of Wound CNP #1200's assessment dated [DATE] revealed Resident #49's sacrum Stage IV pressure ulcer measured 6.4 cm by 8.2 cm with an undetermined depth; a cluster wound with moderate tan, serosanguinous drainage with 30% slough, 10% tendon and 60% necrotic wound base with odor. The wound was noted to have declined. The assessment note also included Resident #49 had contributing factors of being poorly complaint with offloading, dementia/confusion, poor nutritional intake, declining medical condition, poor medical condition and incontinence which makes the presence of the wound unavoidable. Treatment order to increase the concentration of the Dakin's solution to 0.5% and change the dressing twice a day for treatment. The note revealed will start oral antibiotics as well. Review of the physician's order revealed on 05/08/25 the treatment order dated 04/21/25 at 2:11 P.M. to cleanse multiple clustered wounds on sacrum with 0.125% Dakin's solution, 0.125% Dakin's moistened gauze, apply clean dry dressing daily and as needed was discontinued. A new physician order was initiated on 05/08/25 at 5:01 P.M. to cleanse multiple clustered wounds on sacrum with 0.125% Dakin's solution, 0.125% Dakin's moistened gauze, apply clean dry dressing every morning and night shift and as needed. This order increased the frequency of the dressing change to twice a day but did not reflect the CNP's change of concentration of the Dakins solution for Resident #49. Additionally, an order was received on 05/08/25 at 4:51 P.M. for Doxycycline Hyclate (antibiotic) oral tablet 100 milligrams (mg); give one tablet every morning and at bedtime until 05/21/25. Review of the May 2025 Treatment Administration Record (TAR) revealed the order to cleanse wound on sacrum with normal saline pat dry and apply Santyl and cover with dry dressing was an active order through 05/02/25, and all treatments were documented as completed. The order for 0.125% Dakins solution, apply 0.125% Dakins moistened gauze and apply a dry dressing daily completed daily through 05/07/25 and the order was changed on 05/08/25 to cleanse multiple clustered wounds on sacrum with 0.125% Dakin's solution, 0.125% Dakin's moistened gauze, apply clean dry dressing every morning and night shift and as needed. The TAR revealed the treatment was not completed on the day shift on 05/08/25, 05/12/25, or on the day and evening shift on 05/13/25. Review of the May 2025 TAR revealed the ordered treatment to the left medial knee was not completed as ordered on 05/12/25 and 05/13/25. In addition, review of the May 2025 TAR revealed Resident #49 had orders to apply barrier cream to peri-area and/or buttock after each episode of incontinence every shift prevent/personal hygiene, and to turn and reposition every two hours as tolerated every shift not documented as completed on the day shift on 05/12/25 and not completed on the day and evening shift on 05/13/25. Review of the May Medication Administration Record revealed the resident did not receive the Doxycycline Hyclate (antibiotic) 100 mg at bedtime on 05/12/25 or 05/13/25 for the morning dose. Review of the medical record for Resident #49 revealed no monitoring of antibiotic effectiveness once antibiotic was initiated on 05/09/25. Further review of the medical record for Resident #49 revealed no daily skilled charting, which include vital signs, from 05/10/25 until 05/14/25. Review of the skilled nursing charting dated 05/14/25 at 2:29 A.M. revealed Resident #49 was hypotensive with a blood pressure of 84/46. No follow up blood pressure or assessment was documented in the resident's medical record. Review of Wound CNP 1200's assessment on 05/15/25 at 10:45 A.M. revealed the sacrum Stage IV pressure ulcer measured 11.6 cm by 8.4 cm with an undetermined depth; a cluster wound with moderate tan, serosanguinous drainage and 30% slough, 10% tendon, 10% bone, 20% and purple or maroon discoloration with odor. The wound presented worsening of infection with a recommendation to transfer the resident to the emergency department for rapid evaluation of wound. Review of the progress note dated 05/15/25 at 4:15 P.M. revealed Resident #49 was transferred to the hospital and all parties responsible were aware. Interview on 05/20/25 at 9:12 A.M. via telephone with Wound CNP #1200 revealed a facility nurse would perform wound rounds with her while she was seeing residents (including Resident #49) and the facility nurse placed the orders she recommended into the electronic medical record system based on the notes she dictated and verbally communicated to them. Wound CNP #1200 stated she did not know Resident #49 received the Santyl treatment that was ordered on admission from the hospital daily throughout her stay until 05/02/25. The CNP stated she ordered Dakin's solution when she assessed the sacrum wound on 04/10/25 because the wound had odor and Dakins was a good skin first line of treatment for what she observed. The CNP revealed she would recommend the Santyl treatment at a later stage of healing and not at that time based on her initial assessment or her subsequent assessments of the wound during Resident #49's stay. CNP #1200 stated she ordered the antibiotic on 05/08/25 due to odor, the presence of dead skin in the wound, and as it appeared the wound had increased drainage as the wound had worsened. She also stated she ordered 0.5% Dakins solution twice a day on 05/08/25 as well. The next week on assessment on 05/15/25, the wound declined again with the presence of purple tissue and the size was extending of the wound, so she felt a general surgeon needed to assess and recommended the resident be sent to the emergency room . CNP #1200 revealed Resident #49 had contractures to her extremities and the facility had issues positioning the resident, but to her knowledge the resident never refused any care because she was not able to communicate. CNP #1200 verified she was not aware the Dakin's solution treatment ordered on 05/08/25 was not ordered correctly, as she wanted it to be 0.5% solution, an increase due to the worsening of the wound and could not confirm if that contributed to the wound decline, but verified the order was not followed as she wanted it to be. Interview on 05/20/25 at 10:07 A.M. with Licensed Practical Nurse (LPN) #401 revealed he completed rounds with Wound CNP #1200 when she was in the facility and then he entered orders the CNP verbally tells him and dictates on her reports. LPN #401 revealed the CNP sends in the dictations the same day to him, so he is able to put the orders in for the residents for their wound treatments that day. LPN #401 stated when a resident was admitted the floor nurses were responsible for the initial skin assessment on admission and then he tried to come behind to recheck them stated he was not always able to do so. During the interview, LPN #401 revealed he had no training in wound care including staging of wounds and added he stepped in to help when the previous wound nurse left sometime last year. LPN #401 also shared the admitting floor nurse goes through the discharge paperwork for newly admitted residents and places orders for wounds if they had them included in the admission orders. Chart checks were sometimes done by him or the Director of Nursing (DON) to make sure orders were correctly transcribed from admitting orders. The LPN revealed the checks were not always completed but they complete them if they get time. The LPN also revealed Resident #49 was hard to turn and staff had to use a lot of pillows because the resident was very contracted; however, the resident never refused care. LPN #401 verified the Dakin's solution of 0.5% was not ordered correctly on 05/08/25 from Wound CNP #1200 and he entered that order and reviewed her notes. During the interview, LPN #401 also verified Resident #49 did not have an accurate order for the left medial pressure ulcer entered in the system on admission and verified the resident had duplicate treatment orders from 04/10/25 through 04/17/25. The LPN revealed the only treatment that should have been ordered was from Wound CNP #1200. Interview on 05/20/25 at 10:15 A.M. with the DON verified wound measurements were not completed on the admission wound assessment for Resident #49 for the Stage III pressure ulcer to the resident's sacrum or for the left medial knee Stage IV pressure ulcer. The DON also verified there were no further attempts to reassess or measure the pressure ulcers from 04/03/25 through 04/09/25. Interview on 05/20/25 at 10:35 A.M. with the Regional Operations and the DON revealed if an order was in the system for a wound treatment and the wound CNP (CNP #1200) ordered a different treatment, the staff should discontinue the current order and then place the new order for the treatment the CNP ordered. There shouldn't be multiple (different) orders in the resident's chart. The Regional Operations and DON subsequently reviewed and verified for Resident #49 all of the missing treatments on the TAR and MAR for wound treatments, lack of evidence of prevention of pressure ulcers including turning/repositioning and barrier cream to peri area, and the missing antibiotic doses. It was also verified the calcium alginate order from Resident #49's discharge paperwork from another facility where Resident #49 came from did not get ordered on admission for the sacrum Stage III pressure wound. The Regional Operations and DON revealed the previous facility wound nurse (who had wound training) left the facility last year. The DON revealed she had no specific wound training but would take responsibility for not overseeing the wound management as she should for the facility residents since LPN #401 was an LPN and had no wound training as well. Interview on 05/20/25 at 12:20 P.M. with MD #2000 revealed she was not aware Resident #49 was not receiving the calcium alginate and only Santyl to her sacrum pressure ulcer on admission. MD #2000 revealed she was only at the facility on Tuesdays and was not made aware of any concerns from Wound CNP #1200 or the facility staff throughout Resident #49's stay. MD #2000 denied concerns from the facility about issues with Resident 349 being noncompliant with care and had no identified concerns with the resident's nutritional status. MD #2000 revealed she referred to Wound CNP #1200 for all recommendations for wounds and follows the treatments and recommendations she advised and expected facility staff to follow her recommendations and enter them into the system to be followed. Interview on 05/20/25 at 3:40 P.M. with the Regional Operations (RO) verified Resident #49 did not have a recheck of her blood pressure from the check on 05/14/25 at 2:40 P.M. when it was 84/46. The Regional Operations revealed the facility documents by exception, and when residents were on antibiotics, they do not check their vitals daily. However, Regional Operations verified Resident #49 was a skilled resident and although it was not part of the facility policy, it was the expectation of the facility that skilled residents receive daily charting which included a full body assessment and vital signs. During the interview, the RO also verified Resident #49 did not leave for the hospital until 3:44 P.M. on 05/15/25 even though Wound CNP #1200's assessment was completed in the morning with a note for rapid evaluation because the RO believed there was no urgency in transferring the resident. Resident #49 was transported by the facility transportation and not emergency medical services (EMS). Review of hospital admission paperwork dated 05/15/25 revealed Resident #49's vital signs in the emergency room included a pulse 115 (tachycardic), blood pressure of 128/76 and elevated temperature of 99.7 degrees Fahrenheit. Laboratory results revealed an elevated white blood cell count of 12.3 (associated with infection). The hospital record revealed Resident #49 presented with an infected sacral decubitus ulcer with verification of a computed tomography (CAT) scan of abdomen pelvis with contrast revealing a deep sacral decubitus ulcer measuring 15 millimeters (mm) deep and measuring 60 mm mediolaterally. There was underlying exposed bone, with adjacent myositis. This resident was admitted to the hospital for a Stage IV decubitus ulcer infection with osteomyelitis. During the resident's stay, the general surgeon did not want to do surgery but did encourage enzymic debridement. The infectious disease physician continued intravenous (IV) Vancomycin (antibiotic) and Zosyn (antibiotic) started in the emergency room . A wound culture showed the wound with heavy pseudomonas, sensitivities pending. Bacteremia, two sets of blood cultures with coagulase-negative staphylococcus. The wound care team continuing dressing changes daily. Review of the facility undated policy titled Wound and Skin Care revealed if a pressure ulcer was present on admission, a skin care assessment would be completed. A pressure area/ulcer would be measured and monitored weekly. Documentation of the pressure ulcer/area would include measurements in centimeters (width, length, depth), wound margins, undermining, clock hands for tunneling, drainage, amount of drainage, type, color and odor. 2. Review of the medical record for Resident #40, revealed an admitted [DATE] with diagnoses including major depressive disorder, muscle weakness, peripheral vascular disease, altered mental status, dementia, and anxiety. Review of the Braden Scale for Predicting Pressure Sore Risk dated 02/17/25 for Resident #40 revealed a score of 13.0 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at moderate risk for skin breakdown. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired with a Brief Interview for Mental Status (BIMS) of 06. The resident was assessed to require total (staff) dependence for toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also assessed to be at risk for pressure ulcers. Review of the plan of care revised on 04/13/25 revealed Resident #40 had actual skin integrity issues with interventions including but not limited to float heels in bed, turn and reposition every two hours as tolerated and to monitor weekly. Review of a nurse assessment dated [DATE] revealed Resident #40 had a right lateral ankle open area that measured 1.2 cm by 0.9 cm with no depth with minimal drainage and no classification of the wound being a pressure, arterial or vascular ulcer. Further review of the resident's assessments revealed weekly skin assessments were not completed for the dates of: 04/23/25 through 05/06/25 or 05/08/25 through 05/19/25. On 05/21/25 at 9:29 A.M., 11:39 A.M., and 1:36 P.M. Resident #40 was observed in bed, on his back and his heels were not floated. Interview on 05/21/25 at 11:33 A.M. with the RO verified Resident #40 had missing weekly skin assessments for the dates of 04/23/25 through 05/06/25 and 05/08/25 through 05/19/25 and that assessments should be completed weekly. An Interview on 05/21/25 at 1:37 P.M. with LPN #534 verified Resident #40 had not been turned at all today and that his heels were not floated. Observation on 05/21/25 at 2:27 P.M. with the Director of Nursing of Resident #40's right lateral ankle wound revealed the resident had a Stage III pressure ulcer to the area and verified the resident should have his heels floated when in bed. Review of the facility undated policy titled Wound and Skin Care revealed a pressure area/ulcer would be measured and monitored weekly. Documentation of the pressure ulcer/area would include measurements in centimeters (width, length, depth), wound margins, undermining, clock hands for tunneling, drainage, amount of drainage, type, color and odor.

Based on observation, interview, and facility policy review. The facility failed to store Insulin in a safe manner on the 100 and 300 hall medication carts. This had the potential to affect six residents (Residents #2, #14, #16, #36, #41 and #47) who received insulin on those halls. The facility census was 76. Findings include: Observation on 05/20/25 at 8:10 A.M. of 300 hall medication cart revealed the following medications in the top drawer: two Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) with no resident identifier on the Insulin pen which was opened and undated ( date the pen was opened); Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) vial, no resident identifier on the vial which was opened and undated; Tresiba FlexTouch Pen-injector 100 UNITS/ML, with no resident identifier on the pen which was also opened and undated. Interview on 05/20/25 at 8:15 A.M. with Licensed Practical Nurse (LPN) #506 verified insulin vial and pens on 300 hall medication cart that were undated and had no resident identifiers. Observation on 05/20/25 at 8:56 A.M. of 100 hall medication cart revealed the following medications in the top drawer: Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) with no resident identifier on insulin pen which was opened and undated; Admelog Injection Solution 100 UNIT/ML (Insulin Lispro) vial, no resident identifier on insulin vial which was opened and undated; Lantus 100 UNITS/ML (Insulin Glargine) vial, no resident identifier on insulin vial which was opened and undated; Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) vial, no resident identifier on the vial which was also opened and undated. Interview on 05/20/25 at 08:57 A.M. with Registered Nurse (RN) #429 verified Insulin vials and pens on 100 hall medication cart that were undated and had no resident identifiers. Review of the facility policy Storage of Medications dated, April 2007 revealed the facility shall store all drugs and biologics in a safe, secure and orderly manner. It also stated drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received, and drug containers that have a missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing.

Based on observation, staff interview, and review of facility policy, the facility failed to store food in a sanitary manner. This had the potential to affect 73 of 76 residents who ate food from the kitchen (Residents # 20, #42, and #55 were identified by the facility as not eating or drinking from the kitchen.) The facility census was 76 residents. Findings include: Observation on 05/18/25 from 8:25 A.M. to 8:45 A.M. revealed the kitchen dry storage room had three cans of three bean salad, a case of hot dog buns, a case of sliced pineapple rings, and two cases of snack pack puddings that were stored directly on the floor. Interview with Dietary Aide #402 on 05/18/25 at 8:30 A.M. confirmed the above food items were stored directly on the floor in the kitchen's dry storage room. Further interview with Dietary Aide #402 revealed the food items were received at the facility on 05/16/25 and the food items had been stored on the floor since that date. Observation on 05/18/25 from 8:25 A.M. to 8:45 A.M. revealed there was a dusty light fixture over the steam wells in the food serving area, as well as an approximately two-foot-long crack in the painted ceiling, with visible paint chips in it. Interview with Dietary Aide #425 on 05/18/25 at 8:34 A.M. confirmed there was a dusty light fixture and an approximately two-foot-long crack in the painted ceiling. Observation on 05/19/25 from 10:32 A.M. to 10:51 A.M. revealed an approximately four foot crack with peeling paint that was hanging down two inches from the ceiling in the food preparation area. The crack and peeling paint was directly over a rack of stored clean food trays and over open drinking cups. There was also a dusty light fixture over the food serving Interview with Dietary Manager #431 on 05/19/25 at 10:51 A.M. confirmed there was a four-foot crack with peeling paint and a dusty ceiling fan over the steam wells in the food serving area. Review of the facility policy titled, Food Receiving and Storage dated July 2014 revealed food in designated dry storage areas shall be kept off of the floor at least 18 inches. Food services will maintain clean food storage areas at all times.

Based on record review, interview, and facility policy review, the facility failed to ensure enhanced barrier precautions were in place for Resident #49 who had pressure ulcer wounds while at the facility. This affected only Resident #49 who was reviewed for enhanced barrier precautions. This had the potential to affect 10 residents on the same hall. The total facility census was 76. Findings include: Review of the medical record for Resident #49, revealed an admitted [DATE] and a transfer to the hospital date of 05/15/25. Diagnoses included but were not limited to adult failure to thrive, Alzheimer's disease, anxiety disorder, metabolic encephalopathy, and difficulty walking. Review of the active care plans dated 04/03/25 revealed Resident #49 to be on enhanced barrier precautions related to chronic wounds. Review of the physician orders dated 04/03/25 through 05/15/25 for Resident #49 revealed no order for enhanced barrier precautions due to having chronic pressure ulcer wounds. Interview on 05/21/25 at 2:35 P.M. with Regional Administrator #417 verified no order was present for enhanced barrier precautions during facility stay for Resident #49. No policy on enhanced barrier precautions was provided by the facility.

Based on medical records review, observations and staff interviews, the facility failed to provide dignity with dining for two residents who needed assistance with their meals (Resident # 4 and #31) out of fourteen residents reviewed for dining observation. This had the potential to affect five residents (#4, #12, #21, #31, and #33) that needed assistance with dining. The facility census was 76 residents. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included muscle wasting, and glaucoma. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. Review of Resident #4's full nutrition assessment dated [DATE] revealed he requires assistance with his meals. Review of Resident #4's physician order dated 09/26/23 revealed he was to have assistance with all meals on every shift. Observation on 05/19/25 at 8:17 A.M. revealed Resident #4 was being fed by Certified Nursing Assistant (CNA) #434. CNA #434 was standing over Resident #4 while she fed the resident. Interview with Registered Nurse (RN) #429 on 05/19/25 at 8:19 A.M. confirmed CNA #434 was standing over Resident #4 while feeding him. She stated that it was not a dignified dining procedure. RN #429 stated there was not a reason for CNA #434 to stand while feeding Resident #4 his meal. 2. Resident #31 was admitted to the facility on [DATE] with diagnoses that included unspecified protein-calorie malnutrition, cerebral infarction, aphasia, muscle wasting, dysphagia, vascular dementia, glaucoma and need for assistance with personal care. Review of Resident #31's quarterly MDS assessment dated [DATE] revealed his BIMS score was 6, indicative of severe cognitive impairment. Review of Resident #31's physician orders dated 02/06/25 revealed he was to be assisted with all of his meals. Review of Resident #31's full nutrition assessment dated [DATE] revealed he required assistance with all of his meals. Review of Resident #31's care plan dated 12/26/22 revealed that he need assistance with all of his meals due to poor vision and weakness. Observation on 05/19/25 at 8:28 A.M. revealed CNA #421 was standing over Resident #31 while feeding him in bed. Interview with CNA #421 on 05/19/25 at 8:28 A.M. confirmed she was standing over Resident #31 while feeding him in bed. CNA #421 stated that she knew that she was supposed to sit while assisting residents with feeding; however, she preferred to stand. Observation on 05/20/25 at 8:23 A.M. revealed that CNA #487 was standing over Resident #31 while he was being fed in his room while seated in his bed. Interview with CNA #487 confirmed that she was standing over Resident #31 while assisting him with feeding him his meal. She stated that she could have sat while feeding Resident #31; however, she preferred to stand.

Based on resident record review, observations and staff interviews, the facility failed to provide supervision in the dining room for a resident who was at risk for choking. This affected one resident (Resident #33) and had the potential to affect 23 residents that the facility identified as having dysphagia, difficulty swallowing (Resident #2, #9, #12, #16, #22, #25, #28, #29, #33, #34, #38, #44, #46, #49, #59, #67, #71, #73, #74, #75, #78, #133, and #233.) The facility census was 76 residents. Findings include: Review of Resident #33's medical chart revealed that she was admitted to the facility on [DATE] with diagnoses that included abnormal posture, cognitive communication deficit, muscle wasting and atrophy, dysphagia, and vascular dementia. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that she had a Brief Interview for Mental Status score of 14, indicative of intact cognition. Review of the MDS assessment dated [DATE] revealed that she required supervision or touching assistance for eating. Further review revealed that she was on a mechanically altered diet. Review of Resident #33's Nutrition assessment dated [DATE] revealed that she was recommended to have one-on-one supervision and assistance with her meals. Observation on 05/18/25 from 11:51 A.M. to 11:53 A.M. revealed that there were two residents (Resident #33 and Resident #41) that were unsupervised in the dining room feeding themselves. Certified Nursing Aide (CNA) #469 entered the dining room at 11:53 A.M. Interview with CNA #469 on 05/18/25 at 11:53 A.M. confirmed that Resident #33, who was identified as a choking risk, was unsupervised in the dining room eating.

Based on interview, medical record review, and facility policy review, the facility failed to communicate with dialysis center and failed to perform pre and post dialysis assessments for one, Resident #29. This had the potential to affect four residents (Residents #6, #29, #31 and #36) who received dialysis. The facility census was 76. Findings include: Review of Resident #29's medical record revealed that he was admitted on [DATE] with diagnoses that included congestive heart failure, diabetes mellitus with neuropathy, morbid obesity, chronic obstructive pulmonary disease, dependent on renal dialysis and end stage renal disease. Review of Resident #29's most recent Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Review of Resident #29's Physician's orders dated 04/25/25 revealed an order for dialysis in center every Monday, Wednesday and Friday at 1:15 P.M. The orders did not indicate any before or after dialysis assessment. Review of Resident #29's progress notes dated 04/19/25 to 05/20/25 revealed no notes for pre- dialysis or post- dialysis assessment. Review of Resident #29's assessments, dated March 2025 to May 2025 revealed no assessments for pre-dialysis or post-dialysis. Review of Resident #29's Dialysis communication records revealed missing communication records for 04/23/25, 05/02/25, 05/14/25 and 05/19/25. Further review revealed the dialysis communication records contained no pre-dialysis assessments on 04/21/25, 04/23/25, 04/30/25, 05/02/25, 05/05/25, 05/12/25, 05/14/25 and 05/19/25 and no post-dialysis assessments on 04/21/25, 04/23/25, 04/25/25, 04/28/25, 04/30/25, 05/02/25, 05/05/25, 05/07/25, 05/09/25, 05/12/25, 05/14/25, 05/16/25 and 05/19/25. Interview on 05/20/25 with RN #429 revealed the process for dialysis patients on dialysis days is the day shift nurse takes the residents vitals, they send communication sheet with the resident to the dialysis center and the dialysis center returns the sheet with vitals, residents weight, and any new orders. There is an order prompt in electronic medication administration record (eMAR) to complete pre/post dialysis communication for the staff to document all the information into the electronic health record. They also do vitals and check for pain, bleeding or swelling at the shunt site and put in any new orders. She also stated that after reviewing the dialysis communication sheet the nurse files the sheets in the resident's chart or dialysis book. RN# 429 confirmed there was no order to complete pre/post communication forms for Resident #29 in the eMAR. Interview on 05/21/25 at 11:50 A.M. with the Director of Nursing (DON) revealed residents who receive dialysis have a communication sheet the nurse sends to the dialysis center on dialysis days, the sheet is completed by the nurse with residents' weight and vitals. When the resident returns, the nurse checks communication sheet for any new orders and puts them in the computer if needed, the nurse should also check the resident for pain, bleeding and shunt function. She also stated that all dialysis residents should have an order to add information. Review of communication sheets with DON on 05/21/25 at 11:55 A.M. confirmed there were multiple days of missing communication sheets and that multiple sheets were void of pre and post dialysis assessments on multiple days. Review of undated facility Hemodialysis policy states that the facility will assure each resident receives care and services for the provision of hemodialysis consistent with the professional standards of practice. It also stated that the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The nurse will monitor the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. The nurse will ensure that the dialysis access site (AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for bruit and palpating for thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure proper parameters were identified for as needed (PRN) pain medications. The deficient practice affected one resident (#26) of five residents reviewed for unnecessary medications. The facility census was 76. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE]. Medical diagnoses included obesity, Type II Diabetes, anxiety, adjustment disorder, adult failure to thrive, lymphedema, hypertension, personal history of pulmonary embolism, and panniculitis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating intact cognition. Review of facility care plan for Resident #26 initiated 09/23/24 revealed Resident #26 had chronic pain due to his diagnoses and that medications should be administered as ordered. Review of the physician orders dated 04/17/25 revealed Resident #26 had an order for Oxycodone (opioid)/Acetaminophen (analgesic) 7.5-325 milligrams (mg) with instructions Give 1 tablet by mouth every 6 hours as needed (PRN) for severe pain. The order did not define the word severe. This order was discontinued 05/16/25. Review of the Medication Administration Record (MAR) dated May 2025 revealed Resident #26 received PRN administration of the Oxycodone/Acetaminophen 7.5-325 mg every day from 05/01/25 through 05/15/25. On the May MAR, the patient's pain levels recorded at the time PRN Oxycodone/Acetaminophen was administered ranged from zero (no pain) to nine (severe pain). Resident #26 also had an order dated 05/16/25 for Percocet Oral Tablet 7.5-325 MG (Oxycodone /Acetaminophen) which stated, give one tablet by mouth every six hours for moderate pain for three days and give one tablet by mouth every six hours as needed for moderate pain. This order did not define the word moderate. Interview on 05/20/25 at 2:14 P.M. with Registered Nurse (RN) #446 confirmed the Oxycodone/Acetaminophen orders did not define or provide a numeric rating for the words moderate or severe. She stated that resident wouldn't ask for pain medicine unless he was in pain. She said she thought of moderate pain as a rating of three through seven. She admitted she didn't have a reference point for that definition. Interview on 05/20/25 at 2:28 P.M. with Director of Nursing (DON) who confirmed the orders on the MAR did not have parameters and that severe and moderate should have been defined in the orders. She wondered whether it was left off when information was transferred to the MAR and noted they just recently changed their process. Review of facility policy titled Pain Assessment and Management revealed that pain management interventions shall reflect the sources, type and severity of pain.

Based on medical review, observation, staff interview and review of facility policy and procedure, the facility failed to follow infection control practices when changing a dressing. This affected one resident (#78) of three sampled residents. The census was 89. Findings include: Review of Resident #78's record revealed he was admitted to the facility on [DATE]. Diagnoses included anterior cord syndrome at T7-T10 level of the thoracic spinal cord, atrial fib, chronic kidney disease (CKD), and peripheral vascular disease. Review of the annual MDS dated [DATE] revealed his cognition was moderately impaired. He requires setup/clean up assistance for meals and oral hygiene and is dependent for toileting, shower/bathing, upper body dressing, footwear, personal hygiene and turning and repositioning. He is frequently incontinent of urine and always incontinent of bowel. Review of the physicians orders for 12/06/24 revealed to cleanse wounds to the superior sternum with normal saline and pat dry. Then apply hydroconductive dressing (wound dressings utilize a hydroconductive material to aid the clinician in wound bed preparation. It is a highly absorbent wound dressing that facilitates the movement of wound exudates into and through the dressing to the outer secondary material) to wound bed then cover with a super absorbent dressing, change on Monday, Wednesday, Friday, and when needed. On 01/29/25 at 11:00 A.M. observation of a dressing change to Resident #78's superior sternum wound revealed Licensed Practical Nurse (LPN) #257 cleaned her hands and put on gloves. LPN #257 then removed the old dressing on his chest, and a moderate amount of bloody drainage was noted on the old dressing. LPN #257 then removed her gloves and put on new gloves without washing her hands, and cleansed the wounds to the chest with normal saline and gauze. LPN #257 then removed her gloves and put on new gloves without washing her hands and placed the hydroconductive dressing on the wound and covered it with a dressing. LPN #257 then removed her gloves and cleaned her hands with sanitizer. On 01/29/25 at 11:05 A.M. interview with LPN #257 verified she had not washed her hands in between glove changes. Review of the Hand Washing/Hand Hygiene policy and procedure (dated 08/2015) revealed use of an alcohol-based hand rub or alternatively soap and water after removing gloves. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00161811.

Based on record review, staff interview, review of Self-Reported Incident (SRIs), and review of the facility policy, the facility failed to ensure allegations of physical abuse were reported immediately to the state agency as required. This affected one (Resident #3) of three residents reviewed for abuse. The facility census was 87 residents. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including chronic systolic heart failure, type two diabetes mellitus, atrial fibrillation, hypertension, and anxiety disorder and a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 11/17/24 revealed the resident had intact cognition and required supervision or touching assistance with activities of daily living (ADLs.) Review of the hospital note for Resident #3 dated 11/20/24 timed at 9:47 P.M. revealed the resident was admitted with complaints of back pain and alleged he had been pushed by an employee at the facility during an altercation on 11/18/24 which caused the resident to fall backwards. Review of the physician progress note for Resident #3 dated 11/20/24 revealed during hospital transfer the resident reported a recent altercation with a staff member a couple of days prior and noted worsening back pain. Review of local hospital case management initial assessment for Resident #3 dated 11/22/24 timed at 4:12 P.M. revealed the resident alleged the social worker at the facility had pushed him down causing him to fall. Review of the facility Self-Reported Incident (SRI) involving Resident #3 initiated 11/26/24 at 10:42 A.M. revealed the Administrator became aware of the allegation of abuse per Resident #3 towards SSD #233 through the Surveyor. SSD #233 was suspended pending investigation on 11/26/24. The facility was unable to substantiate the allegation of abuse. Interview on 11/25/24 at 4:29 P.M. with the Director of Nursing (DON) confirmed hospital staff had informed her on 11/22/24 that Resident #3 had alleged Social Services Director (SSD) #233 had pushed him down to the ground on 11/18/24. Interview on 11/26/24 at 9:42 A.M. with the Administrator confirmed he was not aware of Resident #3's allegation of abuse per SSD #233 which allegedly occurred on 11/18/24. The Administrator confirmed staff should report concerns of abuse to the administrator immediately. Interview on 11/26/24 at 9:45 A.M. with the DON confirmed she had not informed the Administrator of Resident #3's allegation of abuse which she became aware of on 11/22/24 because there was no official documentation to support the claim. Interview on 11/26/24 at 11:31 A.M. with Nurse Practitioner (NP) #221 confirmed Resident #3 reported to her on 11/20/24 that he had been involved in an altercation with a staff member on 11/18/24 but the resident did not provide details of the altercation or allege abuse. The NP instructed the nursing staff to address the resident's concerns and document them accordingly. The NP confirmed an altercation with a staff member was documented in Resident #3's progress notes. Interview on 11/26/24 at 12:06 P.M. and 12:45 P.M. with Hospital Staff #1 confirmed Resident #3 had reported being pushed by facility staff, causing his fall. The admission notes included the statement the resident claimed he was pushed by an employee, leading to the fall. When preparing for the transfer back to the facility, the admissions coordinator received the case management initial assessment, which documented the resident stated the social worker pushed him twice before he fell . Hospital Staff #1 confirmed the facility DON, admissions personnel, and regional staff all had access to Resident #3's complete hospital record. Interview on 11/26/24 at 12:45 P.M. with Hospital Staff #2 confirmed Resident #3 made an allegation that facility staff, SSD # 233, had pushed him and caused a fall. Hospital Staff #2 confirmed they did not directly report this to facility staff, although it was included in Resident #3's emergency room documentation which the facility staff had access to. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 10/27/17 revealed the facility was required to report all allegations of abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property immediately to the administrator. If an abuse allegation was reported, it should be reported to the Ohio Department of Health (ODH) immediately, but no later than two hours after the allegation was made. This deficiency represents noncompliance investigated under Complaint Number OH00160059.

Based on record review, staff interview, review of Self-Reported Incident (SRIs), and review of the facility policy, the facility failed to ensure residents were protected from further potential abuse during abuse investigations. This affected one (Resident #3) of three residents reviewed for abuse. The facility census was 87 residents. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including chronic systolic heart failure, type two diabetes mellitus, atrial fibrillation, hypertension, and anxiety disorder and a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 11/17/24 revealed the resident had intact cognition and required supervision or touching assistance with activities of daily living (ADLs.) Review of the hospital note for Resident #3 dated 11/20/24 timed at 9:47 P.M. revealed the resident was admitted with complaints of back pain and alleged he had been pushed by an employee at the facility during an altercation on 11/18/24 which caused the resident to fall backwards. Review of the physician progress note for Resident #3 dated 11/20/24 revealed during hospital transfer the resident reported a recent altercation with a staff member a couple of days prior and noted worsening back pain. Review of local hospital case management initial assessment for Resident #3 dated 11/22/24 timed at 4:12 P.M. revealed the resident alleged the social worker at the facility had pushed him down causing him to fall. Review of the facility Self-Reported Incident (SRI) involving Resident #3 initiated 11/26/24 at 10:42 A.M. revealed the Administrator became aware of the allegation of abuse per Resident #3 towards SSD #233 through the Surveyor. SSD #233 was suspended pending investigation on 11/26/24. The facility was unable to substantiate the allegation of abuse. Interview on 11/25/24 at 4:29 P.M. with the Director of Nursing (DON) confirmed hospital staff had informed her on 11/22/24 that Resident #3 had alleged Social Services Director (SSD) #233 had pushed him down to the ground on 11/18/24. Interview on 11/26/24 at 9:42 A.M. with the Administrator confirmed he was not aware of Resident #3's allegation of abuse per SSD #233 which allegedly occurred on 11/18/24. The Administrator confirmed staff should report concerns of abuse to the administrator immediately, and if a staff member was accused of abuse they should be suspended from work immediately pending the outcome of the investigation. Further interview with the Administrator confirmed SSD #233 was not suspended until 11/26/24. Interview on 11/26/24 at 9:45 A.M. with the DON confirmed she had not informed the Administrator of Resident #3's allegation of abuse which she became aware of on 11/22/24 because there was no official documentation to support the claim. Interview on 11/26/24 at 11:31 A.M. with Nurse Practitioner (NP) #221 confirmed Resident #3 reported to her on 11/20/24 that he had been involved in an altercation with a staff member on 11/18/24 but the resident did not provide details of the altercation or allege abuse. The NP instructed the nursing staff to address the resident's concerns and document them accordingly. The NP confirmed an altercation with a staff member was documented in Resident #3 's progress notes. Interview on 11/26/24 at 12:06 P.M. and 12:45 P.M. with Hospital Staff #1 confirmed Resident #3 had reported being pushed by facility staff, causing his fall. The admission notes included the statement the resident claimed he was pushed by an employee, leading to the fall. When preparing for the transfer back to the facility, the admissions coordinator received the case management initial assessment, which documented the resident stated the social worker pushed him twice before he fell . Hospital Staff #1 confirmed the facility DON, admissions personnel, and regional staff all had access to Resident #3's complete hospital record. Interview on 11/26/24 at 12:45 P.M. with Hospital Staff #2 confirmed Resident #3 made an allegation that facility staff, SSD # 233, had pushed him and caused a fall. Hospital Staff #2 confirmed they did not directly report this to facility staff, although it was included in Resident #3's emergency room documentation which the facility staff had access to. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 10/27/17 revealed if a staff member was accused of abuse the facility should immediately remove that staff member from the facility and from the schedule pending the outcome of the abuse investigation. This deficiency represents noncompliance investigated under Complaint Number OH00160059.

Based on medical record review, staff interview, and policy review, the facility failed to complete a comprehensive assessment of continence for a resident. This affected one of three residents reviewed for incontinence (Resident #27). The facility census was 88. Findings include: Review of the medical record for Resident #27 revealed an admitted [DATE] and diagnoses including diabetes, bipolar disorder, and septic arthritis of the left leg. Review of a nursing admission assessment dated [DATE] revealed a question: How long has the resident been incontinent or had a catheter? it was documented N/A Continent. It further stated the resident was wet during day and night time, small amounts. It stated the resident was continent of bowel. No further information was documented related to bowel or bladder incontinence. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed it stated Resident #27 had a brief interview for mental status score of 15, indicating intact cognition. It stated the resident required supervision with toileting, could walk 10 feet with supervision, and was frequently incontinent of bowel and bladder. Review of urinary incontinence tracking records revealed, between 03/29/24 and 04/22/24, the resident had two incidents of bladder continence and 44 incidents of bladder incontinence. Interview with Resident #27 on 04/22/24 at 10:35 A.M. revealed she indicated she only had a few bladder accidents and mostly went to the bathroom or used the bedside commode for toileting. However, interview with Nursing Assistant #137 on 04/23/24 at 11:50 A.M. revealed Resident #27 was incontinent of bowel and bladder all the time. She just goes in the bed. She stated she did not know why the resident did this when she is able to ask for assistance with toileting. Record review did not reveal any further assessment of the incontinence identified on the MDS on 04/05/24. There was no evidence of a comprehensive assessment to include any observations, communication with the resident or staff to assess the incontinence. There was no evidence of a comprehensive assessment to attempt to identify the cause of the incontinence, prior history of bladder function, voiding patterns, tests or studies to identify the type of incontinence, or any environmental factors to provide direction for the development of appropriate interventions to maintain as much normal bladder function as possible. Review of the facility policy (revised October 2010) titled Behavioral Programs and Toileting Plans for Urinary Incontinence stated to conduct a thorough assessment of the resident and his or her environment to determine factors that may have contributed to any recent decline in urinary incontinence and assess the resident for appropriateness of behavioral programs which promote urinary incontinence. Interview with Regional Director of Clinical Services #300 on 04/23/24 at 11:20 A.M. confirmed there was not a comprehensive assessment of Resident #27's bowel and bladder incontinence. She stated the only assessment available was the admission nursing assessment. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00152613.

Based on medical record review and staff interview, the facility failed to ensure laboratory testing was completed as ordered, the physician was notified timely of the results after completed, and physician's orders were followed related to medication administration for one of five sampled residents (Resident #2). The facility census was 88. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted [DATE] from the hospital where she had been treated for C-difficile colitis (inflammation of the colon caused by bacteria) with diarrhea, weakness, decreased appetite and malnutrition. The resident had additional diagnoses including adult failure to thrive, hypothyroidism, dysphagia, rheumatoid arthritis, cerebral vascular accident, and bipolar disorder. Review of a nursing progress note on 04/15/24 at 4:12 P.M. revealed the nurse was notified by physical therapy about a change in the resident's condition. The resident was assessed. Resident alert to self and denied pain. Resident stated she was ok and just tired. Vital signs were stable. The physician was notified and a new order was received for a Complete Blood Count (CBC) test and a urinalysis. Review of a physician's progress note on 04/16/24 revealed the resident had been in the hospital from 03/12/24 to 03/20/24 for diarrhea and weakness. Positive for C-difficile toxin which resulted in malnutrition. Hospital course included antibiotics and electrolyte replacement. Hospital course complicated by stroke alert for left sided weakness and ataxic gait. The note indicated the resident's thyroid supplement medication had been increased on admission to 75 micrograms due to hypothyroidism. A follow up TSH level was ordered. The note stated she was asked to see the resident by the nurse for altered mental status, suspected urinary tract infection and lab work was pending. A nursing progress note on 04/16/24 at 5:30 P.M. (late entry-not documented until after the surveyor requested the laboratory results on 04/22/24) revealed the resident refused a straight cath, was assisted to toilet and unsuccessful for urine collection. It was documented that the provider was made aware and an order was obtained to discontinue the urinalysis test. Review of laboratory results revealed on 04/17/24 blood was collected for a comprehensive metabolic panel (CMP), a Thyroid Stimulating Hormone (TSH), and Vitamin D level. The laboratory indicated that the quantity of blood collected was not sufficient to complete a CBC test as ordered. There was no evidence of additional attempts to obtain the CBC until 04/22/24 (5 days later). Review of the laboratory results for 04/17/24 revealed several abnormal levels including: Calcium 8.3 (normal 8.6-10.3), Albumin 2.9 (normal 3.5-5.5), TSH 15.4 (normal 0.3-5.5 and noted as very high), Vitamin D level less than 7 (normal 30-100 and noted as very low). The laboratory results had a notation stating the results were reviewed with provider which was noted by Director of Nursing (DON) #100 and a new order obtained to discontinue urinalysis (order received 04/16/24). Interview with the director of nursing (DON) #100 on 04/23/24 at 10:25 A.M. revealed the results were not reviewed with the provider 04/16/24, even though documented as such. She confirmed the medical provider was not made aware of the results of the laboratory testing done on 04/17/24 until 04/22/24. She stated the order to discontinue the urinalysis had been received from the psych provider, not the medical provider. She further confirmed that, even though the CBC was ordered due to a change in condition on 04/15/24, it was not obtained until 04/22/24. Interview with Certified Nurse Practitioner (CNP) #220 on 04/23/24 at 10:25 A.M. revealed she was not notified of the results of the laboratory tests from 04/17/24 until 04/22/24. She confirmed staff should not have waited to obtain the CBC until 04/22/24. Review of a nursing progress note on 04/22/24 at 3:02 P.M. revealed Resident #2's family member was concerned about resident not being able to perform activities of daily living. The physician was notified and laboratory testing was ordered including CBC, CMP, and Urinalysis. (These tests had already been ordered on 04/15/24 and completed on 04/17/24 (except urinalysis). However, the physician was not notified of the results until 04/22/24). A CBC, BMP, and urinalysis were completed on 04/22/24. The urinalysis did not indicate a urinary tract infection. The resident's red blood cell count was 2.55 (normal 4-5.2), hemoglobin 7.2 (normal 12-16), and hematocrit 23.7 (normal 36-46). Interview with CNP #220 on 04/23/24 at 10:25 A.M. revealed, as a result of the TSH and Vitamin D laboratory tests on 04/17/24, she had given orders on 04/22/24 to increase the resident's thyroid supplement medication from 75 micrograms daily to 100 micrograms daily. She also ordered a Vitamin D supplement. Review of the physician's orders and medication administration record (MAR) for April 2024 on 04/23/24 revealed no order for a Vitamin D supplement. Further review revealed that a thyroid supplement medication 100 micrograms had been added daily on 04/22/24. However, the 75 microgram supplement was not discontinued. Review of the MAR for 04/23/24 revealed the nurse documented at 6:00 A.M. the Resident #2 received both the 75 microgram and the 100 microgram Thyroid supplement medication. Interview with CNP #220 on 04/23/24 at 10:25 A.M. confirmed the resident should not receive both dosages. She was only to receive 100 micrograms. Interview with Assistant Director of Nursing (ADON) #106 on 04/23/24 at 10:45 A.M. revealed he had received the order from CNP #220 on 04/22/24 to increase the thyroid supplement. He confirmed he did not discontinue the 75 microgram supplement when he added the 100 microgram supplement and should have. He stated he was distracted. He stated he did not remember the CNP giving an order for a Vitamin D supplement. The facility then provided documentation to the surveyor that the nurse who documented she gave the 75 microgram thyroid supplement on 04/23/24 at 6:00 A.M. had documented on 04/23/24 at 12:28 P.M. (after surveyor questioned that both doses were documented as given) that the 75 microgram dose was not given. The facility provided no explanation as to why, if the nurse knew that she was not supposed to give the 75 microgram dose of thyroid supplement, she left the medication on the MAR where it would be given by the next nurse when it was due again the next day. This deficiency represents non-compliance investigated under Complaint Number OH00152613.

Based on observations, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status including body weight. This affected one of three residents reviewed for meal assistance (Resident #2). The facility census was 88. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted [DATE] from the hospital where she had been treated for C-difficile colitis (inflammation of the colon caused by bacteria) with diarrhea, weakness, decreased appetite and malnutrition. The resident had additional diagnoses including adult failure to thrive, dysphagia, rheumatoid arthritis, cerebral vascular accident, and bipolar disorder. The resident was noted with a pressure ulcer on the right buttock on admission. The resident weighed 153.7 pounds on admission and had a physician's order dated 03/20/24 to weigh weekly for four weeks then monthly. Review of a nutritional assessment on 03/25/24 revealed the resident was 66 inches tall and was on a regular diet. Current intake noted to be 50-75% of meals. Has a pressure ulcer on right buttock. The goal was to tolerate diet, consume greater than 50%, and for her weight to remain stable. Recommendations included assistance with meals and house shake from kitchen on lunch tray to support calorie intake due to risk of malnutrition. There was no evidence of follow up on the recommendation for a house shake from kitchen on lunch tray until 04/15/24 when a physician's order was obtained (21 days after recommended). Interview with Dietary Director #201 on 04/23/24 at 12:55 P.M. revealed he had received an order for a house shake from the kitchen on lunch tray for Resident #2 on 04/17/24 and it was added to her tray card (for dietary staff to follow when preparing tray). Review of the plan of care dated 03/25/24 revealed it stated Resident #2 was at risk for impaired nutritional status related to enterocolitis with C-difficile, dysphagia, adult failure to thrive, and wound. The goal was for the resident to be free from significant weight change. There was an intervention for diet as ordered. The interventions did not include any nutritional supplements. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 14, indicating intact cognition. It stated the resident required set up help with eating. However, a MDS assessment on 03/31/24 stated the resident required partial to moderate assistance with eating. Review of a physician's progress note on 04/16/24 revealed the resident had been in the hospital from 03/12/24 to 03/20/24 for diarrhea and weakness. Positive for C-difficile toxin which resulted in malnutrition with a history of 15 pound weight loss in February. Hospital course included antibiotics and electrolyte replacement. Hospital course complicated by stroke alert for left sided weakness and ataxic gait. The note indicated lab work was pending. Review of laboratory results on 04/17/24 revealed the resident's albumin level was 2.9 (normal listed as 3.5-5.5). (Low albumin is a symptom of malnutrition). Interview with Certified Nurse Practitioner #220 on 04/23/24 at 10:25 A.M. revealed she was not made aware of the results of the lab tests until 04/22/24. Observation of the lunch meal on 04/22/24 at 12:18 P.M. revealed Resident #2 did not receive a house shake on the lunch tray. The resident received ham, sweet potato, green beans, roll, cake, and lemon aide. Nursing assistant #137 assisted the resident with eating. The resident ate only a few bites. Interview with Nursing Assistant #137 on 04/23/24 at 11:50 A.M. revealed the resident had never received a nutritional supplement with lunch. Interview with the Assistant Director of Nursing #106 on 04/23/24 at 10:45 A.M. revealed nutritional supplements were to be listed on the medication administration record so the nurse could sign off that they were given. He confirmed Resident #2 did not have a nutritional supplement listed on the medication administration record and there was no evidence a supplement had been provided daily as ordered on 04/15/24. Interview with Resident #2 on 04/23/24 at 1:35 P.M. revealed she did not remember if she had received any nutritional supplements prior to 04/23/24. She stated that she had received two already on 04/23/24. Review of the facility policy (revised September 2008) and titled weight assessment and intervention revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at that point, weights will be measured monthly thereafter. Weights will be recorded in the medical record. Review of a nutritional progress note on 04/22/24 revealed the resident's intakes had been 25-75% of meals. Resident does require assistance with meals. Recommendations included to update weight and start a house supplement 240 milliliters daily from nursing to support oral intakes due to risk of malnutrition. As of 04/23/24, there was no evidence Resident #2 had been weighed since admission on 03/20/24. There was no evidence of any additional nutritional supplement orders. Interview with Director of Nursing #100 on 04/23/24 at 10:25 A.M. confirmed there was no evidence Resident #2 had been weighed since 03/20/24. Interview with Certified Nurse Practitioner #220 on 04/23/24 at 1:00 P.M. confirmed weights should have been done weekly for Resident #2 and are helpful to monitor nutritional status. Resident #2 was weighed on 04/23/24 per surveyor request with a weight of 147.5. This indicated a 6.2 pound, 4% weight loss in one month. This deficiency represents non-compliance investigated under Complaint Number OH00152613.

Based on record review, interview, and facility policy review the facility failed to report allegations of misappropriation to the state agency. This affected one resident (#86) of five residents reviewed for misappropriation. The facility census was 84. Findings Include: Review of the closed record for Resident #86 revealed an admitted [DATE] and discharge date [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), intermittent explosive disorder, cocaine abuse, opioid abuse, cannabis abuse, and depression. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 (no impairment). The assessment revealed Resident #86 had behaviors towards staff, was frequently incontinent of urine and bowel, used a wheelchair for self-propelling, nursing care for a diabetic skin impairment and required limited assist from staff for activities of daily living (ADL) including transfers and incontinence care, with care needs fluctuating daily. Review of a care plan dated 10/10/22 revealed Resident #86 had an activities of daily living (ADL) self-care performance deficit related to abnormalities of gait and mobility, and paraplegia requiring assistance from staff for transfers and toileting. Resident #86 used an electric wheelchair for mobility. Review of the progress notes/medical record from 01/20/24 through 01/31/24 revealed no documentation of the resident threatening to harm the staff with his electric wheelchair Review of the facility's self-reported incident history revealed there were no current incidents completed for misappropriation. Interview on 02/07/24 at 10:22 A.M. with Resident #86 revealed he had left the facility last week (01/31/24). Resident #86 stated, A couple days before I left the facility, that other administrator took my wheelchair charger and the power cord. I was not able to charge my wheelchair afterwards. I then asked a couple other people that had electric wheelchairs if I could borrow their chargers to use on my wheelchair. One of the power cords worked for my wheelchair, so I used it to charge up my chair. Once they found out I was using someone else's charger they had the maintenance man come in and cover my outlets. Later that night he came back and removed the covers. I was told I would not get my charger back until I left the facility for good. When I left, they gave me back the charger and the power cord. I have them right now here in my room. Interview on 02/07/24 at 10:40 A.M. with State tested Nursing Assistant (STNA) #40 revealed Resident #86 was without the use of the charger for his electric wheelchair prior to him being discharged . STNA #40 stated, They took the charger to his electric wheelchair away from him and wouldn't give it back to him until he left the facility. I guess he had to borrow someone else's charger until he left the facility. Interview on 02/07/24 at 10:58 A.M. with the Administrator confirmed Resident #86 did use a manual wheelchair at one time prior to being discharged from the facility. The administrator stated, Resident #86 did have the charger to his wheelchair when we transported him to the hotel. Interview on 02/07/24 at 11:10 A.M. with the Director of Nursing (DON) revealed she was not aware of any time Resident #86 was without the charger to his electric wheelchair. The DON also shared the only time the outlets would be covered is on the memory unit for a resident's safety. Interview on 02/07/24 at 11:22 A.M, with the Environmental Director #166 revealed the only time the outlets would be covered would be on the memory unit for the safety of a resident. The electric wheelchairs are usually placed in the hallway to charge them when the resident isn't using the chair. Interview on 02/07/24 at 12:38 P.M. with Resident #26 revealed the use of an electric wheelchair for mobility. Resident #26 stated, I do use an electric wheelchair, it's the one over there (Resident #26 pointed out into the hallway to where an electric wheelchair was located). There's no room in here, so they charge it out there I the hallway. I did let a guy use my charger and power cord a couple times. I guess his wasn't working or something like that. Interview on 02/07/24 at 12:48 P.M. with Resident #44 revealed the use of an electric wheelchair for mobility. Resident #44 stated, I do use an electric wheelchair to get around here. It's the one parked out there in corner of the hallway. I did let a man use my charger just recently. I guessed it worked; I didn't get to talk with him after he used it. He kind of had a situation and now he's not here anymore. Interview on 02/07/24 at 12:50 P.M. with Licensed Practical Nurse (LPN) #126 stated, The other administrator took the charger to his electric wheelchair and put it her car. They tried to make him use a manual wheelchair. The wheelchair did not fit him, and his feet would drag on the ground. He borrowed another resident's charger to charge his chair. When they got wind of that, they covered the outlets in his room, but then I heard the maintenance man came back and uncovered one of the outlets because he didn't agree with what he did. They did give him the charger back when he was leaving the facility the day he discharged . The LPN shared the charger was missing a few days before the resident discharged . Interview on 02/07/24 at 12:19 P.M. with the Regional Director of Operations (RDO) #2 revealed she was the acting administrator from approximately 11/27/23 until 01/02/24. Resident #86 was given a manual wheelchair to use due to threats towards staff of harming them with the electric wheelchair. RDO #2 stated, at no point was his charger removed or the outlets covered in his room. Interview on 02/07/24 at 12:44 P.M. with the Administrator verified the allegation of Resident #86's wheelchair charger being removed met the facility's abuse policy definition of misappropriation. The Administrator also verified a self-reported incident was not submitted as required. Review of the January 2024 Missing Items Log revealed no report of the resident's wheelchair charger missing. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 10/27/17 revealed it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of a resident's property in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator/designee and the the State Agency in accordance with the procedures in this policy. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. When possible, the State Agency will be notified using the online Enhanced Information Dissemination and Collection (EIDC) system. The facility will submit an online Self-Reported Incident in accordance with the State Agency's then-current instructions. This deficiency represents non-compliance investigated under Master Complaint Number OH00150746 and Complaint Number OH00150534.

Based on record review, interview, and facility policy review the facility failed to investigate an allegation of misappropriation. This affected one resident (#86) of five residents reviewed for misappropriation. The facility census was 84. Findings Include: Review of the closed record for Resident #86 revealed an admitted [DATE] and discharge date [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), intermittent explosive disorder, cocaine abuse, opioid abuse, cannabis abuse, and depression. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 (no impairment). The assessment revealed Resident #86 had behaviors towards staff, was frequently incontinent of urine and bowel, used a wheelchair for self-propelling, nursing care for a diabetic skin impairment and required limited assist from staff for activities of daily living (ADL) including transfers and incontinence care, with care needs fluctuating daily. Review of a care plan dated 10/10/22 revealed Resident #86 had an activities of daily living (ADL) self-care performance deficit related to abnormalities of gait and mobility, and paraplegia requiring assistance from staff for transfers and toileting. Resident #86 used an electric wheelchair for mobility. Review of the progress notes/medical record from 01/20/24 through 01/31/24 revealed no documentation of the resident threatening to harm the staff with his electric wheelchair Review of the facility's self-reported incident history revealed there were no current incidents completed for misappropriation. Interview on 02/07/24 at 10:22 A.M. with Resident #86 revealed he had left the facility last week (01/31/24). Resident #86 stated, A couple days before I left the facility, that other administrator took my wheelchair charger and the power cord. I was not able to charge my wheelchair afterwards. I then asked a couple other people that had electric wheelchairs if I could borrow their chargers to use on my wheelchair. One of the power cords worked for my wheelchair, so I used it to charge up my chair. Once they found out I was using someone else's charger they had the maintenance man come in and cover my outlets. Later that night he came back and removed the covers. I was told I would not get my charger back until I left the facility for good. When I left, they gave me back the charger and the power cord. I have them right now here in my room. Interview on 02/07/24 at 10:40 A.M. with State tested Nursing Assistant (STNA) #40 revealed Resident #86 was without the use of the charger for his electric wheelchair prior to him being discharged . STNA #40 stated, They took the charger to his electric wheelchair away from him and wouldn't give it back to him until he left the facility. I guess he had to borrow someone else's charger until he left the facility. Interview on 02/07/24 at 10:58 A.M. with the Administrator confirmed Resident #86 did use a manual wheelchair at one time prior to being discharged from the facility. The administrator stated, Resident #86 did have the charger to his wheelchair when we transported him to the hotel. Interview on 02/07/24 at 11:10 A.M. with the Director of Nursing (DON) revealed she was not aware of any time Resident #86 was without the charger to his electric wheelchair. The DON also shared the only time the outlets would be covered is on the memory unit for a resident's safety. Interview on 02/07/24 at 11:22 A.M., with the Environmental Director #166 revealed the only time the outlets would be covered would be on the memory unit for the safety of a resident. The electric wheelchairs are usually placed in the hallway to charge them when the resident isn't using the chair. Interview on 02/07/24 at 12:38 P.M. with Resident #26 revealed the use of an electric wheelchair for mobility. Resident #26 stated, I do use an electric wheelchair, it's the one over there (Resident #26 pointed out into the hallway to where an electric wheelchair was located). There's no room in here, so they charge it out there I the hallway. I did let a guy use my charger and power cord a couple times. I guess his wasn't working or something like that. Interview on 02/07/24 at 12:48 P.M. with Resident #44 revealed the use of an electric wheelchair for mobility. Resident #44 stated, I do use an electric wheelchair to get around here. It's the one parked out there in corner of the hallway. I did let a man use my charger just recently. I guessed it worked; I didn't get to talk with him after he used it. He kind of had a situation and now he's not here anymore. Interview on 02/07/24 at 12:50 P.M. with Licensed Practical Nurse (LPN) #126 stated, The other administrator took the charger to his electric wheelchair and put it her car. They tried to make him use a manual wheelchair. The wheelchair did not fit him, and his feet would drag on the ground. He borrowed another resident's charger to charge his chair. When they got wind of that, they covered the outlets in his room, but then I heard the maintenance man came back and uncovered one of the outlets because he didn't agree with what he did. They did give him the charger back when he was leaving the facility the day he discharged . The LPN shared the charger was missing a few days before the resident discharged . Interview on 02/07/24 at 12:19 P.M. with the Regional Director of Operations (RDO) #2 revealed she was the acting administrator from approximately 11/27/23 until 01/02/24. Resident #86 was given a manual wheelchair to use due to threats towards staff of harming them with the electric wheelchair. RDO #2 stated, at no point was his charger removed or the outlets covered in his room. Interview on 02/07/24 at 12:44 P.M. with the Administrator verified the allegation of Resident #86's wheelchair charger being removed met the facility's abuse policy definition of misappropriation. The Administrator confirmed there was no investigation completed regarding the resident's alleged missing motorized wheelchair charger despite the allegation meeting the facility definition of misappropriation. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 10/27/17 revealed it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of a resident's property in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator/designee and the the State Agency in accordance with the procedures in this policy. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. When possible, the State Agency will be notified using the online Enhanced Information Dissemination and Collection (EIDC) system. The facility will submit an online Self-Reported Incident in accordance with the State Agency's then-current instructions. Once the Administrator and State Agency are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days, unless there are special circumstances causing the investigation to continue beyond five working days. This deficiency represents non-compliance investigated under Master Complaint Number OH00150746 and Complaint Number OH00150534.

Based on medical record review, interviews with facility staff, review of laboratory test results, review of hospital records, and review of facility policies, the facility failed to provide timely, adequate, and necessary care and treatment to Resident #74 following laboratory notification of a critically low potassium level. This resulted in Immediate Jeopardy and Actual Harm on 09/08/23 when a Basic Metabolic Panel (BMP) laboratory blood test showed a critically low potassium level of 2.7 milliequivalents (meq)/hour (hr) (normal 3.5 to 5.3 meq/hr), and the facility failed to notify the physician or provide treatment until 09/15/23. On 09/15/23 Resident #74 was assessed to be dehydrated and had increased confusion which had worsened over the previous week. From 09/15/23 to 09/19/23 the facility failed to ensure physician orders related to a fluid bolus were clarified and failed to ensure nursing staff adequately monitored the resident. On 09/19/23 the resident was transferred to the hospital and treated for ventricular tachycardia (VT) requiring one electric shock treatment before a return of spontaneous circulation (ROSC) was received as well as treatment for hypokalemia (low potassium). The resident was hospitalized until 09/22/23 and then admitted to Hospice care services on 09/27/23. Additionally, a concern that did not rise to an Immediate Jeopardy occurred when facility staff failed to timely notify the physician or accurately address abnormal laboratory testing for Resident #19, #24 and #34. This affected four residents (#19, #24, #34, and #74) of four residents reviewed for laboratory services, physician notification, and quality of care. The facility census was 84. On 11/28/23 at 4:10 P.M., the Administrator, Regional Director of Operations #224, Corporate Director of Nursing (CDON) #102, Director of Nursing (DON), [NAME] President of Clinical Services #230, and [NAME] President of Operations #231 were notified Immediate Jeopardy began on 09/08/23 at 2:55 P.M. when a critically low potassium level of 2.7 for Resident #74 was received and the facility failed to notify Physician #191 of the critical lab results or provide treatment until 09/15/23 (one week later). Additionally, on 09/15/23 the facility failed to ensure a complete physician's order was obtained for a bolus of fluids to treat Resident #74's dehydration. The facility failed to monitor Resident #74 every two hours as their policy stated while the resident received the fluids. The facility failed to develop and implement a comprehensive care plan for Resident #74 that addressed the resident's risk for low potassium levels. The resident required hospital treatment/intervention after being transferred from the facility to the hospital on 09/19/23. The Immediate Jeopardy was removed on 11/29/23 when the facility completed the following actions: On 09/19/23 at 9:00 A.M., an order was received to send Resident #74 to the hospital after reassessment due to altered mental status (AMS), lethargy and elevated blood pressure of 174/94. The resident was readmitted to the facility on [DATE] at 5:43 P.M. On 11/27/23 at 11:00 A.M. the facility subcutaneous (SQ) infusion policy was reviewed by [NAME] President of Clinical Services #230, [NAME] President of Operations ##231, Regional Director of Operations #224, and CDON #103 with no changes made to policy. On 11/28/23 at 5:00 P.M., a whole house audit for any resident with any change in condition in the last seven days was completed to ensure care plans were in place and address specific interventions by the Minimum Data Set (MDS) Nurse Director #212. MDS Nurse Director #212 also audited all current residents with chronic clinical condition history to ensure care plans reflected monitoring. On 11/28/23 at 5:00 P.M., a whole house audit was completed to ensure labs drawn in the last seven days had physician notifications for any critical results by CDON #103. On 11/28/23 at 5:00 P.M., a whole house audit was completed to ensure any changes in condition in the last seven days had physician notification by CDON #103. On 11/28/23 at 5:10 P.M., nursing management was educated on Change of Condition, Lab Services, and Notification per facility policy by CDON #103. Nursing managers included: ADON #105, DON, and Unit Manager #109. On 11/28/23 at 5:44 P.M., an Ad Hoc Quality Assessment Performance Improvement (QAPI) meeting was conducted with the Administrator, ADON #105, CDON #103, Human Resources Director #204, Dietary Director #207, and Physician #191 (Medical Director), Therapy Director #225, Business Office Manager (BOM) #209, Housekeeping Director #232, MDS Nurse Director #212, Unit Manager #109, and Activities Director #214. The Immediate Jeopardy Notification was reviewed, policies on Change of Condition, Lab Services, and Notification were reviewed. Also, audits were implemented, and a plan for weekly QAPI to take place. Policies were reviewed at this time with no changes made. The facility would also hold weekly QAPl meetings times four weeks. On 11/28/23 at 6:22 P.M., a whole house education was completed to all nurses (20 LPNs and seven RNs) by the DON, ADON #105, and Unit Manager #109. Change of Condition, Lab Services, and Notification were reviewed. At the time of the training, the facility identified they used no agency staff, and no current employees were on leave. On 11/28/23, audits began and would be conducted five times weekly by the DON/designee to ensure any critical lab values had physician notification promptly times four weeks then weekly thereafter for eight weeks. On 11/28/23, audits began and would be conducted five times weekly by the DON/designee to ensure any change in condition is reassessed 24 hours after the initial change in condition with physician notification, the care plan is updated after the initial change in condition, and that physician notification is completed with any discrepancies from reassessment and orders obtained if appropriate times four weeks, then weekly thereafter for eight weeks. On 11/29/23 at 5:50 P.M., whole house education was completed to nursing managers including the ADON, Unit Manager (UM) #109, MDS Nurse Director #212, and the DON by CDON #103 related to infusion orders that included the SQ infusion policy and chronic clinical history care planning. Infusion education was to cover all forms of possible infusions. On 11/29/23 at 6:32 P.M., whole house education was completed for all nurses (20 LPNs and seven RNs) by ADON #105, the DON, and Unit Manager (UM) #109 over infusion orders, SQ infusion policy, and chronic clinical history care planning. The facility has no agency nurses or staff on leave at the time of the training. For all newly hired nurses, the facility would complete education during orientation. The infusion education covered all forms of possible infusions. On 11/29/23, audits were started and would be conducted five times weekly by the DON/designee to ensure any infusion orders had the correct rate, dose, amount, and time along with assessments of sites while infusions run times four weeks, then weekly thereafter for eight weeks. All audits would be discussed/reviewed through QAPI weekly times four weeks. Any discrepancies will be addressed at that time. Although the Immediate Jeopardy was removed on 11/29/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1.Review of the medical record for Resident #74 revealed an admitted [DATE] with medical diagnoses including cerebral infarction (stroke), type II diabetes mellitus, generalized muscle weakness, difficulty in walking, vascular dementia with behavioral disturbance, other abnormalities of gait and mobility, essential primary hypertension (high blood pressure), hypokalemia (added on 09/22/23) (low potassium level), paroxysmal atrial fibrillation, syncope and collapse, cardiac arrhythmia (added on 09/22/23), and congestive heart failure (added on 09/22/23). Review of Resident #74's laboratory testing result history from 03/15/22 through 10/27/23 revealed Resident #74's potassium levels ranged from 3.1 to 5.2 milliequivalents (meq)/hour (hr). The normal range for potassium level is 3.5 to 5.3 meq/hr. Review of the plan of care, dated 06/07/23 revealed Resident #74's risk for hypokalemia (low potassium levels) was not addressed in the resident's care plan. A diagnosis of hypokalemia was added to the care plan for cardiovascular status on 09/22/23. However, there were no specific interventions related to the hypokalemia diagnosis added to the care plan. Review of Physician #191's progress note dated 09/07/23 revealed the physician visited Resident #74 for a scheduled surveillance visit. Physician #191 was notified Resident #74 had experienced two falls that week and diarrhea for four days. Resident #74's blood glucose levels, blood pressures, and neurological checks were within normal limits. Physician #191 ordered orthostatic blood pressures, a Clostridium difficile (C. Diff) test, complete blood count (CBC) and basic metabolic panel (BMP) laboratory tests. Review of the corresponding physician's orders for September 2023 revealed on 09/07/23 orders for a CBC, BMP, and urinalysis (UA) laboratory tests. Review of the laboratory test results dated 09/08/23 revealed Resident #74 had a renal critically low (RCL) potassium level of 2.7 milliequivalents (meq)/hour (hr). Test results also show hypoglycemia with a low glucose level of 58, and a high creatinine level of 1.6 (normal range was listed as 0.6 to 1.2). The results were reported (from the lab to the facility) on 09/08/23 at 2:55 P.M. Review of the progress notes revealed there was no documented evidence the physician was notified of the critical lab results for Resident #74. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition with a score of five out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #74 required supervision from one staff to complete bed mobility and limited assistance from one staff to complete transfers. Resident #74 required extensive assistance from one staff to complete dressing, toileting, and personal hygiene tasks. Resident #74 had not experienced any falls and did not receive any special services, including hospice services. Review of Physician #191's untimed progress note dated 09/15/23 (seven days after the laboratory results were obtained) revealed Resident #74 was seen for follow-up of abnormal lab results. Resident #74 was noted with dehydration, acute injury of the kidney most likely in setting of low perfusion (reduced peripheral blood flow) and dehydration, hypokalemia (low potassium level) with critically low potassium level of 2.7, worsened anemia without an obvious source of bleeding, and high creatinine level. Physician #191 ordered a STAT (immediate) CBC, BMP, and UA along with a potassium supplement (on 09/15/23). Physician #191 confirmed the facility did not notify her of Resident #74's critical lab results (on 09/08/23). Physician #191 was informed by the nurse at the time of the visit that Resident #74 had not had diarrhea during the shift but was unable to state when it had improved. Resident #74 had poor intakes for some time. Unit Manager (UM) #111 notified Physician #191 Resident #74 had been more confused than normal for over one week. The nurse notified Physician #191 later in the day (on 09/15/23) that the laboratory testing (ordered on this date) could not be completed as attempts to obtain blood from the resident were unsuccessful. Physician #191 ordered a subcutaneous (SQ) bolus of 500 milliliters (mL) of normal saline (NS) with labs to be repeated once fluids were administered. Physician #191 noted having a lengthy conversation with ADON #105, CDON #103, and UM #111 related to proper notification protocols of abnormal lab results. Review of additional physician's orders dated September 2023 revealed Resident #74 had an order for STAT CBC and BMP laboratory tests one time only for altered mental status dated 09/15/23 at 6:30 P.M. The tests were ordered by Physician #191 and had an end date on 09/16/23 at 6:29 P.M. Resident #74 had a physician's order for 500 mL of 0.9% NS bolus one time only for hydration dated 09/15/23. The order did not indicate a rate, end date, or end time. The order was made by Physician #191. Resident #74 had an order for Potassium Chloride Extended Release 20 meq with instructions to give two tablets one time only for hypokalemia (administer a total of 40 meq). The order was dated 09/15/23. Review of the progress note dated 09/15/23 at 6:23 P.M. by LPN #226 revealed a lab technician arrived to draw STAT CBC and BMP labs but was not able to obtain. Physician #191 was notified and gave orders to administer 500 mL bolus of 0.9% NS and 40 meq of potassium one time. Repeat STAT CBC and BMP after administration of fluids. The note did not specify a rate for the bolus or an end date or time. Review of the progress note dated 09/15/23 at 6:24 P.M. by LPN #226 revealed the nurse placed a SQ IV in Resident #74's lower left quadrant of her abdomen. Resident #74 tolerated the placement well. The IV line was patent and running. The note indicated LPN #226 would continue to monitor. Review of the Medication Administration Record (MAR) dated September 2023 revealed Resident #74 received potassium supplement and IV fluids as ordered. The bolus was signed off on the MAR on 09/15/23 at 09:16 P.M. by LPN #155. The STAT CBC and BMP lab order was signed off on 09/15/23 at 9:22 P.M. by LPN #155. Review of the lab results dated 09/16/23 revealed Resident #74 had a low potassium level of 3.0 millimoles per liter (mmol/L). The results were faxed to the facility on [DATE] at 7:45 P.M. There were no additional progress notes entered on Resident #74 until 09/17/23 at 11:32 A.M. (approximately 41 hours after the IV line was placed). Review of the progress note dated 09/17/23 at 11:32 A.M. (approximately 16 hours after the results were faxed to the facility) by LPN #176 revealed lab results were received and the on-call physician was notified. A new order for potassium 40 meq was received with instructions to administer twice daily for three days. LPN #176 would continue to monitor. Review of the physician orders dated September 2023 revealed Resident #74 had an order for potassium oral tablet with instructions to give 40 meq twice daily for supplement for three days until 09/20/23. The order was dated 09/17/23. Review of the MAR dated September 2023 revealed Resident #74 received the potassium supplement at 8:00 P.M. on 09/17/23 and on 09/18/23 at 8:00 A.M. and 8:00 P.M. Resident #74 was out of the facility on 09/19/23 at 8:00 A.M. The potassium was marked as administered on 09/19/23 at 8:00 P.M. but Resident #74 was out of the center on 09/20/23 at 8:00 A.M. according to the MAR. Review of the progress note dated 09/19/23 at 9:00 A.M. by RN #160 revealed Resident #74 was found lying down in bed very lethargic, unable to sit or stand. Resident #74 was not able to eat or drink breakfast. Resident #74's blood pressure was (elevated/hypertensive) 174/94, pulse was 71, respiratory rate was 20, and oxygen saturation was 95%. The nurse practitioner was notified and ordered Resident #74 to be sent to the emergency department. The DON and resident's family were notified. Resident #74 was hospitalized from 09/19/23 to 09/22/23. Resident #74's payer source was changed to a Hospice payer on 09/27/23. Review of the progress note dated 09/22/23 at 9:17 P.M. revealed Resident #74 returned to the facility from the hospital on 09/22/23 at 4:45 P.M. Review of hospital records dated 09/22/23 revealed Resident #74 was treated for an elevated troponin level (a protein released into the bloodstream during a heart attack and a sign of some damage to the heart), tachycardia (fast heart rate) with frequent premature ventricular contractions (PVCs), ventricular tachycardia (a condition caused by faulty heart signaling that triggers a fast heart rate in the lower heart chambers), hypertension, hypokalemia, and hypomagnesemia. Resident #74's blood pressure was 180/65 while lying down. Upon admission on 09/19/23, Resident #74 had a low potassium level of 3.3 and critically high troponin levels of 251 initially and 128 upon repeat. Review of the after-visit summary (AVS) dated 09/22/23 revealed Resident #74 was treated for ventricular tachycardia (VT) felt to be electrolyte related. Resident #74 experienced VT arrest with return of spontaneous circulation (ROSC) following a single defibrillation. Treatment for hypokalemia and hypomagnesemia (low magnesium level) included replacing electrolytes, maintaining potassium level above four, and maintaining a magnesium level over two. At discharge, Resident #74 would continue potassium and magnesium supplements. Review of the progress note dated 09/27/23 at 4:06 P.M. revealed Resident #74 was accepted to Hospice and palliative care. Interview on 11/22/23 at 5:15 P.M. with Regional Director of Operations #224 and Corporate Director of Nursing (CDON) #103 confirmed Resident #74's physician was not notified of the critical lab results that were received on 09/08/23 until 09/15/23 (one week later). CDON #103 stated Resident #74 received a potassium supplement and IV fluids on 09/15/23. Resident #74 was sent to the hospital on 09/19/23 for a change in condition. CDON #103 confirmed Resident #74 experienced VT in the hospital and confirmed the resident was treated for heart issues and low potassium. Interview via telephone on 11/27/23 at 10:02 A.M. with LPN #176 revealed she worked at the facility on the weekends and was familiar with Resident #74. LPN #176 stated if a resident had an order to receive SQ IV fluids, the order should include a rate and time frame for it to infuse over. If the order did not include these instructions, the nurse should clarify the order (with the physician). LPN #176 also stated the resident should be monitored while the fluids were administered to ensure the line was patent and flowing and that the resident was tolerating the treatment. The observations of the resident should be documented in the medical record. Interview via telephone on 11/27/23 at 11:44 A.M. with Physician #191 confirmed the facility failed to notify her of Resident #74's critical lab results on 09/08/23. Physician #191 stated she was at the facility for a regular visit on 09/15/23 and Resident #74 was not on her schedule to be seen that day. When she arrived on-site, she happened to find and reviewed Resident #74's lab results. At that time, Physician #191 decided to see Resident #74 on 09/15/23 to follow up. Physician #191 stated there were concerns Resident #74 was dehydrated based on the resident's appearance. The resident appeared dehydrated and had dry lips. Physician #191 stated she was told the DON would be available to monitor the bolus while the fluids were being administered. Physician #191 confirmed she could not confirm the rate at which the nurse was ordered to administer the fluids. Physician #191 stated the rate was determined based on the resident's weight and other factors. Physician #191 stated the bolus should have been administered at a rate less than 70 mL/hr. Physician #191 confirmed MedOne (the physician's group) received notification of the lab results completed on 09/16/23 on 09/17/23 at 11:41 A.M. Physician #191 stated she had considered sending Resident #74 to the hospital on 09/15/23 but the nursing staff reported the resident had been at baseline, looked okay, and vital signs were within normal limits. Physician #191 decided to treat Resident #74 at the facility. Physician #191 reported if a resident had low potassium levels, she would want to replace it as soon as possible because there would be concern for the resident's heart health. Interview on 11/27/23 at 2:13 P.M. with CDON #103 confirmed there was no documented evidence in the medical Resident #74 had been monitored every two hours. There was no documented evidence of any observations completed on Resident #74 except on 09/15/23 at 6:23 P.M. when the nurse placed the line for the SQ IV fluids and 09/15/23 at 9:16 P.M. when the night shift nurse signed off on the MAR. Interview via email on 11/27/23 at 5:40 P.M. with CDON #103 confirmed Resident #74's abnormal lab results were faxed to the facility on [DATE] at 7:45 P.M. and there was no documented evidence the physician was notified until 09/17/23 at approximately 11:30 A.M. Interview on 11/28/23 at 10:47 A.M. with LPN #226 confirmed she was the nurse who started the SQ IV fluids for Resident #74 on 09/15/23 ordered by Physician #191. LPN #226 confirmed Physician #191 did not provide a rate at which the fluids should have been administered. LPN #226 confirmed Resident #74 should have been observed/monitored at least every two hours to make sure the line was still in place, running without any issues, and the resident was tolerating the infusion without any adverse effects. LPN #226 stated she thought it was an open line. LPN #226 stated the nursing staff should notify the physician of any lab results regardless of whether the results were abnormal. Interview on 11/28/23 at 4:00 P.M. with CDON #103 confirmed Resident #74's care plan did not address the resident's risk for low potassium levels until Resident #74 returned from the hospital on 09/22/23 with that diagnosis. Interviews on 11/29/23 at 3:40 P.M. with RN #160 and Assistant Director of Nursing (ADON) #105 confirmed the physician should be notified immediately upon receipt of any lab results regardless of if the results were normal or abnormal. Both nurses confirmed this had always been the facility's process for the nursing staff. Both nurses confirmed all notifications should be documented in the electronic medical record. Review of the facility policy, Lab and Diagnostic Test Results-Clinical Protocol, revised 09/2012, revealed nursing staff would consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: the result was something that should be conveyed to a physician regardless of other circumstances (the abnormal result is problematic regardless of any other factors), the resident's clinical status was unclear or worsening. Furthermore, if the resident had signs and symptoms of acute illness or condition change and he/she was not stable or improving, the nurse would notify the physician promptly to discuss the situation. Facility staff should document information about when, how, and to whom the information was provided and the response in the Progress Notes section of the medical record and not on the lab results report. Review of the facility policy, Guidelines for Reporting Abnormal Test Results to Physicians, revised 02/2014, revealed for a chemistry test, immediate notification should be completed if potassium level was less than 3.0. Review of the undated facility policy, Hypodermoclysis revealed hypodermoclysis was subcutaneous administration of fluid to correct dehydration. Infusion sites would be observed at least every two hours for redness, swelling, leaking, or discomfort. Document date and time of procedure, site assessment, patient response to procedure and/or medication, and patient teaching on appropriate nursing document. Review of the facility policy, Change in a Resident's condition or Status, revised 12/2016, revealed the nurse would notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition or need to alter the resident's medical treatment significantly. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services that were to be furnished to attain or maintain the resident's highest physical, mental and psychosocial well-being, describe services that would otherwise be provided for the above, but were not provided due to the resident exercising his or her rights, including the right to refuse treatment, include the resident's stated goals upon admission and desired outcomes, incorporate identified problem areas, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility policy, Medication Orders, revised 11/2014, related to intravenous orders included when recording orders for IV solutions, specify the type of solution, rate of flow, and volume to be infused. Example: 1000 cc D5W I.V. at 50 cc/hr. Discontinue when infused. 47059 2. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV) disease, atrial fibrillation, type two diabetes mellitus with neuropathy, cardiomyopathy, peripheral vascular disease, anxiety disorder, major depressive disorder, and pulmonary embolism without acute cor pulmonale. Review of Resident #19's quarterly MDS assessment dated [DATE] revealed Resident #19 was cognitively impaired with a BIMS score of an eight out of 15 and required extensive assistance for mobility and general personal care. Resident #19 was on medication to thin the blood that put Resident #19 at risk for bruising and bleeding. Resident #19 was listed on the facility's quality improvement monitoring log indicating Resident #19 had lab work drawn on 10/09/23 and the physician was notified of results on 10/09/23 at 7:30 P.M. Resident # 19's electronic medical record indicated Resident #19 had a PT (prothrombin time)/INR (international normalized ratio) test results called to the physician 10/12/23 at 4:25 P.M. and 10/19/23 at 11:37 A.M. Resident #19's paper chart has a PT/INR listed as drawn 10/13/23 at 11:11 A.M. and resulted 10/13/23 at 6:21 P.M., with results listed as high outside the normal range, and a hand written note stating the physician was notified with no documented evidence of the date or time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information and the paper chart for Resident #19 was missing information. Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day. 3. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, type two diabetes mellitus with neuropathy, peripheral vascular disease, vascular dementia, and a history of falls. Review of Resident #24's quarterly MDS dated [DATE] revealed Resident #24 mildly cognitively impaired with a BIMS score of 11 out of 15. Resident #24 was on medication to thin the blood that put Resident #24 at risk for bruising and bleeding. Resident #24 was listed on the facility's quality improvement monitoring log reflecting Resident #24 had lab work drawn on 10/13/23 and the physician was notified of results on 10/13/23 at 7:00 P.M. with results listed as highly outside the normal range. Resident #24's electronic medical record indicated Resident #19 had a PT/INR test results called to the physician 10/12/23 at 4:25 P.M. and 10/19/23 at 11:37 A.M. Resident #19's paper chart had a PT/INR listed as drawn 10/13/23 at 11:11 A.M. and resulted 10/13/23 at 6:21 P.M. with a handwritten note stating physician notified 10/13/23 with no documented evidence of the time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information and the paper chart for Resident #24 was missing information. Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day. 4. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, type two diabetes mellitus with neuropathy, congestive heart failure, cardiomyopathy, and peripheral vascular disease. Review of the annual MDS dated [DATE] revealed Resident #34 was cognitively intact with a BIMS score of 12 out of 15 and required supervision for mobility, general activities of daily living, and personal care. Resident #34 was on medication to thin the blood that put Resident #34 at risk for bruising and bleeding. Resident #34 was listed on the facility's quality improvement monitoring log stating Resident #34 had lab work drawn on 09/27/23 and the physician was notified of results on 09/28/23 at 1:00 A.M. Resident # 34's electronic medical record indicates Resident #34 had a PT/INR test results called to the physician 09/28/23 at 12:23 P.M. Review of Resident #34's paper chart revealed a PT/INR listed as drawn 09/27/23 at 8:26 P.M. and resulted 09/27/23 at 9:50 P.M. with no documented evidence of the time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information, and the paper chart for Resident #34 was missing information. Interview on 11/29/23 at 3:30 P.M. with Regional Director of Nursing #103 revealed not all notification of lab work reported to the physician was in the electronic medical record. The nurses may also document notification in the paper chart. Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day.

Based on observation, record review, review of the facility Perineal Care policy and procedure and family and staff interview, the facility failed to implement adequate skin risk interventions, including timely incontinence care and treatment for Resident #34, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning, to prevent the development of a pressure ulcer to the resident's coccyx. Actual harm occurred on 08/13/23 at 7:04 A.M. when a reddened area was noted to Resident #34's coccyx area without evidence of effective preventative measures being in place or additional interventions implemented at that time. On 08/14/23 at 10:13 P.M. the Wound Certified Nurse Practitioner (CNP) assessed Resident #34 to have a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer to the coccyx. However, treatment orders were not implemented until 08/16/23 when an order was received for the application of Desitin 40-percent (provides a protective barrier with maximum-level of zinc oxide) to be applied every shift. This affected one resident (#34) of three residents reviewed for pressure ulcers. The facility census was 86. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy, dysphagia, subarachnoid hemorrhage, history of transient ischemic attack, and dementia. Review of the plan of care dated 07/11/22 revealed Resident #34 was at risk for skin breakdown. Interventions included to encourage and assist Resident #34 to turn and reposition as tolerated, keep skin clean, dry, and odor free, and staff to apply barrier cream after each incontinent episode. An additional plan of care dated 07/11/22 revealed Resident #34 had activities of daily living self-care performance deficit. Interventions included to apply moisture barrier to buttocks, noted the resident required extensive assistance of two (staff) for bed mobility, and included an intervention for the resident to be checked for incontinence every two hours. A plan of care dated 07/27/22 revealed Resident #34 had incontinence of bowel and bladder. Interventions included to apply moisture barrier to buttocks, document when incontinent, and use pads/briefs to manage incontinence. A plan of care dated 11/17/22 revealed Resident #34 had the potential for changes in mood/behaviors and refused care, medications, and treatments at times. Interventions included to administer medications as ordered and behavioral health consult as needed. Review of the Braden Scale for Predicting Pressure Sore Risk assessment, dated 04/21/23 revealed Resident #34 was at risk for the development of pressure sores. A physician's order dated 07/13/23 revealed Resident #34 was to have house barrier cream applied with each incontinence episode. The resident also had orders to encourage to turn and reposition every two hours as tolerated, encourage to float heels as tolerated, and pressure reducing mattress to bed. Review of incontinence documentation from 08/02/23 to 08/30/23 revealed incontinence care was documented as only being provided once a day on 08/03/23, 08/06/23, 08/08/23, 08/10/23, 08/18/23, 08/25/23, 08/26/23, and 08/28/23. The other days in August 2023, staff documented the provision of incontinence care for the shift as opposed to with each episode of incontinence. In addition, review of the administration records revealed no evidence staff documented turning and repositioning every two hours for the resident. A weekly skin assessment dated [DATE] revealed Resident #34 had no reddened areas, rash, bruises, blisters, dry/flaky skin, or open lesions, cuts, lacerations, skin tears, wounds, or open ulcers at this time. A general progress note dated 08/13/23 at 7:04 A.M. revealed Resident #34 screamed all night and fights staff during patient care. The note documented it was hard to turn Resident #34 every two hours. A reddish area was noted to Resident #34's sacral area. The note documented the nurse cleansed the area with normal saline and notified the director of nursing, physician, and family. However, there was no other assessment/description of the area to Resident #34's coccyx noted in the medical record on 08/13/23 and no evidence any new interventions were considered/implemented in regard to staff having difficulty with turning the resident or fighting with staff during care. A wound care note by the Wound CNP dated 08/14/23 at 10:13 P.M. revealed Resident #34 had a Stage III pressure ulcer to coccyx that measured 1.3 centimeters (cm) long by 1.5 cm wide with a depth of 0.1 cm. There was a shallow open area with granulation tissue and a scant amount of serous (thin, watery, clear) drainage. The peri wound appeared to be macerated (resulting from when skin is in contact with moisture for too long). The note indiciated the area was to be cleansed with soap and water and Desitin 40-percent was to be applied with the wound left open to air. The note revealed the area was to be offloaded regularly and Resident #34's brief was to be left off at night. A physician order dated 08/14/23 at 2:46 P.M. revealed Resident #34 was ordered an air mattress (following the development of the pressure ulcer) and moisture barrier cream (already ordered prior to the development) to coccyx area with each incontinence episode. A physician order dated 08/16/23 at 6:33 A.M. (two days after the pressure ulcer was assessed by the wound CNP) revealed an order was received for Resident #34's coccyx area to be cleansed with soap and water and Desitin 40-percent to be applied every shift. Review of the treatment administration record (TAR) revealed the first new treatment following the identification of the ulcer on 08/13/23 was Desitin 40-percent, documented as being applied on 08/16/23 on day shift and night shift. Further review of the TAR revealed the treatment was not completed on day shift on 08/17/23. The TAR reflected on the evening shift on 08/17/23 a treatment of Zinc Oxide was applied, until Desitin 40-percent was received. A wound care note by Wound CNP dated 08/22/23 revealed Resident #34 was a long-term resident that was nonverbal with dementia lying in bed yelling. Resident #34 began yelling when the provider entered the room. After much encouragement, Resident #34 was able to be redirected so her bottom could be assessed. Resident #34 had a Stage III pressure ulcer to the coccyx that measured 1.4 cm length by 1.6 cm width with 0.1 cm depth. The wound base had 100-percent granulation tissue and the peri wound area appeared macerated. Zinc Oxide cream was to be applied every shift and as needed. A wound care note by Wound CNP dated 08/29/23 revealed Resident #34 was confused, obese, and incontinent. Resident #34 had a Stage III pressure wound to the coccyx that measured 1.2 cm length by 1.4 cm width with 0.1 cm depth. The wound base had 100-percent granulation tissue. The peri wound area appeared macerated and Zinc Oxide cream was to be applied every shift and as needed. Interview on 08/31/23 at 2:49 P.M. with Mobile Director of Nursing (DON) #500 revealed Resident #34 was found with a probable Stage I (no-blanchable redness of a localized area usually over a bony prominence) pressure ulcer on 08/13/23 that deteriorated to a Stage III pressure ulcer on 08/14/23. Interview on 08/31/23 at 3:47 P.M. with Assistant Director of Nursing (ADON) #248 revealed Resident #34 had a small open area that was staged as a Stage III pressure ulcer by the Wound CNP on 08/14/23. Interview on 08/31/23 at 4:10 P.M. with a family member of Resident #34 revealed concerns related to the resident's skin breakdown. The family member revealed the the facility had called her and said Resident #34 had an area to her bottom, but it was not open. The family member stated Resident #34 always had an incontinence brief on and she was unable to tell if Resident #34 was soiled. The family member stated there was a turn schedule hanging in Resident #34's room, so she did not understand how Resident #34 developed a pressure ulcer to her bottom. The family member stated she felt an air mattress should have been put in place prior to Resident #34 developing a pressure ulcer because Resident #34 did not want to get out of bed very often. Interview on 08/31/23 at 4:34 P.M. with Licensed Practical Nurse (LPN) #209 revealed Resident #34 would fight with staff at times and would yell out as soon as someone entered her room. At the time of the interview, observation wtih LPN #209 verified a turning schedule was posted on the wall next to Resident #34's bed with 4:00 PM showing Resident #34 should be on left side. LPN #209 verified Resident #34 was observed lying on her back at that time. LPN #209 also verified the turn schedule showed Resident #34 was to be turned every two hours from side to side and not onto her back. Interview on 08/31/23 at 4:40 P.M. with State tested Nursing Assistant (STNA) #268 revealed it required two staff to turn Resident #34 because Resident #34 would fight the staff. STNA #268 stated Resident #34 did not get out of bed and staff were required to turn the resident every two hours. Interview on 08/31/23 at 4:46 P.M. with STNA #256 revealed the turning chart hanging in Resident #34's room was old and was for the previous resident. STNA #256 stated a clear cream was to be applied by STNA staff to Resident #34's buttocks and coccyx because Resident #34 had an area to her bottom before. On 09/05/23 at 11:30 A.M. interview with the Regional Director of Operations (RDO) revealed Desitin cream was purchased by central supply on 8/16/23 due to the facility not having any Desitin. The formulary (list of medications that may be prescribed) revealed Zinc Oxide would replace Desitin, so Desitin was discontinued and Zinc Oxide was ordered. The RDO revealed the Wound CNP's recommendation for Resident #34 not to wear a brief at night was placed inside Resident #34's closet and communicated to the STNA's during report. The Regional Director of Operations verified Resident #34 had been in the same room since admission on 07/11/22. The Regional Director of Operations also verified STNA staff were responsible for charting incontinence care every shift. The RDO revealed if the STNA staff did not chart every shift, they were called to come back to work and complete the documentation or follow up with discipline process. There had been a turnover in staff and some of the staff did not follow instructions. The resident continued to be treated for the Stage III pressure ulcer at the time of the survey. On 09/05/23 at 2:30 P.M. the Regional Director of Operations revealed Desitin had been stopped after being applied twice, not because of formulary, but because there was not enough Desitin to cover the treatments for the upcoming days. The order to apply Desitin was discontinued and a new order was given to apply Zinc Oxide until Desitin became available. Review of Perineal Care Policy and Procedure revised October 2010 revealed the resident's care plan should be reviewed to assess for any special needs of resident. The following information should be recorded in the resident's medical record: the date and time the perineal care was provided and any discharge odor, bleeding, skin care problems or irritation, and complaints of pain or discomfort. This deficiency represents non-compliance investigated under Master Complaint Number OH00145680.

Based on closed medical record review, hospital record review, review of Centers for Disease Control (CDC), National Health Institutes of Health, and National Pressure Injury Advisory Panel (NPIAP) information, review of the facility policy and procedure titled Prevention of Pressure Ulcers/Injuries, review of the facility policy and procedure titled Perineal Care, facility and staff interviews, the facility failed to implement a comprehensive and effective pressure ulcer treatment program to prevent the development of an avoidable pressure ulcer for one newly admitted resident, Resident #14, who was admitted with intact skin, assessed to be at risk for pressure ulcer development, incontinent of bowel and bladder and dependent on staff for bed mobility and personal care. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #14 on [DATE], when the resident was assessed to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the coccyx with deterioration of previously identified moisture associated skin damage (MASD) without evidence adequate interventions (including but not limited to turning and repositioning) had been implemented to prevent the development. Following the development, the ulcer continued to deteriorate and on [DATE] due to a change in responsiveness and vital signs the resident was transferred to the emergency room . The resident was admitted and subsequently diagnosed at the hospital with sepsis and necrotizing fasciitis. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility identified four current residents with pressure ulcers in a facility census of 87. On [DATE] at 5:24 P.M., Regional Director of Operations #800, the Director of Nursing (DON), the [NAME] President of Operations #801, the Regional Director of Clinical Services #802, and the [NAME] President of Clinical Services #803 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide necessary interventions to prevent the development of an unstageable pressure ulcer to Resident #14. On [DATE], Resident #14 was found to have an unstageable pressure ulcer to the coccyx and the pressure ulcer was assessed to be 9.2 centimeter (cm) long and 10.4 cm wide. The wound base had 40-percent granulation tissue (a type of connective tissue that forms on a wound during healing) and 15-percent slough (yellow/white necrotic tissue). There were scatter open granular areas with one small, sloughed area over sacrum. The peri wound area appeared to be macerated. On [DATE], Resident #14 exhibited a change in condition, was hospitalized and admitted with sepsis and necrotizing fasciitis. Resident #14 did not return to the facility and expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 2:00 P.M., the DON notified the Medical Director #950 that the facility created a new skin Quality Assurance Performance Improvement (QAPI). The skin QAPI plan is to address concerns with in-house pressure growth and the need for staff training due to turnover in management and nursing. On [DATE], DON and ADON #603 completed a whole house skin audit with no unidentified areas observed. On [DATE], all nurses, one registered nurse (RN) and 18 licensed practical nurses (LPNS), were in-serviced on preventative interventions to prevent skin breakdown by the DON. All 36 State tested Nursing Assistants (STNA) in-serviced on turns and repositioning, and incontinence care by the DON. On [DATE], all six residents with noted pressure areas were evaluated by the DON to ensure all preventative measures were appropriate and in place with no concerns noted. On [DATE], Resident #14 was sent to the emergency room and did not return back to the facility. On [DATE], the facility completed a QAPI meeting to discuss that the facility had a skin QAPI in place and the facility identified no further in house pressure ulcers developed. Medical Director #950, DON, Administrator, Medical Records and Central Supplies #615, Unit Manager #901, ADON #603, Admission Coordinator #620, Activity Director #630, Housekeeping Supervisor #640, Maintenance Director #645, and Business Office Manager #650 were all in attendance at the QAPI meeting. On [DATE] at 9:00 A.M., the DON completed a Braden risk assessment on all current residents to identify any high-risk residents. Changes were made in the resident's plan of cares who were identified at high risk and active pressure ulcers by the Minimum Data Set Nurse #900. The care plans were updated to reflect all preventative interventions. On [DATE], Unit Manager #901 completed a skin assessment on all 88 current residents residing in the facility. No new skin areas or pressure ulcers were found. On [DATE], the DON educated all 30 LPNs (no RN) on Prevention of Pressure Ulcers/Injuries Policy and 46 STNAs were educated on turning and repositioning and incontinence care. Beginning on [DATE], the DON/designee will audit three random residents with high-risk Braden assessments weekly for four weeks. The DON/designee will audit all new admissions weekly for four weeks to ensure all preventative measures are all on the care plan. On [DATE], interviews with LPN #401, STNA #402, STNA #403, LPN #404, LPN #405, and STNA #406 revealed the staff were knowledgeable on the education they had received on pressure ulcer in-regards to documentation, assessments, prevention and treatment of pressure ulcer, notification, and turning and repositioning. Beginning on [DATE], weekly QAPI meetings will be completed so any discrepancies from the audits can be reviewed with the team. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #14, revealed an admitted [DATE] and a discharge date of [DATE]. Resident #14 had diagnoses including transient cerebral ischemia, cerebral infarction, anxiety, altered mental status, occlusion and stenosis, and peripheral vascular disease. Review of the hospital after visit/discharge summary dated [DATE] revealed Resident #14 had a transient ischemic attack (stroke). Speech and language pathology discharge recommendations included dysphagia (difficulty swallowing) treatment, one assist with meals, upright position for oral intake, diet tolerance monitoring, swallow function, and cognitive communication functioning. Resident #14 was to follow up with neurologist and heart and vascular specialists. Review of the nursing assessment dated [DATE] revealed the resident was admitted with no pressure areas. The resident was noted to have bunions to her bilateral feet. Review of the Braden scale assessment (assessment for risk factors for developing pressure ulcers) dated [DATE] revealed Resident #14 was at high risk for the development of pressure ulcers. Review of the plan of care (POC) dated [DATE] revealed Resident #14 had a potential for impairment to skin integrity with skin risk related to artery occlusions, peripheral artery disease (PAD), cardiac disease, cardiomegaly, high-density lipoprotein, hypertension, left ventricular hypertrophy, abnormal labs and blood sugars, nicotine use, fragile skin, muscle wasting, incontinence of bowel and bladder, decreased mobility, and history of wound to lower leg. Interventions on the [DATE] POC included to avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, keep skin clean and dry and use lotion on dry skin, monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash or allergic reactions which could exacerbate skin injury, obtain blood work and culture and sensitivity of any open wounds as ordered by physician, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, wound and treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, medications, treatments, labs, tests and consultations as ordered or needed, and see medication and treatment administration record, wound reports and skin assessments as appropriate. Review of the POC dated [DATE] revealed Resident #14 had an activities of daily living (ADL) self-care performance deficit related to aphasia, cardiomegaly, hypertension, impaired gait/balance, impaired vision, left ventricular hypertrophy, nicotine dependence, PAD, history of altered mental status, anxiety, cerebrovascular accident, left facial droop, left-sided weakness, shortness of breath, and stroke. Interventions included repositioning and toileting with a two-person assist. The POC did not specify any interventions related to the frequency of turning or repositioning for the resident. In addition, record review revealed no documented evidence staff provided turning and repositioning between [DATE] and [DATE]. The resident did not have any type of air mattress during this time. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had impaired cognition. The assessment revealed the resident required extensive assistance from two staff for bed mobility and transfers, staff assistance for eating and was frequently incontinent of bowel and bladder. The assessment revealed Resident #14 had no skin concerns. A weekly skin assessment dated [DATE] revealed Resident #14 had no skin concerns. On [DATE] a physician order was obtained for zinc barrier cream to be applied to the resident's buttocks every shift for prevention and as needed. The treatment administration record (TAR) included documentation of the zinc barrier cream being applied as ordered beginning on [DATE]. Record review revealed no additional assessment of the resident's skin at this time or information to note why the zinc was ordered. A skin sweep/bathing sheet dated [DATE] revealed a red area was marked to Resident #14's right buttock. There was no evidence of new interventions initiated at that time. A weekly skin assessment dated [DATE] revealed Resident #14 had moisture associated skin damage (MASD) to her bilateral buttocks/sacrum area. The assessment indicated preventive measures (zinc barrier cream) were put in place. MASD is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. A progress note dated [DATE] at 9:00 A.M. revealed a State tested Nursing Assistant (STNA) #400 summoned the DON and the DON noted the resident had an unstageable pressure area to her coccyx that measured one cm long and 1.9 cm wide to the right buttocks. The note indicated the DON realized once Resident #14 started getting into a specialized Broda chair, Resident #14 started getting pressure from the chair. Orders were received on [DATE] for a cushion to be placed in the Broda chair and the note documented every two-hour turns were to continue. A Broda chair is a specialized type of wheelchair that provides tilt-in-space positioning, recline and leg rest adjustments. However, there was no documented evidence to support every two-hour turns were being provided for the resident. Review of the wound nurse practitioner (CNP #400), note dated [DATE] revealed Resident #14 was seen for an unstageable pressure wound to sacrum that measured 9.2 cm long by 10.4 cm wide. The wound base had 40-percent granulation tissue and 15-percent slough. There was a scant amount of serous (thin, watery, clear) drainage and no signs of infection. The CNP noted a new treatment order for Triad (a sterile coating that can be used on broken skin, keeping the wound covered and protected from incontinence). On [DATE] Resident #14's POC was updated to include interventions of an air mattress to assist in redistribution, every two hour turns, and use of a pillow/cushion when sitting in Broda chair. A skin sweep/bathing sheet dated [DATE] revealed Resident #14 had a new area to buttocks. An arrow drawn on the sheet appeared to be pointed to the left buttock/sacrum area. Review of a weekly skin assessment dated [DATE] revealed Resident #14 had an unstageable pressure ulcer to sacrum that measured 9.2 cm long and 10.4 cm wide. Review of a weekly wound assessment dated [DATE] revealed Resident #14's coccyx/sacrum pressure ulcer had worsened/deteriorated, and a new treatment order was received for the area to be cleansed with normal saline, packed with Dakin's solution (moist to dry dressing), and covered with bordered foam dressing twice a day and as needed. The unstageable pressure ulcer to Resident #14's coccyx measured 9.2 cm long by 10.4 cm wide. The peri-wound tissue appeared macerated. A corresponding note, from CNP #400 also dated [DATE] revealed Resident #14 had an unstageable pressure ulcer to the sacrum that measured 9.2 cm long by 10.4 cm wide. There was undermining between 12 o'clock for a maximum of 4.8 cm. The wound base had 20-percent granulation and 60-percent slough. The note revealed there had been a rapid decline of the wound. The treatment was changed on this date with a new order to pack wound with Dakin's solution (wound cleanser to treat and prevent infections) wet to moist dressing twice daily to help clean out remaining slough. There was a large amount of serosanguinous (blood and serous fluid). CNP #400 revealed there were no signs of infection and the peri wound appeared to be macerated. The overall wound condition had declined. CNP #400 documented Resident #14 was immobile and unable to offload pressure areas independently, had poor nutritional intake, dementia/confusion, incontinence, overall poor medical condition, and declining medical condition which she believed made the deterioration or presence of the wound unavoidable. However, record review revealed Resident #14 was dependent on staff for off-loading interventions and the resident's medical record contained no additional evidence of non-compliance from the resident. Review of a weekly skin assessment dated [DATE] revealed Resident #14 had an overall wound decline to the sacrum. The area measured 9.2 cm long by 10.4 cm wide. Review of a note by CNP #400 dated [DATE] revealed Resident #14 had an unstageable pressure ulcer to the sacrum that measured 9.6 cm long by 10.9 cm wide. There was now undermining between 8 o'clock and 4 o'clock for a maximum of 4.6 cm. There was 80-percent slough to the wound. The wound bed was filled with black necrotic tissue and the area was debrided. A new order was received to stop Dakin's solution and start Anasept (antimicrobial wound cleanser) gel and pack with normal saline wet to moist gauze. A progress note dated [DATE] at 10:30 A.M. revealed Resident #14 was cool to touch and non-responsive. The resident's blood pressure was ,d+[DATE] millimeter of mercury (mmHg), pulse was 113 beats per minute, oxygen saturation was 97-percent, and temperature was 94.7 degrees Fahrenheit (F). Resident #14 was sent to the hospital for evaluation. Review of the hospital Orthopedic Surgery Consultation Note from Physician #940 dated [DATE] revealed Resident #14 presented to the emergency room revealed the general surgery team had a concern for a necrotizing soft tissue infection arising from her full-thickness sacral decubitus ulcer. Review of the hospital Orthopedic Surgery consult dated [DATE] from Physician #958 revealed general surgery did recommend to debride the sacral decubitus ulcer. Review of the hospital nephrology consultation note dated [DATE] revealed Resident #14 was brought into the hospital with a large decubitus infected wound. Resident #14 was found to have severe necrotizing soft tissue infection on cat (CT) scan. Resident #14 was admitted to the intensive care unit for sepsis. On presentation the resident had lactic acidosis and acute kidney injury. On [DATE] at 1:21 P.M. interview with Wound Care Nurse Practitioner (CNP) #400 revealed Resident #14 had an unstageable pressure ulcer when the resident was seen on [DATE]. There was slough and the area appeared to be superficial, so barrier paste was ordered. Wound Care Nurse Practitioner #400 stated she thought it was possibly a Kennedy ulcer due to how quickly it deteriorated. The CNP indicated the wound never appeared red or had a foul odor to indicate it was infected. A Kennedy ulcer, also known as a Kennedy terminal ulcer (KTU), is a dark sore that develops rapidly during the final stages of a person's life. Kennedy ulcers grow as skin breaks down as part of the dying process. Record review from [DATE] to [DATE] revealed no evidence Resident #14 was terminal or actively dying. On [DATE] at 1:26 P.M. interview with the Director of Nursing (DON) revealed Resident #14 had only been up in the Broda chair once prior to the pressure ulcer developing. The DON indicated she believed Resident #14 was provided incontinence care and repositioned every two hours. However, the DON verified there was no documented evidence to support this care was provided. The DON indicated she had observed the area to Resident #14's sacrum on [DATE] and indicated the area was consistent with MASD. The DON verified on [DATE] the area to Resident #14's sacrum was consistent with an unstageable pressure ulcer and the wound nurse practitioner was asked to look at the area on [DATE]. On [DATE] at 11:29 A.M. interview with Resident #14's family, Family #700 revealed they were not aware Resident #14 had a pressure ulcer or that the resident had sustained a health decline. Family #700 revealed after being sent to the hospital, they were told Resident #14 had a bad infection that had to be removed surgically. Resident #14 was at the hospital from [DATE] to either [DATE] or [DATE] (unable to recall exact date). Family #700 stated Resident #14 was discharged from the hospital to another long-term care facility with Hospice services. Resident #14 passed away on [DATE]. Family #700 stated a vascular surgeon reported to them Resident #14 would not survive another surgery because everything was too weak. Family #700 stated they did not know if the surgeon meant she was weak from the stroke, infection, or just in general. Family #700 stated they were disappointed in the care Resident #14 received at the facility. Family #700 indicated they sought nursing home placement for the resident as they were unable to provide the necessary care for her in the home setting. On [DATE] at 2:04 P.M. an interview with DON revealed the standard of care was for all residents to be turned and repositioned every two hours. The standard of care also included incontinence care to be provided every two hours. The DON verified zinc barrier cream was not added until [DATE] as a preventative measure. The DON also verified there was not a POC implemented for the resident related to incontinence care. On [DATE] at 2:29 P.M. interview with State tested Nursing Assistant (STNA) #850 revealed she had provided care for Resident #14 and had alerted the nurse that a dry area was noted to Resident #14's bottom (date not provided) but there were no open areas. STNA #850 revealed when she returned to work a few days later, the areas to Resident #14's bottom were significantly bigger. STNA #850 stated Resident #14 was unable to turn or reposition herself and was incontinent. On [DATE] at 3:26 P.M. interview with Regional Director of Clinical Services (RDO) #802 revealed it was automatic for each resident to be turned and repositioned and that this intervention was not care planned. The RDO revealed the area to Resident #14's sacrum appeared to be MASD but was actually necrotizing fasciitis. During the interview, RDO #802 revealed different interventions were not implemented for residents assessed to be at different risk for development of pressure ulcers. She stated interventions were resident specific and case by case. Regional Director of Clinical Services #802 was unable to provide any additional information to support effective and individualized interventions were implemented for Resident #14, who was assessed on admission to be at high risk for the development of pressure ulcers. On [DATE] at 1:02 P.M. interview with Medical Physician (MD) #600, the physician assigned to care for Resident #14 during her stay revealed the resident was seen on [DATE]. The resident was at baseline and alert to self but aphasic (a symptom of damage to parts of the brain that control language and make it difficult to read, write and say what the person wants to say). The physician indicated her main concern during the visit was Resident #14's elevated blood pressures. The resident had recently had a stroke and continued with elevated blood pressures. The blood pressures were within acceptable parameters but were being monitored. MD #600 stated the nursing staff were asked if Resident #14 had any skin concerns on her back or bottom to which they denied. MD #600 stated she visited Resident #14 again on [DATE]. Resident #14 was asleep but was easily awakened. MD #600 revealed the resident continued at her baseline; alert to self and aphasic. MD #600 revealed she collaborated with the nurse and STNA and was told there was nothing new. The nursing staff did not report Resident #14 any skin concerns at that time. MD #600 stated the documentation she reviewed on [DATE] did not show any skin impairment. MD #600 revealed in general she looked at wounds if the wound nurse practitioner had not recently looked at them or if there was concern. MD #600 again verified there was nothing documented in the notes that were reviewed on [DATE]. Review of Policy for Perineal Care revised [DATE] revealed the purposes of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The procedure revealed the following information should be recorded in the resident's medical record: the date and time that perineal care was given, the name and title of the individual giving the perineal care, how the resident tolerated the procedure, and the signature and title of the person recording the data. Review of Policy for Prevention of Pressure Ulcers/Injuries revised [DATE] revealed to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: Assess the resident on admission for existing pressure ulcer/injury risk factors. Conduct a comprehensive skin assessment upon admission. Inspect the skin on a daily basis when performing or assisting with personal care and ADLs. Reposition resident as indicated on the care plan. Prevention included keeping the skin clean and free of exposure to urine or fecal matter. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated at 30-degress or more. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. Select appropriate support surfaces based on the residents' mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Necrotizing Fasciitis: All You Need to Know, last reviewed [DATE], revealed necrotizing fasciitis is a rare bacterial infection that spreads quickly in the body and can cause death. Accurate diagnosis, rapid antibiotics, and prompt surgery are important to stopping this infection. To prevent necrotizing fasciitis, wash your hands often and clean and care for wounds. Review of pubmed.ncbi.nlm.nih.gov revealed necrotizing soft tissue infections (STI) are serious complications that may arise from pressure ulcers. Necrotizing STIs developed primarily from pressure ulcers over the sacrum. Necrotizing STI's arising from pressure ulcers are generally caused by mixed pathogens and exhibit symptoms that are milder than those of necrotizing fasciitis caused by group A Streptococcus. Review of the information from the NPIAP at https://npiap.com/ revealed facilities should develop and implement a risk-based prevention plan for individuals identified being at risk for developing pressure injuries. Reposition all individuals with or at risk of pressure injuries on a individualized schedule, unless contraindicated. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. Promote seating out of bed in an appropriate chair or wheelchair for limited periods of time. Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. Further review revealed an Unstageable Pressure injury was defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. This deficiency represents non-compliance investigated under Complaint Number OH00141720.

Based on record review, review of the facility's investigation, review of an employee personnel file, observation, resident interview, family interview, staff interview, and policy review, the facility failed to provide the appropriate level of supervision necessary to prevent a cognitively impaired resident (who resided on the secured behavior unit and was known to the facility as having a previous elopement from the facility) from eloping from the facility on 09/02/22. This resulted in Immediate Jeopardy when Resident #5 was left unsupervised in the facility's secured unit's adjoining courtyard and was able to exit the courtyard through a gate that had been known by the facility to be in disrepair and unable to be properly secured. Resident #5 left the facility's grounds and was found at the home of his ex-wife three hours after he was last seen by staff in the secured unit's courtyard. The ex-wife's house was approximately 8 miles/ 15 minutes away from the facility and the resident reportedly took a bus that picked him up at the end of the road where the facility was located (0.1 miles away). Resident #5 was returned to the facility by his family with no known injuries. This affected one (Resident #5) of one resident reviewed for elopement. On 09/08/22 at 3:09 P.M., the facility's Administrator, Vice President of Clinical Services, Regional Director of Clinical Services, and the Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 09/02/22 at 6:30 P.M. when Resident #5 (who was a high risk for elopement and was known to previously elope from the facility) was left unsupervised while smoking in the secured unit's courtyard. Resident #5 was checked on at 7:00 P.M. and noticed not to be in that area nor was he found on the facility grounds. Resident #5 had reportedly taken a bus and was found at the home of his ex-wife somewhere around 8:45 P.M. to 9:00 P.M. when the facility staff had contacted the family to inquire about their knowledge of Resident #5's whereabouts. The Immediate Jeopardy was removed on 09/03/22 at 3:00 P.M. when the facility implemented the following corrective action: 09/02/22 at 8:05 P.M.- All exit doors and wander guard alarms were checked by the Regional Director of Clinical Services and were found to be functioning appropriately. 09/02/22 at 8:06 P.M. - The gate lock to the courtyard fence (connected to the 300-hall secure unit) was found in disrepair by the Regional Director of Clinical Services. All smoking was ceased on 300-hall secured unit at the time the identification the gate lock needed repaired. 09/02/22 at 8:10 P.M.- All staff education was initiated on Elopement, Supervised Smoking, and Smoking policy by the Director of Nursing (DON). 09/02/22 at 8:10 P.M.- Seventeen (17) residents who smoke were assessed for smoking safety by the Regional Director of Clinical Services. Based on the outcome of the smoking assessments, the facility ensured all residents who smoke are supervised during smoking and reeducated staff on supervised smoking. 09/02/22 at 8:40 P.M.- Elopement review was initiated by the ADON on all residents in the facility. 09/02/22 at 8:44 P.M.- An elopement review was completed on Resident #5 by the Regional Director of Clinical Services and Resident #5 continued to be identified as a high risk for elopement. 09/02/22 at 9:30 P.M. -The Maintenance Director was notified by the Administrator via telephone and a work order was completed for repairing the latch on the gate to the 300-hall secured unit's enclosed courtyard. 09/02/22 at 10:00 P.M. -Resident #5 returned to the facility with his daughter. Resident #5 was placed on 15-minute checks by the Regional Director of Clinical Services. A smoking cessation patch was offered to Resident #5 and the resident accepted. 09/02/22 at 10:10 P.M.- A smoking assessment was completed for Resident #5 by the Regional Director of Clinical Services. 09/02/22 at 10:14 P.M. - A skin assessment was completed for Resident #5 by the Regional Director of Clinical Services. Beginning on 09/03/22 at 9:30 A.M.- Audits for supervised smoking in the 300-hall secured courtyard were initiated and continue daily at every scheduled smoking time by the DON or designee for four weeks then reviewed during QAPI monthly to determine if audits should be continued. A random audit continued daily to ensure all secured exit doors are locked and functioning properly by the Maintenance Director or Designee for four weeks then reviewed during QAPI monthly to determine if audits should be continued. An audit will be conducted three times a week to ensure that elopement assessments are completed appropriately on all new admissions by the DON or designee for four weeks then reviewed during QAPI monthly to determine if audits should be continued. 09/03/22 at 11:00 A.M. -The Maintenance Director repaired the 300-hall secure unit latch of the gate and checked all secured exit doors to ensure they were functioning properly. As a result of the check, all secured exit doors were identifies as functioning properly. 09/03/22 at 11:30 A.M. -An elopement drill was completed by the Maintenance Director and all staff responded appropriately and was knowledgeable about the elopement procedures. 09/03/22 at 12:15 P.M. -All elopement reviews were completed on all residents in the facility by the Regional Director of Clinical Services, DON, and ADON. No adjustments were needed based on reviews completed. 09/03/22 a 12:30 P.M. -The elopement book located at the front desk was reviewed and updated with updated pictures and Face Sheets by the Regional Director of Clinical Services. 09/03/22 at 1:30 P.M. Resident #5 resumed supervised smoking in the 300-hall secured unit's enclosed courtyard by staff. 09/03/22 at 1:30 P.M.- An audit was initiated to ensure residents smoking on the 300-hall secured courtyard are supervised at all times to prevent elopement. The audit is completed by the DON or designee daily for four weeks. 09/03/22 at 3:00 P.M.- All staff education was completed on Elopement, Supervised Smoking, Smoking policy by DON or designee. Staff who received education included 9 Registered Nurses (RN)'s, 23 Licensed Practical Nurses (LPN)'s, 49 State tested Nurse Aides (STNA)'s, 8 House Keepers (HK)'s, 13 Dietary Staff, 2 Activities Staff, and 9 Department Heads. 09/03/22 at 10:45 P.M. -Resident #5's 15-minute checks were discontinued. 09/12/22 from 9:16 A.M. to 9:32 A.M.,- surveyor interview with two LPN's (#45 and #130), three STNA's (#100, #105, #117) and one Social Service Designee (SSD #150) confirmed receiving education from the facility on the Elopement Policy, need to notify the facility's management team as soon as a resident was reported missing, the facility's Smoking Policy, and the need to ensure all residents were supervised while smoking. Although the Immediate Jeopardy was removed on 09/03/22 at 3:00 P.M., the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: A review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included alcohol dependence with alcohol-induced persisting dementia, [CONDITION(S)], mood disorder, major depressive disorder, tobacco use, [CONDITION(S)], and a traumatic subdural hemorrhage. He was admitted to the facility's secured behavioral unit. A review of Resident #5's Elopement Review assessment completed on 06/14/22 revealed he was assessed as a high risk for elopement. His risk factors included being ambulatory, having the diagnosis of dementia, displaying purposeful exit seeking behavior, and being a new admission. The assessment indicated he had a transient medical cause contributing to increasing confusion. A wanderguard alarm was placed on his right leg to help prevent elopements from occurring. Under the additional comments section, the resident was indicated to have dementia associated with alcoholism. A review of Resident #5's Smoking Safety Screen dated 06/14/22 revealed the resident was not indicated to have any cognitive loss despite having the diagnosis of alcohol induced dementia. He was known to smoke between five to 10 cigarettes per day and smoked mornings, afternoons, evenings, and nights. The assessment deemed the resident was felt to be safe to smoke without supervision. A review of Resident #5's admission Minimum Data Set (MDS) 3.0 assessment completed on 06/20/22 revealed the resident did not have any communication issues but his cognition was moderately impaired. No physical or verbal behaviors were indicated to have occurred, but the resident was indicated to display behaviors that were not directed at others occurring one to three days of the seven-day assessment period. He was also indicated to display wandering behaviors that occurred four to six days of the seven-day assessment period. Supervision with set up help was needed with transfers, ambulation in the room, and locomotion on the unit. Supervision with the assist of one was needed for ambulation in the hall and locomotion off the unit. No mobility devices were needed with ambulation. A review of Resident #5's active care plans revealed he had a care plan for being an elopement risk related to being disoriented to place, history of attempts to leave the facility unattended, and impaired safety. It was initiated on 06/22/22. The interventions included the use of a wanderguard alarm to his left ankle. Resident #5 also had a care plan in place for residing on the secured unit due to confusion and a history of elopement. The care plan was initiated on 08/12/22. Interventions included monitoring the resident for exit seeking behaviors and document if noted. He was to reside on the secured unit as per the physician's orders and supervision was required for all activity off the secured unit. A review of Resident #5's active physician's orders revealed he had an order for the use of an alarming security bracelet (wanderguard). The order originated on 06/15/22. 1 a.) A review of Resident #5's nurses' progress notes revealed a nurse's note dated 06/19/22 at 8:43 P.M. from LPN #31 that indicated the resident went out for a smoke break with staff, came back in, and was later nowhere to be found. Resident #5 was indicated to have a wanderguard alarm bracelet on his left ankle. The staff member that had Resident #5 out for the smoke break did not know that he was a resident who resided on the secured unit. Education was provided to the staff on duty to ensure they brought Resident #5 back to the secured unit, after he had finished smoking. The nurse's note indicated a search had been done and a staff member found Resident #5 at a store down the street buying cigarettes. He was returned to the facility without injury or incident and encouraged to let staff know when he needed to go out. A review of the facility's investigation of Resident #5's elopement from the facility on 06/19/22 revealed the incident occurred at 8:00 P.M. with the location of the incident being the corner store. A basic description of the incident revealed Resident #5 left the facility and an elopement search was initiated. He was indicated to have been found at the corner store as the resident indicated he wanted to buy cigarettes. Resident #5 was to smoke in the secured unit's courtyard from that point on. A Smoking Safety Screen had been completed as part of the facility's investigation and was completed on 06/19/22. The Smoking Safety Screen identified Resident #5 as having cognitive loss that was not previously indicated on his prior smoking assessment. The result of the assessment revealed the resident was deemed to be safe for smoking but required supervision. The facility educated its staff on 06/20/22 regarding the facility's Elopement Policy. On 09/08/22 at 12:50 P.M., an interview with LPN #31 via phone revealed she was the floor nurse that was working on 06/19/22 when Resident #5 eloped from the facility. She reported she was an agency nurse and that was the first and only day she had worked at the facility. She recalled Resident #5 was taken out to smoke and did not come back to the secured unit. The nursing assistant (unidentified) on the secured unit passed him off to a nursing assistant (again, unidentified) working the other side of the facility so Resident #5 could smoke with the other residents in the facility's designated smoking area. The other nursing assistant reported he was brought back into the building, but the nurse was not sure if that meant he was returned to the secured unit or not. The nursing assistant who was working the secured unit was the one who realized Resident #5 was missing. LPN #31 confirmed Resident #5 was found at the convenience store at the end of the road and across the road (0.1 miles away). LPN #31 was not sure how the resident was able to exit the building after he had been brought in from the smoke break. The resident told her he wanted to go buy cigarettes. LPN #31 denied Resident #5 had any injuries because of that elopement. On 09/08/22 at 3:20 P.M., an interview with the Administrator revealed she was not sure who the nursing assistant was that took Resident #5 out to smoke on 06/19/22, when he eloped from the facility. The Administrator was only able to determine it was an agency aide, but she denied having any contact information for her. The Administrator confirmed they were able to determine Resident #5 was brought back inside but was not returned to the secured unit as he should have been. The Administrator stated, from what she was able to determine, Resident #5 exited out the front entrance. Per the Administrator, it was after hours, so they assumed he followed a staff member out after a code had been entered that also disarmed the wanderguard system. 1 b.) Record review of Resident #5 revealed a nurse's progress note dated 09/02/22 at 7:55 P.M. by Registered Nurse (RN) #57 revealed, while she was passing medications, a nursing assistant (unidentified) approached her with Resident #5 and asked for his cigarettes. The nursing assistant then took Resident #5 out to smoke. One hour later, the same nursing assistant came to her and reported Resident #5 was missing. RN #57 asked her how Resident #5 was missing and the nursing assistant replied he was smoking, now he was not there. The last time Resident #5 was indicated to have been seen was 6:30 P.M. An elopement search was initiated. All staff members were indicated to have searched rooms, bathrooms, and the area around the facility. The on-call manager and the local police was notified when Resident #5 could not be found. The nurse attempted to contact Resident #5's family multiple times without success. A review of a nurse's progress note dated 09/02/22 by the facility's ADON revealed, while she was working as the on-call nurse, she received a call from the 300- hall/ secured unit nurse informing her that Resident #5 was last seen smoking outside the facility in the designated area. Elopement procedures were initiated. The ADON called the physician, the resident's daughter, the resident's significant other, the local police, and each staff member who worked the previous shift. One aide (unidentified) had mentioned that Resident #5 kept saying his wife was picking him up that day but, none of the facility staff were aware of the scheduled leave of absence. The ADON was trying to contact the resident's family to further investigate and ensure the resident's safety. The elopement protocol was on going and other management staff had been notified. A follow up progress note from the ADON on 09/02/22 at 8:09 P.M. revealed she had contacted Resident #5's daughter and ex-wife and had heard other family members in the background. While speaking with the daughter, the resident's ex-wife took the phone. The ADON asked her about the reports of the resident saying his wife was coming to pick him up. The ex-wife questioned why the facility would document that as the resident had dementia and was not known to tell the truth. Resident #5's ex-wife confirmed they planned to spend the holiday with him but never said when. The ADON then heard the daughter in the background say that was why he (Resident #5) was sitting right there on the couch. She confirmed with Resident #5's ex-wife that what she heard about the resident sitting there on the couch was true and the ex-wife confirmed it was. The ex-wife stated he must have found his way there. The family reported they would drop the resident off. The nurses' progress notes documented Resident #5 was returned to the facility in a nurse's note by RN #57 on 09/02/22 at 10:10 P.M. A review of the facility's investigation into Resident #5's elopement on 09/02/22 revealed the investigation included an incident report dated 09/02/22 at 7:20 P.M. The nursing description revealed the same information that was documented in the ADON's nurse's progress note on 09/02/22 at 7:23 P.M. The immediate action taken included the same information documented in her nurse's progress note dated 09/02/22 at 8:09 P.M. In addition, the immediate action taken included documentation of all staff being educated (not specific to what the staff were educated about), Resident #5 was placed on 15-minute checks upon his return, Resident #5 was ordered/ offered smoking cessation, and maintenance fixed the latch on the gate to the courtyard's fence. Predisposing situation factors to the elopement was indicated to be unsupervised smoking. A review of a Work Order Form dated 09/02/22 revealed a concern was reported that a gate lock needed repaired. The work order was not specific as to the location of the gate lock that needed to be repaired. The resolution that was written on the form revealed a panel on the fence had been replaced and a pad lock had also been added. A review of a Disciplinary Action Form dated 09/02/22 for STNA #19 revealed the nursing assistant was discharged from her employment at the facility. Her performance had been found unsatisfactory for letting a dementia diagnosed resident out to smoke without supervision. The resident (not specified) left the premises causing an elopement. Due to the severity of the incident, termination was felt to be warranted. A review of a Quality Assurance and Performance Improvement Action Plan revealed an action plan had been initiated on 09/06/22 for an unspecified resident leaving the facility without staff's knowledge. Actions on the action plan were initiated on 09/02/22 and included placing the resident on 15-minute checks, assessing for injuries, updating his elopement assessment and care plan. Gate lock was also indicated to have been repaired. All staff were indicated to have been educated on elopement and exit seeking behavior. Audits were to be conducted weekly to ensure that elopement assessments were completed appropriately, and interventions were in place to prevent elopements. The QAPI plan did not include educating staff on the need to supervise residents who smoke on the secured unit while in the secured unit's courtyard. The QAPI plan also did not include audits of those residents who smoke to ensure the appropriate level of supervision was provided when residents were out in the secured unit's courtyard to smoke. On 09/07/22 at 10:02 A.M., an observation of the facility's 300-hall secured unit's courtyard revealed the courtyard was enclosed and surrounded on three sides by the exterior of the facility. There was a long wooden fence that extended from outside wall of the secured unit's dining room and the outside wall of the 100- hall. It was a six-foot fence that had a secured gate with a pad lock on the outside of the gate that prevented it from being open. The latch and gate were new as there was no evidence of any rust present. A panel of the fence had been replaced as well as one of the posts that supported two fence sections that joined. The wooden fence was old but did not have any gaps/ spaces that would be easy to pass through. The courtyard adjoined the secured unit's dining room and required a code to be entered into a keypad to gain access through a double glass door. It was noted to have an ash tray and other evidence of being used as a designated smoking area. On 09/07/22 at 10:13 A.M., an observation of Resident #5 noted him to be lying in bed in his room watching television. He was noted to have a wanderguard alarm bracelet on his left ankle. An interview with Resident #5 at the time of the observation revealed he was disoriented to the month and year but had good short-term memory as he recalled the circumstances of what brought him to the facility, what he had for breakfast that morning, and recalled the incident that occurred on 09/02/22 when he eloped from the facility. He stated he came to the facility from the hospital after he had a drink, fell , and hit his head. He reported he wanted to go see his daughter on 09/02/22. He confirmed the staff assisted him into the courtyard to smoke when he got the urge to break out of there. They usually supervised him while he was out there, but he was not sure where the staff member was that assisted him out there. Sometimes they were known to sit out there with him and other times they sat in a chair inside the building in the dining room. On that date, he claimed he just walked through the gate. He was not sure if the gate was equipped with a lock or not as all he knew was, he was able to open it enough to pass through. He stated the female worker that should have been watching him was fired because of that incident. He was asked how he ended up at his ex-wife's house eight miles away and reported he took a bus. He caught the bus at the end of the road and paid them $2.00 for the bus ride there. He estimated it was about a 10-minute bus ride there. After he had been there a while, the facility staff tracked him down and he had his family bring him back. He stated the facility staff were upset with him because he left the facility without telling them. On 09/08/22 at 9:47 A.M., a phone interview with STNA #19 revealed she was the nursing assistant that assisted Resident #5 out to smoke the evening of 09/02/22. She was still within her 90-day probationary period and worked on the afternoon shift on the secured unit when she worked. She recalled it was around 6:30 P.M. when she assisted Resident #5 out to the courtyard to smoke. She stated she helped him light his cigarette then she left him out there. She confirmed the courtyard was enclosed but did have a gate. She was not sure if the gate to the courtyard was locked or not. She thought maybe the gate had been broken at that time, but she was not sure how long it had been like that. She denied the gate had a lock on it and denied Resident #5 had to break it to get out. She reported she left him when a call light went off and she responded to answer it. She recalled the nurse being in the general area so she assumed the nurse would keep an eye on him while she answered the call light. She assisted two residents with care that took her about 30 minutes or so. She then went to knock on Resident #5's door to his room to see if he was in there but got no response. She went to the courtyard to see if he was still out there, but he was gone. She informed the nurse Resident #5 was nowhere to be found. That was when they initiated the elopement response. When she checked the courtyard. She found the gate to be open. She noticed there was a cement bucket in front of the gate that was being used to keep the gate from closing. She searched the unit and all the residents' rooms then got in her car to see if he was somewhere around the neighborhood. From what she had been told, he was found at the home of his ex-wife. She was not sure how he got there or how long he may have been there before he was found. She felt Resident #5 was in his right mind and would have known what he was doing. She reported Resident #5 was known to display exit seeking behaviors and was known to have eloped from the facility before, but she never saw that from him when she was there. She confirmed the Administrator interviewed her as part of the facility's investigation into the elopement and as a result her employment at the facility was terminated. She stated she was terminated because Resident #5 eloped from the facility when she should have been supervising him while he was in the courtyard smoking. On 09/08/22 at 10:13 A.M., an interview with RN #57 revealed she was the nurse that was on duty 09/02/22 when Resident #5 eloped from the facility on 09/02/22. She stated that she was an agency nurse and that was the first and the last day she had worked on the secured unit. She recalled Resident #5 was wanting to go out and smoke. Resident #5 had asked her to take him out to smoke, but she was busy passing medications and had informed him she would take him out after she had finished. Resident #5 then approached her a second time with another resident's visitor with him to try to get the visitor to be able to take him out. The nurse explained to the resident that it had to be a staff member that took him out, so he came back a third time with a nursing assistant. She could not recall the nursing assistant's name, but RN #57 did provide her with the smoking material needed for her to take the resident out to smoke. She assumed the nursing assistant would be staying out there with him but was not sure if the nursing assistant stayed out there or not. The nursing assistant would have been required to enter a code on the keypad at the side dining room door to allow the resident out into the courtyard. RN #57 continued to pass her medications to the other residents. After she had administered medications to two other residents, the nursing assistant informed her she could not find Resident #5. She asked the nursing assistant at that time if she stayed out there with him and was told she just entered the code to let him out but did not go out with him. The nursing assistant reported she went back, and he was gone. RN #57 was not sure how long the resident was out there. RN #57 confirmed the courtyard had a gate but when they went outside, they noticed it was open. RN #57 denied the gate was previously locked and there was no evidence of the resident breaking his way out. RN #57 could not recall if the gate had a means to lock it or not. RN #57 described the gate as being partially open when she found it and confirmed a bucket with some heavy material inside of it had been placed in front of it to keep it from closing. RN #57 then contacted the management staff so they could help locate the resident. RN #57 confirmed Resident #5 was later found at the home of his ex-wife as reported by the on-call nurse and confirmed by the local police. RN #57 stated it was on 09/02/22 around 6:30 P.M. when the nursing assistant let Resident #5 out and around 7:00 P.M. when the nursing assistant reported she could not find him. It was not until about 8:45 P.M. or 9:00 P.M. that the on-call nurse told her Resident #5 had been found. Upon his return, Resident #5 told her he took a bus to his ex-wife's house. RN #57 denied Resident #5 had any injuries as a result of the incident. On 09/08/22 at 10:44 A.M., a phone interview with Resident #5's family confirmed Resident #5 eloped from the facility and showed up at the ex-wife's house on 09/02/22. The family had been previously contacted earlier that evening to let them know he had eloped. The daughter was out in the front of the house talking to her boyfriend about the resident's elopement when Resident #5 came walking up to the house. She stated she was not surprised to see him there as he reported earlier that he was wanting to come. She denied they had any plans for Resident #5 to be there that day and denied anyone had picked him up. She reported Resident #5 had alcohol induced dementia but was with it most of the time. Resident #5 also told her that he took the bus to get there. She confirmed the ex-wife's house was about a 15-minute drive from the facility. She stated Resident #5 had $3.00 dollars in his pocket and wanted to buy beer. She went ahead and bought him beer so he would not have any more money left to take a bus anywhere. She stated she also hoped by getting him a beer it would calm him down enough to where they could take him back. She stated the family stopped visiting Resident #5 earlier that August as he kept wanting them to take him with them when they were there. She recalled the last time the family did visit, Resident #5 pointed out to them that the gate to the courtyard was open and broke. She was concerned with Resident #5 being able to get out of the facility and stated they should have been supervising him as well as the other residents who resided on that secured unit. On 09/08/22 at 10:51 A.M., an interview with Maintenance Director #82 revealed he had worked at the facility since the first part of July 2022. He denied he was there at the facility the evening Resident #5 eloped but was told to fix the lock on the gate of the secured unit's courtyard the day after the incident occurred. He stated the door had been broken for a while prior to Resident #5 getting out. It had been like that ever since he started working there July 2022. He just never got around to fixing it before that. He indicated the fence was old and busted. The gate had an old latch system, but the latch system was gone. He had to put a new panel on it and secured a brand-new latch and pad lock. Prior to Resident #5's elopement, he denied the gate had a lock on it. The gate would have been able to be opened and closed from the inside, but it just did not latch. On 09/08/22 at 10:58 A.M., an interview with the ADON confirmed she was the on call nurse when Resident #5 eloped on 09/02/22. She received a call from the 300- hall/ secured unit nurse somewhere around 7:19 P.M. informing her the nursing assistant on the secured unit was reporting she did not see Resident #5 on the unit. The last time he had been seen was around 6:30 P.M. when he was assisted out to the courtyard to smoke. The staff informed her they had already searched the building, but she wanted them to search again. She initiated the elopement process again and notified the other managers of the facility what was going on and also called the resident's family. She denied she had spoken directly to the nursing assistant involved but believed the Administrator had talked with her. She stated it was her understanding the nursing assistant went out with the resident but agreed he would not have been able to elope if she had been with him. She confirmed Resident #5 should have been supervised when he went outside to smoke as should all the residents in the facility. She denied they had any residents that were able to smoke without supervision. She was asked if the 300-hall secured unit's courtyard was enclosed, and she replied it was now. She confirmed upon the facility's investigation it was determined the latch was not latching properly. It was presumed that was how the resident was able to leave the courtyard and ultimately the facility grounds. She denied the gate to the fence on the secured unit's courtyard had a pad lock on it prior to the 09/02/22 incident. She stated the first time she reached out to Resident #5's family to let them know he was missing they informed her that he was likely out looking for a drink. She confirmed Resident #5 had alcohol induced dementia. It was mentioned by an aide working the previous shift that Resident #5 was saying his ex-wife was picking him up that day. The family denied picking him up and told her they suspected he would go on a leave of absence. Her second call to the family revealed Resident #5 did show up at his ex-wife's house. She w [TRUNCATED]

Based on interview and record review, the facility failed to timely treat Resident #83's [CONDITION(S)]. Actual harm occurred on 03/30/22 when Resident #83 sustained a fall which resulted in pain to his right upper thigh. On 03/31/22 Resident #83 complained of pain to his right upper thigh, which was noted to be swollen, an x-ray order was obtained for ankle to hip and x-rays were completed later that day. On 04/01/22 around 1:00 A.M. to 2:00 A.M. Licensed Practical Nurse (LPN) #151 received a result for the x-ray of the right tibia and fibula which he faxed to the physician. LPN #151 notified the physician and oncoming nurse that Resident #83's x-ray results were negative. LPN #151 was not aware additional images were taken and did not request additional results. Resident #83 had decreased mobility on 04/01/22, 04/02/22, and 04/03/22 with reports of pain with movement. Resident #83 was sent to the hospital on 04/04/22 after the guardian evaluated the resident and determined he needed to be sent to the hospital. In the hospital Resident #83 was found to have a right [CONDITION(S)] that required surgery. This affected one resident (Resident #83) of three residents reviewed for falls. The facility census was 82. Findings include: Review of the medical record revealed Resident #83 admitted on [DATE] and discharged on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #83 had severely impaired cognition. He required the limited assist of one person to walk in room or corridor. Review of Resident #83's care plan revealed the resident was at risk for fall related injury due to some wandering behavior, antidepressant usage, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included administering medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 03/30/22 at 7:59 P.M. revealed Resident #83 was in the dining room and started to walk, he lost his balance and dropped on the floor. No injury was noted, and the resident was placed on 15-minute checks. The family and physician were notified of the fall. Review of the fall investigation dated 03/30/22, revealed Resident #83 had a fall in the dining room at 6:22 P.M. All prior fall interventions were deemed to be in place. The resident was seated in the dining room prior to fall, he fell after losing balance while walking away from the table. Initially, the resident complained of pain to his right knee, but he denied pain a few minutes later. The physician was notified, and the resident was placed on 15-minute checks. Review of the interdisciplinary team review note dated 03/31/22 revealed Resident #83's fall was discussed. Resident #83 complained of slight right knee pain upon fall, but no swelling, redness or bruising was noted. All prior interventions were in place at the time of the fall and a new intervention was put in place. The physician and guardian were aware. Review of the March and April 2022 physicians' orders for Resident #83 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic MAR progress note dated 03/31/22 at 12:05 P.M. revealed Resident #83 had right leg pain and was given 650 mg of Acetaminophen. At 2:06 P.M. his follow up pain was noted to be a two and the medication was deemed effective. Review of the progress note dated 03/31/22 at 2:09 P.M. revealed Resident #83 was complaining of right leg pain and pain medicine was given. Physician #170 was notified of the reports of pain and a new order was put in place for a two-view x-ray of his right leg from hip to ankle. A message left for guardian to call facility for an update. Review of the progress note dated 03/31/22 at 11:01 P.M. revealed Resident #83 continued with post event supervision. An x-ray to his right foot and hip were completed and results were pending. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for a pain level of four out of 10. Review of four patient reports dated 03/31/22 of Resident #83's right tibia and fibula, right knee, and right ankle revealed they were negative for fractures. Review of the patient report dated 03/31/22 revealed Resident #83 had a radiologic examination of the right femur performed and an acute right intertrochanteric [CONDITION(S)] was noted. Review of the patient report dated 03/31/22 revealed radiographs of Resident #83's hip and pelvis were obtained due to pain and an acute intertrochanteric [CONDITION(S)] was noted. Review of the progress note dated 04/01/22 at 4:14 A.M. revealed the results of Resident #83's x-ray was received, and the physician was notified. No new orders were received. Review of the progress note dated 04/01/22 at 1:23 P.M. revealed Licensed Practical Nurse (LPN) #161 spoke to Resident #83's guardian to give her the results of the x-ray. Review of the MAR for April 2022 revealed Resident #83 was given Acetaminophen on 04/04/22 at 1:30 P.M. for a pain level of seven out of 10. Review of the EMAR progress note dated 04/04/22 at 1:30 P.M. revealed Resident #83 was given Acetaminophen for right leg pain. At 2:25 P.M. the residents follow up pain was four and it was deemed effective. Review of the progress note dated 04/04/22 at 2:30 P.M. revealed Resident #83 continued to have right leg pain and swelling. The guardian requested the resident be sent to the hospital and the physician was notified. A new order was put in place to send Resident #83 to the hospital for evaluation of right leg pain. Review of the physician note dated 04/04/22 at 2:54 P.M. revealed the doctor was informed Resident #83 was still not bearing weight on his right hip even though his x-rays were non diagnostic. The legal guardian was informed and agreed to have the resident sent to the hospital for further evaluation. Review of the change in condition evaluation dated 04/04/22 revealed Resident #83 had uncontrolled pain beginning on the morning of 03/31/22. At the time of the evaluation, he reported a pain of eight to his right thigh. Review of the facility to hospital transfer form dated 04/04/22 revealed Resident #83 was to be transferred to the hospital on 04/04/22 due to pain to his right thigh. Review of the progress note dated 04/06/22 at 2:01 P.M. revealed the LPN #161 spoke to the Resident #83's guardian. In the hospital, Resident #83 was found to have a right [CONDITION(S)] and had surgery on 04/05/22 to place rods to his right hip. The physician was made aware. Interview on 04/13/22 at 11:14 A.M. with Resident #83's guardian revealed when she spoke to staff after his x-ray, she was told Resident #83 was fine and had no problems. She reported when she saw the resident on 04/04/22 it was clear he was in pain, and she wanted him sent to the hospital. She reported the resident received surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/13/22 at 12:27 P.M. and on 04/14/22 at 9:39 A.M. with LPN #161 revealed she had been the residents nurse on 03/31/22 when the aide reported Resident #83 was complaining of pain. LPN #161 assessed him and confirmed he was in pain he additionally had right upper thigh swelling. She reported she called the physician who ordered x-rays. LPN #161 did not see the results of the x-ray, she stated when she came in on 04/01/22 the previous nurse told her the x-rays were negative, so she contacted the guardian to inform her. On 04/04/22 she was working once again when the guardian came in and the resident was still complaining of pain and the area remained swollen. LPN #161 reported the resident was unable to rate his pain. She additionally reported the resident had not been getting out of bed during her shifts. LPN #161 revealed the resident did not have pain initially but had pain with movement, which she treated. The nurse reported they assessed his pain using physical signs such as grimacing. Interview on 04/13/22 at 12:48 P.M. with State tested Nursing Assistant (STNA) #105 revealed she worked with Resident #83 following his fall. They reported the resident had stayed in bed which was unusual for him. STNA #105 stated at one point she was going to walk him to the restroom, but he was unable to walk due to pain. She therefore had to use briefs, however, when she was turning him, he was going oh wait, oh wait and he said he was in pain. Interview on 04/13/22 at 2:33 P.M. with Physician #170 revealed Resident #83's x-rays were obtained as a result of the fall. He stated the facility staff reported in a text the x-rays were negative. He stated he received a copy of the lower leg results only. Physician #170 was unaware the radiologic examination of the right femur and hip and pelvis, showed a [CONDITION(S)]. Physician #170 revealed he would have sent the resident to the hospital if he knew the results were positive. Interview on 04/13/22 at 2:39 P.M. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed Resident #83 was fine after the initial fall with no significant concerns. On 03/31/22 he began complaining of pain and an x-ray was ordered. One x-ray result came back (the tibia and fibula) and was negative. They reported they had just switched x-ray companies and previously the company had put it all on one sheet. When the nurse saw the result, he notified the physician of the negative result. They confirmed the receiving nurse should have looked for and requested the additional results. Interview on 04/13/22 at 3:35 P.M. and on 04/14/22 at 9:00 A.M. with LPN #141 revealed Resident #83 complained of pain to his right thigh region initially. He reported when he asked the resident a few minutes later he denied pain. LPN #141 revealed he had placed the resident on 15-minute checks due to his initial report of pain and impaired cognition. LPN #141 stated he was present to assist technicians with obtaining x-rays, when Resident #83 was moved for the x-ray, he reported hip pain. Further interview on 04/14/22 at 9:00 A.M. revealed Resident #83 was not getting out of bed over the weekend on 04/02/22 and 04/03/22 and was not able to put weight on his right leg. He had pain with movement, he was not given pain medication because he did not ask for medication and was able to ask for it. Additionally, LPN #141 reported the pain subsided when he was not moving. LPN #141 over the weekend he was unsure what the plan was for Resident #83's decreased mobility because the x-ray was negative. Interview on 04/14/22 at 8:27 A.M. with LPN #151 revealed Resident #83 did not get out of bed on his shifts over the weekend (04/02/22 and 04/03/22). He reported he received the x-ray results around 1:00 A.M. to 2:00 A.M. on 04/01/22. LPN #151 could not recall what the x-ray was of, he stated when he got the report, he went straight to the conclusion which was negative. He then informed the physician and faxed him the one-page report. LPN #151 stated he was not sure what x-ray was done and he thought the one page contained all the results. Interview on 04/14/22 at 9:39 A.M. with STNA #163 revealed she worked with Resident #83 over the weekend on 04/02/22 and 04/03/22. STNA #163 reported Resident #83 was usually up walking around and was not during this time. STNA #163 reported they were told by nursing to put him in a chair if he wanted up, but they were not sure why. Review of the policy titled, Falls- Clinical Protocol, dated September 2012, revealed the staff would follow up on any fall with associated injury until the resident was stable and delayed complications such as late fracture had been ruled out. Delayed complications such as late fractures could occur hours or several days after a fall. Review of the policy titled, Lab and Diagnostic Test Results- Clinical Protocol, dated September 2012, revealed a nurse was to review all diagnostic results. The person who was to communicate the results to a physician would review and be prepared to discuss the resident's current condition and health status, why the tests were obtained, how the results might relate to the resident's current status or treatments, and any concerns the physician will be expected to address. This deficiency substantiates Complaint Number OH 832.

Based on observation, medical record review, review of fire department run report, review of hospital records, emergency personnel interview, staff interviews, family interview, and resident interview, the facility failed to properly assess and provide care and treatment to a resident experiencing respiratory difficulty and failed to provide oxygen to residents as ordered by the physician. This affected two (Resident #66 and Resident #19) of ten residents reviewed who received oxygen therapy. Harm occurred to Resident #66 when facility staff failed to thoroughly assess the resident's respiratory status resulting in the resident notifying emergency services and subsequent hospitalization for treatment. Findings include: 1. Review of a medical record revealed Resident #66 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 dated 01/20/17 revealed Resident #66 had no cognitive impairment. Further review of the MDS revealed Resident #66 required extensive assistance of two for bed mobility and transfers. The MDS also revealed Resident #66 received oxygen therapy. Review of the care plan for Resident #66 revealed a plan in place for cardiovascular and respiratory complications with interventions to observe for complications such as shortness of breath and dyspnea. Medical record review revealed nursing admission documentation dated 01/13/17 identified Resident #66 had diminished bilateral lung sounds and was on three liters of oxygen. Resident #66 signed a full code status form on 01/13/17. On 02/08/17 at 4:10 A.M. a progress note revealed Resident #66 was short of breath with respirations labored at 20 breaths per minute. Resident #66's oxygen saturation level was 83% on two liters of oxygen. The progress note also revealed after Resident #66 received [MEDICATION NAME]-[MEDICATION NAME] (a [MEDICATION NAME][MEDICATION NAME] that helps open up the airways in your lungs to make it easier to breathe) 3 milliliter (ml) inhalation that was ordered as needed, her oxygen saturation increased to 92%. The nurse notified the certified nurse practitioner and a new order was received for a chest x-ray. The chest x-ray on 02/08/17 revealed Resident #66 had mild [MEDICAL CONDITIONS]. The x-ray results were faxed to the physician on 02/08/17 at 6:17 P.M. On 02/09/17 at 5:45 A.M. the Medication Administration Record [REDACTED]. There was no documentation regarding the condition of the resident, including vital signs, at the time the as needed breathing treatment was administered. Review of the fire department run report revealed emergency personnel were dispatched to the facility on [DATE] at 6:49 A.M. The emergency personnel arrived on scene at 6:54 A.M. on 02/09/17. The documentation revealed when they arrived at the facility the only staff member observed was someone in a winter jacket. The emergency personnel asked the staff member to get a nurse. The emergency personnel were at Resident #66's side at 6:55 A.M. Resident #66 was found lying in bed covered in urine and was obviously short of breath in respiratory distress. Resident #66 stated she had called 911. Resident #66 was administered 10 liters of oxygen by a nonrebreather mask. Vitals taken by emergency personnel revealed Resident #66's pulse was 100 beats per minute, blood pressure was 142/88, respirations were 22 breaths per minute, and oxygen saturation was 94%. According to the fire department run report, the nurse did not appear until Resident #66 was being loaded into the ambulance. On 02/09/17 at 7:04 A.M. Resident #66 was transported to the hospital due to shortness of breath. Resident #66 told emergency personnel she had been intubated in the past and had the same symptoms. According to a hospital nursing note dated 02/09/17, Resident #66 was in trouble when she first arrived with a non-rebreather mask in place and was barely holding her own. The physical examination revealed Resident #66 was in mild respiratory distress. On 02/09/17 at 11:39 A.M. the hospital records revealed an infectious disease consult was ordered due to Resident #66's worsening pneumonia. Review of hospital history and physical dated 02/09/17 revealed a computed tomography [MEDICATION NAME] was done and showed Resident #66 had areas of consolidation in the right and left lung. Resident #66 was treated with antibiotics in the emergency department. Review of emergency department physician note dated 02/09/17 at 2:15 P.M. revealed Resident #66 stated she was at a rehabilitation facility and had noticed intermittent difficulty with breathing for two or three days. Resident #66's lung sounds were diminished throughout with scattered wheezes. Resident #66's oxygen saturation was 90% on 5 liters of oxygen and Resident #66 was in mild to moderate respiratory distress. The physician note also revealed Resident #66's [MEDICAL CONDITION] (body deprived of adequate oxygen) on five liters of oxygen was concerning for possible [MEDICAL CONDITION] exacerbation, heart failure, or [MEDICAL CONDITION] embolism given Resident #66 had leg swelling. A late entry revealed Resident #66 was evaluated by a respiratory therapist and admitted to the stepdown unit for further respiratory therapy. A chest x-ray dated 02/13/17 revealed Resident #66 had possible atelectasis (a collapse or closure of part or the entire lung) On 02/12/17 at 10:35 A.M. an interview with Emergency Personnel #499 revealed he arrived to the facility on [DATE] around 6:50 A.M. Emergency Personnel #499 stated Resident #66 was having trouble breathing and was lying on sheets with wet and dry urine stains. On 02/13/17 at 1:52 P.M. an interview with Resident #66's family member revealed Resident #66 was still in the hospital with pneumonia. The family member stated Resident #66 called 911 to get help because the nightshift staff would not answer the call light. On 02/14/17 at 6:25 A.M. an interview with State tested Nursing Assistant (STNA) #77 revealed she notified the nurse that Resident #66 was having trouble breathing on 02/09/17. STNA #77 was not sure if the nurse went to assess Resident #66. On 02/15/17 at 7:26 A.M. an interview with Licensed Practical Nurse (LPN) #137 revealed she was working the night Resident #66 was sent to the hospital. LPN #137 stated she had checked Resident #66 on 02/09/17 around 6:00 A.M. and given Resident #66 a breathing treatment. LPN #137 stated when she found out emergency personnel was there to transport Resident #66 to the hospital, she went outside to talk to them as they were putting Resident #66 into the ambulance. On 02/16/17 at 8:33 A.M. an interview with Resident #66 revealed on 02/09/17 the nurse gave her a breathing treatment but forgot to bring the stuff to check her vitals. Resident #66 said the nurse left and said she would be back. Resident #66 stated she called 911 because the nurse never came back and no one answered her call light when she was having trouble breathing. On 02/16/17 at 10:00 A.M. an interview with Director of Nursing (DON) #5 revealed the nurse (LPN #137) had been in Resident #66's room several times that night and Resident #66 had stated she was afraid she was going to die. Review of the enclosed pamphlet for [MEDICATION NAME]-[MEDICATION NAME] revealed a significant cardiovascular effect could be produced in some patients as measured by pulse rate, blood pressure, and other symptoms. A physician order [REDACTED].#66 was ordered oxygen at 2.5 liters. On 01/18/17 a progress note revealed Resident #66's oxygen saturation was 96% on room air. A progress note dated 01/18/17 at 5:30 P.M. revealed Resident #66's oxygen was at 2 liters. On 01/19/17 a progress note revealed Resident #66's oxygen saturation was 96% on room air. Review of progress from 01/19/17 to 01/24/17 revealed Resident #66 was on two liters of oxygen. On 01/25/17 at 5:03 P.M. a progress note revealed Resident #66's oxygen was at two liters. On 01/28/17 at 11:21 A.M. Resident #66 oxygen saturation was at 97% on room air. Review of the medication administration records for January and February, 2017 revealed it was documented Resident #66 was receiving oxygen at 2.5 liters around the clock. Review of the medical record revealed no documentation Resident #66's physician was aware the resident was not being administered 2.5 liters of oxygen at all times. On 02/16/17 at 12:05 P.M. an interview with Administrator #4 revealed Resident #66 did not consistently receive oxygen as ordered at 2.5 liters and there was not a physician's orders [REDACTED]. 2. Review of the medical record of Resident #19 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the February, 2017 current physicians orders of Resident #19 revealed an order started on 12/06/16 for oxygen at two liters per minute via a nasal cannula. Review of the care plan for Resident #19, with a goal date of 04/14/17, revealed the resident was at risk for shortness of breath (SOB), with [DIAGNOSES REDACTED]. Interventions in the care plan included administer oxygen as ordered by the physician. Observation on 02/14/17 at 7:42 A.M., revealed Resident #19 was sitting in her wheelchair in the main dining room. Resident #19 had a portable oxygen tank attached behind her wheelchair, and the resident was wearing the oxygen tubing correctly around her nose. The oxygen tank gauge was in the red area, which indicated the tank was empty. During an interview on 02/14/17 at 7:42 A.M., Resident #19 was asked about her oxygen. Resident #19 stated she always wears oxygen, and it should be on. Resident #19 appeared upset when asked about the tank being empty, and the resident called for State tested Nursing Assistant (STNA) #118 to come change the tank. During an interview on 02/14/17 at 7:43 A.M., STNA #118 confirmed the oxygen tank supplying oxygen to Resident #19 was empty and should contain oxygen, and called for a nurse to change the oxygen tank. During an interview on 02/14/17 at 7:45 A.M., the DON stated the portable oxygen tanks should be replaced every time they get low. This deficiency substantiates Complaint Number OH 513. This deficiency is evidence of continued non-compliance from the complaint survey completed 02/02/17.

Based on record review and interview the facility failed to implement and provide adequate pain management for Resident #70. Actual harm occurred when the facility failed to administer pain medication to Resident #70 for over eight hours following his request for medication which resulted in increased pain rated a ten on a scale of one to ten by the resident. This affected one resident (Resident #70) of three residents reviewed for pain. Findings Include: Review of Resident #70's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the hospital paperwork dated 12/12/16 revealed Resident #70's primary [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 12/15/16 revealed Resident #70 was discharged with the pain regimen [MEDICATION NAME] 15 milligrams (mg) one to two tablets by mouth every 12 hours as needed for pain and [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg one to two tablets by mouth every four to six hours as needed for pain. Review of the skilled note dated 12/15/16 at 6:18 P.M. revealed the resident was alert and oriented and able to make his needs known. The skilled note indicated the resident was independent with his activities of daily living, was three days post operation for a right shoulder replacement and rated his pain 10 out of 10 on a standard pain scale (10 being the most severe pain). Review of the resident's admission comprehensive pain evaluation dated 12/15/16 revealed the assessment was blank. Review of the facility's emergency drug kit slips revealed the resident was administered [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg for pain on 12/15/16 at 6:00 P.M. and 10:34 P.M. Review of the resident's Medication Administration Record [REDACTED].M. On 12/16/16 at 5:45 A.M. interview with Licensed Practical Nurse (LPN) #100 revealed Resident #70 was admitted on [DATE] following surgery. Interview with LPN #100 revealed the resident had not received any pain medication for the previous eight hours because of the inability to get an authorization from the pharmacy to remove the pain medication from the emergency drug kit. LPN #100 stated Resident #70 was really upset due to the pain he was experiencing. Interview with Resident #70 on 12/15/16 at 11:30 A.M. revealed the resident had requested his as needed pain medication throughout the previous night on multiple occasions for a pain level he rated a ten on a scale of one to ten with ten being the most severe pain. The resident stated staff failed to provide him any pain medication. Resident #70 said he was unable to sleep throughout the night or eat his breakfast meal on 12/16/16 due to being in excruciating pain. This deficiency substantiates Master Complaint Number OH 450 and Complaint Number OH 396. This deficiency is also an example of continued non-compliance from the surveys dated 10/13/16 and 12/07/16.

Based on medical record review, observation, resident interview, staff interview and review of facility's policy and procedure, the facility failed to provide adequate supervision on night shift to prevent falls. This resulted in Actual Harm when Resident #46 went to the bathroom by herself on night shift, fell and sustained a leg fracture and multiple rib fractures. The facility failed to thoroughly investigate the circumstances after falls and implement planned interventions. This affected Resident #55. The facility failed to implement their policy when a resident left the facility and returned a few hours later. This affected Resident #58. These concerns affected three of four residents reviewed for accidents. Findings include: 1. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was impaired, required extensive one person physical assistance with bed mobility, and required limited one personal physical assistance with transferring, walking in the room and with toileting. Review of the resident's Fall Management/Psychoactive Drug Usage care plan, dated 12/29/15 and revised on 01/11/16, revealed the resident was at risk for a fall-related injury due to having some impaired mobility/balance during transition, recent history of a fall, daily diuretic usage and daily antidepressant use which placed her at risk for side effects. The goal was for the resident to be free from further injury. Interventions initiated on 12/29/15 included keeping the bed in low position when not providing care, perimeter mattress and ensuring the call light was within reach when the resident was in the room. Review of Resident #46's progress notes dated 11/20/16 revealed a State tested Nurse Aide (STNA) on the 100 hallway answered a call light in the 300 hallway and found Resident #46 on the bathroom floor. The STNA informed Licensed Practical Nurse (LPN) #106 of the fall incident. The LPN checked on the resident and found the resident on the bathroom floor in a sitting position with the left leg bent inwardly. The nurse assessed the resident and noted a deformity above the knee of the left leg. No bruises or discoloration noted. No deformity noted on the right leg. The resident was able to move and raise her arms with no difficulty during the assessment. She had shoes on before and after the fall and safety strips were on the bathroom floor. The resident was sent to the local hospital for evaluation. Review of the hospital paperwork revealed the resident was in the hospital from 11/20/16 to 11/22/16. The resident was diagnosed with [REDACTED]. Review of the facility's fall investigation revealed the new intervention was to place a perimeter mattress, which per the resident ' s plan of care was already an intervention. The facility noted the resident had on non-skid socks and there were skid strips on the bathroom floor. The resident was walking in her room after using the bathroom and fell . Review of the night shift staffing schedule for 11/19/16 and 11/20/16 revealed Licensed Practical Nurse (LPN) #106 was scheduled to work on the 100 and 300 halls, LPN #107 was scheduled to work for four hours from 11:00 P.M. to 3:00 A.M. on the 200 and 400 halls, and LPN #81 was scheduled to work for four hours from 3:00 A.M. to 7:00 A. M. on the 200 and 400 halls. STNA #93 was scheduled to work on the 100 hall and STNA #108 was scheduled to work on the 400 hall. The schedule indicated STNA #109 was to work the 200 hall but was a no show, STNA #110 was to work the 300 hall but she did not pickup that shift and STNA #111 was to work the 300 hall but was a no show. This revealed only two STNA's worked the night shift on 11/19/16. Review of the facility's Resident Census and Conditions of Residents form dated 12/06/16 revealed there were 63 residents that required assistance of one to two staff persons to transfer and to use the toilet. There were nine residents that were dependent on staff to transfer and to use the toilet. Interview with LPN #106 on 12/06/16 at 12:40 P.M. confirmed she worked the entire shift the night of 11/19/16 and only two STNA's worked that night. She confirmed the 300 hall had no scheduled STNA's and stated the STNAs were instructed to answer call lights on the 300 hall. LPN #106 stated she was on break when STNA #93 told her that Resident #46 had fallen and it appeared the resident had a leg fracture. She stated the other nurse on duty that night notified the Administrator that they did not have enough staff. Interview with LPN #81 on 12/06/16 at 4:30 A.M. confirmed there were only two STNA's working in the entire facility when she began her portion of the night shift on 11/19/16. The LPN confirmed there were no STNAs assigned to the 300 hall. LPN #81 stated Resident #46's call light was on and STNA #93 immediately answered the light and found Resident #46 lying on the floor in the bathroom. Interview with STNA #93 on 12/07/16 at 9:41 A.M. confirmed he worked the night shift on 11/19/16 and confirmed there was only one other STNA that worked with him that shift. He stated the other STNA was an agency STNA. He confirmed there was no STNA assigned to the 300 hall. STNA #93 stated when he saw the call light go off, he immediately went to the 300 hall and found Resident #46 on the floor in her bathroom and she had a visible fracture to her leg. He stated the 300 hall was not assigned to him but he had been instructed to answer call lights when he saw them. Interview with the Director of Nursing (DON) on 12/06/16 at 1:30 P.M. and 12/07/16 at 8:15 A.M. confirmed only two STNAs and two nurses worked the night of 11/19/16. 2. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed the resident had severe memory impairments and required extensive assistance with two person physical assistance with transferring and for wheelchair mobility. Review of the resident's Fall plan of care revealed the resident was at risk for injury-related falls. Interventions included to place a dycem on the resident ' s broda chair seat, ensure the resident's call light was within reach when she was in her room, and refer to task list. Review of tasks listed for the resident was to place non-skid socks on the resident. Review of the resident's progress notes dated 10/30/16 at 12:10 P.M. revealed the nurse was summoned to the resident ' s room by an STNA due to an incident. The resident was lying on the floor on her left side with her legs slightly pulled up. There were two small areas of blood visible on the floor. The nurse said he was informed by the STNAs that the resident fell from her broda chair when positioning in her chair. The resident fell from the left side of her chair hitting her head on the roller wheels on the bed. The resident had a 2.5 centimeter (cm) long laceration on the left upper back portion of her head. Pressure was applied to the area with a towel to slow the bleeding. The resident was assisted to a sitting position on the floor. The resident was not yelling or calling out. The resident was sent to the emergency room (ER) and received treatment for [REDACTED]. Review of the facility's fall investigation revealed there were no statements obtained from the STNA's involved in the incident and there was no proof of any staff education completed related to this incident. The fall intervention was for physical therapy to evaluate the resident prior to the resident being placed back into the broda chair. Observation of Resident #55 on 12/06/16 at 11:06 A.M. revealed the resident was in the dining room and had her legs to one side of the broda chair. The resident was not wearing non-skid socks and after surveyor intervention STNA #105 placed non-skid socks on the resident. Observation with LPN #86 on 12/06/16 at 11:06 A.M. revealed the dycem under the resident was all squished together and was not in proper placement. Interview with LPN #86 on 12/06/16 at 11:06 A.M. confirmed the resident should be wearing non-skid socks and the dycem in the broda chair was not properly placed. Interview with LPN #86 on 12/06/16 at 12:13 P.M. revealed he was the LPN working when Resident #55 fell from her broda chair on 10/30/16. He stated one STNA was behind the broda chair, one STNA was in front of the sit to stand lift and the resident was in the broda chair safely. As the STNA pulled away the lift from the resident, the resident lurched forward and fell out of the broda chair. Interview with STNA #113 on 12/06/16 at 12:15 P.M. stated on 10/30/16, she and another STNA finished toileting the resident, the resident was positioned in the broda chair and they were done transferring her. She said the resident began to scoot in her broda chair and just fell out of it on the left side. Interview with the DON on 12/06/16 at 12:30 P.M. confirmed the facility's fall investigation did not include the STNA's statements and did not indicated if the dycem was in place in the broda chair at the time of fall. Observation with STNA #105 on 12/07/16 at 7:35 A.M. revealed the resident was lying in bed and the resident's bed was placed diagonal in the room. The sides of the bed were not against the wall and the resident's call light was lying on the floor next to the wall. STNA #105 confirmed the call light was not within the resident's reach and was on the ground near the wall. Review of the facility's policy and procedure on Falls-Clinical Protocol, dated September 2012, revealed the cause identification included that staff would attempt to define possible causes within 24 hours of the fall. The staff and physician would continue to collect and evaluate information until either the cause of the fall had been identified or it was determined that the cause could not be found or that finding a cause would not change the outcome of the management of falling and fall risk. 3. Medical record review of Resident #58 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the resident's MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition and required supervision with set up assistance to walk in the corridor and for locomotion on and off the unit. Review of a progress note dated 11/26/16 at 5:06 P.M. revealed Registered Nurse (RN) #115 documented the resident had been seen with other residents at approximately 3:30 P.M. The RN had prepared Resident #58's intravenous medication but the resident was not in his room or the facility. The facility was searched and the DON was notified at 4:30 P.M. The note indicated staff would continue to search for the resident. There was no other documentation in the medical record regarding when the resident returned to the facility or who was notified and if there was any education completed on 11/26/16. Review of documentation in the medical record dated 11/28/16 at 1:10 P.M. revealed Social Worker Designee #99 spoke with the resident in regards to leaving the facility on LOA where there was an order for [REDACTED]. The resident stated he was aware he was not to leave but it was an emergency that he had to meet his sister. The resident stated he understood he was to sign out if for any reason he did leave the facility but he was aware he was not to leave the facility for any reason. The resident was educated about signing out of the facility. Interview with Resident #58 on 12/07/16 at 7:13 A.M. said he only left for 15 minutes and waited at the store near the facility so he could obtain money from his sister. The facility called him and told him to come back and he said he did. Interview with LPN #115 on 12/07/16 at 9:29 A.M. stated Resident #58 had a history of [REDACTED]. The LPN stated on 11/26/16 at around 3:30 P.M., he noticed the resident was not in the facility. He stated he went to the store to look for the resident around 3:40 P.M. to 3:50 P.M. and the resident was not there. LPN #115 stated he went back to the facility and called the DON around 3:50 P.M. to 4:00 P.M. The LPN stated the DON told him not to do anything until the DON called the Administrator. The DON called him right back and told him to call the resident's cell phone number. The LPN stated he then left a message on the resident's phone. The staff looked for the resident in the facility. The LPN stated around 4:30 P.M. the resident called him and said he was at the store and would be right back to the facility. The LPN stated the resident returned to the facility around 6:00 P.M. LPN #115 confirmed he did not document in the medical record that the resident returned to the facility and if the physician, DON or Administrator was notified that the resident returned to the facility. The LPN confirmed he did not call the police and he did not have staff search the area around the facility to locate the resident. Interview with LPN #116 on 12/07/16 at 11:00 A.M. stated she was unsure of where residents were to sign out when they went out of the facility. She said there may be a binder at the nurses station and said she couldn't find one. She said sometimes they were in the resident's chart and looked at a chart and said it was not there. She asked the receptionist and the receptionist pointed to the book that residents were to sign out in, which was located in the main lobby area on a table against the wall. Interview with DON at 12/07/16 11:09 AM stated LPN #115 spoke to her on 11/26/16 regarding Resident #58. She said she told him to call the resident's cell phone and ask the resident where he was. The DON said she was told the resident answered his phone the first time LPN #115 called him and was told he came right back to the facility. The DON stated she told LPN #115 that if the resident was not there to call her back and she said they called her and said he was back in the facility. The DON was not aware of the physician orders [REDACTED]. The DON confirmed the resident did not sign out on the LOA book on 11/26/16 and confirmed LPN #116 was not aware of the LOA procedure. Interview with the Administrator on 12/07/16 at 11:26 A.M. confirmed Resident #58 did not sign out on 11/26/16 when he went LOA and confirmed there was a physician order [REDACTED]. The Administrator said the resident was gone for about three hours. The Administrator confirmed the physician was not notified of the resident ' s return to the facility. The Administrator said she knew staff immediately educated the resident when he returned and confirmed this was not in the medical record. The Administrator said she would look to see if she had any investigation notes on the incident. As of 12/07/16 at 4:00 P.M. there was no investigation notes provided. Review of the policy and procedure on Elopements, dated December 2007, revealed the staff shall investigate and report all cases of missing residents. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building and premise; c. if the resident is not located, notify the Administrator and the the Director of Nursing Services, the resident's legal representative, the attending physician, law enforcement officials and (as necessary) volunteer agencies. d. Provide search teams with resident identification information; and e. initiate an extensive search of the surrounding area. When the resident returns to the facility, a. the DON or charge nurse shall examine the resident for injuries b. contact the physician and report findings and conditions of the resident c. notify the resident's legal representative d. notify search teams that the resident has been located e. complete and file an incident report; and f. document relevant information in the resident's medical record. This deficiency substantiates Complaint Number OH 241 and OH 232. This deficiency is evidence of continued non-compliance from the surveys dated 09/13/16 and 10/13/16.

Based on policy review, medical record review, resident interviews and staff interviews, the facility failed to be adequately staffed to supervise residents on night shift. Actual Harm occurred when the 300 hall on night shift was not adequately staffed and Resident #46, who resided on that hall, fell and sustained a leg fracture and multiple rib fractures. This affected one (Resident #46) of 25 residents residing on the 300 hall. The facility failed to have enough qualified staff to ensure a resident received all doses of an ordered intravenous antibiotic. This affected one (Resident #58) of two residents ordered to receive intravenous medications. Findings include: Review of the facility's policy and procedure on Staffing, dated April 2007, revealed the facility provided adequate staffing to meet needed care and services for their resident population. The policy interpretation and implementation included the facility maintained adequate staff on each shift to ensure that the residents' needs and services were met. Licensed registered nursing and licensed nursing staff were available to provide and monitor the delivery of resident care services. 1. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was impaired, she required extensive one person physical assistance with bed mobility, and required limited one person physical assistance with transferring, walking in the room and with toileting. Review of the resident's progress notes revealed the resident fell on [DATE] at 4:40 A.M. and State tested Nursing Aide (STNA) #93 found her lying in on her bathroom floor and her left leg bent inwardly on the bathroom floor. The resident was residing on the 300 hallway at the time of the fall. The resident was sent to the hospital on [DATE] and returned the facility on 11/22/16 with new [DIAGNOSES REDACTED]. Review of the night shift staffing schedule for 11/19/16 and 11/20/16 revealed Licensed Practical Nurse (LPN) #106 was scheduled to work on the 100 and 300 halls, LPN #107 was scheduled to work for four hours from 11:00 P.M. to 3:00 A.M. on the 200 and 400 halls, and LPN #81 was scheduled to work for four hours from 3:00 A.M. to 7:00 A. M. on the 200 and 400 halls. STNA #93 was scheduled to work on the 100 hall and STNA #108 was scheduled to work on the 400 hall. The schedule indicated STNA #109 was to work the 200 hall but was a no show, STNA #110 was to work the 300 hall but she did not pickup that shift and STNA #111 was to work the 300 hall but was a no show. This revealed only two STNA's worked the night shift on 11/19/16. Review of the facility's Resident Census and Conditions of Residents form dated 12/06/16 revealed there were 63 residents that required assistance of one to two staff persons to transfer and to use the toilet. There were nine residents that were dependent on staff to transfer and to use the toilet. Interview with LPN #106 on 12/06/16 at 12:40 P.M. confirmed she worked the night of 11/19/16 and worked the entire shift. She confirmed only two STNA's worked that night and the 300 hall had no scheduled STNA's. She stated the two STNAs were instructed to answer call lights on the 300 hall. LPN #106 stated she was on break when STNA #93 told her that Resident #46 had fallen and it appeared the resident had a leg fracture. She stated the other nurse on duty that night notified the Administrator that they did not have enough staff. Interview with LPN #81 on 12/06/16 at 4:30 A.M. confirmed there was only two STNA's working in the entire facility when she began her portion of the night shift of 11/19/16. The LPN also confirmed that there were no STNAs assigned to the 300 hall. LPN #81 stated Resident #46's call light was on and STNA #93 immediately answered the light and found Resident #46 lying on the floor in the bathroom. Interview with STNA #93 on 12/07/16 at 9:41 A.M. confirmed he worked the night shift on 11/19/16 and confirmed there was only one other STNA that worked with him that shift. He stated the other STNA was an agency STNA. He confirmed there was no STNA assigned to the 300 hall. STNA #93 stated when he saw the call light go off, he immediately went to the 300 hall and found Resident #46 on the floor in her bathroom and she had a visible fracture to her leg. He stated the 300 hall was not assigned to him but he was instructed to answer call lights when he saw them. Interview with the Director of Nursing (DON) on 12/06/16 at 1:30 P.M. and 12/07/16 at 8:15 A.M. confirmed only two STNAs and two nurses worked the night of 11/19/16. Interview with LPN #99 on 12/06/16 at 4:16 A.M. stated she did not feel there was adequate staff at night. She stated there was one STNA per hall and two on the 300 hall. She stated if a resident was a hoyer lift then an STNA had to get pulled from one hallway to assist the other STNA with the hoyer lift and that left one hallway without an STNA to answer call lights. LPN #99 stated she had two hallways to administer medications to the residents and this did not leave a lot of time to assist the STNAs. Interview with STNA #83 on 12/06/16 at 4:43 A.M. stated she felt some hallways need two STNAs becuase of the heavy workload. 2. Medical record review of Resident #58 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the November 2016 Medication Administration Record [REDACTED].M. was administered. Review of the medical record revealed there was no explanation why it was not administered. Review of LPN qualifications to administer IV medications revealed LPN #112 was not licensed to administer IV medications. Review of Resident #58's November 2016 MAR indicated [REDACTED].M. and 4:00 P.M. This was confirmed with the DON on 12/07/16 at 11:09 A.M. The DON confirmed the MAR indicated [REDACTED].M. and there was no explanation given. Interview with Resident #58 on 12/06/16 at 4:48 A.M. revealed he felt staffing was inadequate and stated that his IV antibiotic medication had been missed two times because there was no staff qualified to administer his IV antibiotic. This deficiency substantiates Complaint Numbers OH 241 and OH 232.

Based on medical record review, resident and staff interview, and Pain Management Policy and Medication Not Available policy review the facility failed to provide adequate pain management for one resident. This resulted in Immediate Jeopardy when Resident #79 was not given pain medication in a timely manner. Resident #79 complained of pain at approximately 9:00 A.M and 4:00 P.M on both 11/14/15 and 11/15/15 and no pain medication was administered as requested. Resident #79 experienced burning radiating pain of a 9 on a scale of 1-10 with 10 being the worst pain. This affected one of three residents reviewed for pain (Resident #79). The facility identified 42 residents were on a pain management program. The Administrator and Director of Nursing (DON) were notified on 11/19/15 at 1:30 P.M. that Immediate Jeopardy began on 11/14/15 at approximately 9:00 A.M when Resident #79, who was assessed to be alert and oriented requested pain medication related to pain in her knees and hips. Pain medication was not administered until 11/16/15 at 3:50 A.M. and resulted in the resident experiencing unrelieved burning radiating pain and rated it a 9 on a scale of 1-10 with 10 being the worst pain; experienced a headache with sharp pain behind the eyes on Sunday and the pain kept her from transferring herself; did not want to get up and be around people because of the pain and the resident remained in bed over the weekend due to the severity of the unrelieved pain. The Immediate Jeopardy was removed on 11/19/15 when the facility implemented the following corrective actions: · On 11/16/15 at 3:50 A.M. RN#43 administered [MEDICATION NAME] 5/325mgs to Resident #79 and an order was received to continue [MEDICATION NAME] 5/325mg one to two tablets as needed every four hours until [MEDICATION NAME] 5mg arrived. · On 11/19/15 Resident #79 ' s pain level was assessed and a new order was obtained for [MEDICATION NAME] 5mg daily in the morning and to continue [MEDICATION NAME] 5mg every six hours as needed. · On 11/19/15 Interviews were completed by ADON #75 with two licensed practical nurses (LPNs #31 and #83) and one registered nurse (RN #61) that were on the shifts over the weekend (11/14/15 and 11/15/15) to identify if any pain management protocols were implemented. · On 11/19/15 and 11/20/15 10 RNs, 20 LPNs, and 17 state tested nurse aides (STNAs) were educated by the DON and the Assistant Director of Nursing (ADON) #75 on pain management protocol/procedure, addressing unavailability of medications, and protocol for notification of physician. STNAs were educated by the DON and ADON #75 on observation of signs and symptoms of pain and communication to nurses if pain noted. Nurses and STNAs that are not working were educated by phone by the DON and ADON #75, and those on leave will be educated prior to next scheduled shift. · On 11/19/15 the DON and ADON #75 assessed other residents that are on pain medications to validate medication is currently available. Weekly audits of residents on pain medication will be completed for one month then monthly for two months. · On 11/19/15 the DON and ADON #75 interviewed five random alert and oriented residents and observed cognitively impaired residents that have orders for pain medications five times per week for four weeks then weekly for two months for pain symptoms. · On 11/20/15 all residents were evaluated and assessed for pain and every shift per the facility policy and documentation will be on the EMAR. · On 11/20/15 the DON and ADON #75 reviewed the comprehensive pain evaluation for current residents taking narcotic pain medication for accuracy. Shift evaluation will continue every shift per the facility policy. · On 11/20/15 the DON or designee will begin to review progress notes and the electronic Medication Administration Record (EMAR) documentation during clinical start up for applicable follow up for pain management five times per week for four weeks then weekly for two months. · On 11/20/15 the DON or designee will begin to review new orders for pain management to validate that medication is available during clinical start up for one month then weekly for two months. · On 11/20/15 interviews from 12:50 P.M. until 1:00 P.M. with Licensed Practical Nurse (LPN) #83, LPN#99, State tested Nursing Assistant (STNA) # 30, and STNA #90 revealed staff have been educated regarding recognizing pain and management. Residents #4, #16, #66, and #94 were interviewed and confirmed staff members have assessed them for pain, and they are not currently experiencing any pain. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of implementing on-going monitoring of the corrective measures, education of staff, and implementing an audit system. Findings Included: Record review revealed Resident #79 was admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Care Plan for Pain dated 09/28/14 revealed the resident needed assistance with her pain and discomfort due to the resident was in chronic pain. Interventions included to administer medications as ordered, and to assess the resident ' s pain per the facility ' s policy. Review of telephone order dated 06/11/15 revealed to decrease the anti-convulsant medication [MEDICATION NAME] 150mg to three times a day for Chronic Pai[DIAGNOSES REDACTED] and to give the [MEDICATION NAME] 5-325mg one tablet every four hours for moderate pain as needed; take two tablets by mouth every four hours for severe pain as needed. Review of Quarterly Pain Management Evaluation dated 08/06/15 revealed the resident experienced occasionally moderate achy pain to her bilateral legs. Interventions that helped included as needed pain medications, and this did not limit her activities of daily living or affect her sleep. Review of Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and needed limited assistance for dressing and hygiene, and was independent for locomotion on and off the unit. Review of the narcotic count sheet dated 11/06/15 until 11/13/15 included the resident received the [MEDICATION NAME] as needed [MEDICATION NAME] 5-325mgs (two tablets) one to two times daily. Two tablets of [MEDICATION NAME] were administered to Resident #79 on 11/06/15 at 8:25 A.M., 11/07/15 at 8:20 A.M., 11/08/15 at 1:18 P.M., 11/09/15 at 8:30 A.M., 11/09/15 at 8:15 P.M., 11/10/15 at 8:30 A.M., 11/10/15 at 8:30 P.M., 11/11/15 at 8:56 A.M., 11/12/15 at 8:30 A.M., and 11/13/15 at 12:57 P.M. Review of telephone order on 11/13/15 at 1:04 P.M. included to discontinue as needed [MEDICATION NAME] 5-325mgs tablet. Telephone order dated 11/13/15 at 1:15 P.M. included an [MEDICATION NAME] 5mg tablet; give one tablet every six hours for pain PRN. Review of nursing notes and electronic medical record on 11/14/15 and 11/15/15 did not include any assessments for pain were conducted per the facility policy. Interview on 11/16/15 at 10:47 A.M., 11/17/15 at 2:43 P.M., 11/18/15 at 11:30 A.M., 11/20/15 at 12:19 P.M with Resident #79 revealed Resident #79 stated she requested Certified Nurse Practitioner (CNP)#114 on 11/13/15 to change her pain medication because the [MEDICATION NAME] were large and did not digest well due to her recent gastric sleeve surgery (readmitted on [DATE]). Resident #79 stated her pain was typically in the knees, legs, and hips because of her arthritis. The resident said her pain level was 9 on a scale of 1-10 when she did not have the pain medication over the weekend 11/14/15 and 11/15/15. She stated she can usually tolerate a pain level of a 6 or 7 on a scale of 1-10 with 10 being the worst. Resident #79 stated she experienced burning radiating pain this weekend due to not having her pain medication. She also had a headache with sharp pain behind the eyes on Sunday. The pain kept her from transferring herself, and she did not want to get up and be around people because of the pain. She stated she reported on 11/14/15 and 11/15/15 to RN #61 that she was in pain, and RN#61 stated the medication was not available. Resident #79 stated was so upset that she wanted to snatch the hair piece off of RN#61. Resident #79 stated she usually takes the pain medication in the morning so she can independently go about her day. The resident further revealed she remained in bed over the weekend because she was unable to be independent. The resident shared she was aware she was on [MEDICATION NAME], but that was for nerve pain in her shoulders; however [MEDICATION NAME] did not relieve the arthritis pain in her knees, legs, and hips. Interview on 11/18/15 at 2:51 P.M with STNA #47 confirmed she worked with Resident #79 on first shift 11/14/15 and first and second shifts on 11/15/15. STNA #47 revealed she reported to RN #61 on multiple occasions on both dates, that the resident was reporting pain (typically the resident does not report significant pain). STNA #47 revealed the resident usually only needed set-up help and was independent with her activities of daily living; however on 11/14/15 and 11/15/15 the resident needed total care of two aides. STNA #47 stated the resident remained in bed on Saturday and Sunday, and did not participate in activities either day. She stated the resident always goes to Church on Sunday. Telephone interview on 11/18/15 at 4:27 P.M with CNP #114 revealed she was notified by LPN#83 on 11/13/15 that the order she wrote for [MEDICATION NAME] was invalid, because it was missing a quantity. CNP #114 faxed over a clarifying order from a different facility. CNP#114 stated if she was aware the [MEDICATION NAME] was not going to be available on 11/13/15 and over the weekend, she would have continued the [MEDICATION NAME] order until the [MEDICATION NAME] was available. CNP #114 stated the resident takes the pain medications regularly for relief of Arthritis pain. CNP #114 stated she told LPN#83 that [MEDICATION NAME] was available in the emergency box at the facility. CNP #114 stated she saw Resident #79 on 11/17/15 and the resident reported to CNP #114 that she was lying in the bed all weekend in pain, because of not having pain medication. CNP #114 stated she would have expected the nurses to assess pain for residents at risk at a minimum of each shift, and also as often as the resident could get the pain medication. CNP #114 was concerned that the resident was not given pain relief over the weekend; however CNP #114 had not reported it to the DON. Interview on 11/18/15 at 4:41P.M. with RN #43 revealed she worked third shift 11/15/15 into 11/16/15. The nurse stated she did not get anything in report related to the resident ' s pain. Resident #79 asked RN #43 for pain medication. RN #43 contacted CNP #114 to get an order to restart the [MEDICATION NAME] until the [MEDICATION NAME] arrived, and administered [MEDICATION NAME] 5/325mg at 3:50 A.M . RN #43 was not aware, and did not check if [MEDICATION NAME] 5mg was available in the emergency box located at the facility. The resident reported pain of 8 on a scale of 1-10 to RN #43. It was not documented in the medical record and the nurse did not remember where the resident ' s pain was located, and the nurse did not assess the effectiveness of the medication. Interview on 11/18/15 at 5:18 P.M. with the DON and ADON #75 revealed they were both unaware that there were concerns with Resident #79 not getting pain medications all weekend. Both were unaware of the facility ' s policy on assessing residents for pain, and the DON stated she expected residents who were alert and oriented to self-report pain. The DON confirmed and submitted a copy of available medications in the emergency box that [MEDICATION NAME] 5mg was available in the emergency box at the facility and could have been obtained after contacting the pharmacy for permission. Telephone interview on 11/19/15 at 12:45 P.M. with RN #61 stated she worked first shift on 11/14/15 and 11/15/15 and confirmed she never assessed Resident #79 for pain on either date. RN #61 stated the resident was alert and oriented and should self-report pain. RN#61 was unaware of the facility ' s pain management policy to assess every shift. RN #61 confirmed she did not follow up on the pain medication not being in the facility. RN #61 stated the resident was usually independent for activities of daily living. Review of the Pain Management Policy dated 09/15 included functions of appropriate pain management included to intervene to treat pain before the pain becomes severe; documenting pain assessment, intervention, and evaluation of activities in a clear and concise manner per the plan of care. The procedure to assess for pain included that residents are evaluated each shift for pain. Findings are documented on the Medication Administration Record (MAR) and /or on a progress note. Review of Medication Not Available Policy dated 06/15 revealed if a medication is not available then immediately or as soon as possible the nurse is to check the emergency box for medication availability, notify the DON. The pharmacy should be called as soon as it is noted that a medication needed prior to the next delivery is not available. Utilize a call log to track communications with pharmacy providers. The DON and Director of Pharmacy Services should be notified if medications are unavailable despite following the proper procedures. This deficiency substantiates Complaint Number OH 413.

Based on observation, record review and interview the facility failed to ensure Resident #84 and Resident #28, who were assessed to be dependent on staff for activities of daily living (ADL) care, received care to maintain adequate personal hygiene including nail and/or oral care. This resulted in actual harm when Resident #84 reported and complained of difficulty walking due to very thick, curved and painful toenails. This affected two residents (Resident #84 and #28) of three residents reviewed for activities of daily living. Findings Include: 1. Review of Resident #84's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had clear speech, usually understands others, usually makes himself understood and has a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 08. Review of the resident's November 2015 monthly physician's orders [REDACTED]. On 11/16/15 at 2:45 P.M., observation made of Resident #84 revealed long, jagged fingernails with a brown substance under the nails. On 11/17/15 at 2:57 P.M., observation made of Resident #84 revealed the resident's fingernails remained long, jagged and the brown substance remained under the nails. On 11/17/15 at 2:50 P.M., interview with Resident #84 revealed he would like to have his fingernails cleaned and trimmed but would rather see someone about his toenails. Resident #84 said his toenails were so long they hurt him when he walked. Observation of Resident #84's toenails at the time of the interview revealed long, thickened, curved greenish-yellow nails. On 11/17/15 at 3:03 P.M., interview with the Director Of Nursing (DON) verified the resident's fingernails were long and the resident's toenails were long, curved, thick and greenish-yellow in color. On 11/18/15 at 11:12 A.M., observation of the resident's nails revealed the resident's fingernails remain long and jagged but the brown substance had been removed. On 11/17/15 at 3:08 P.M., interview with Social Service Employee (SS) #104 revealed he was unsure of when Resident #84 was last seen by the facility contracted podiatrist. On 11/18/15 at 12:15 P.M., interview with SS #104 revealed Resident #84 had not been seen by the facility contracted podiatrist since the resident's admission to the facility on [DATE]. Review of the podiatrist consult note dated 11/18/15 revealed the resident was being seen for difficulty with walking and toenail deformity causing pain. The resident's toenails were found to be mycotic (nails that are infected with fungus), thick, yellow, crumbly and gryphotic (an abnormal thickness and curvature of the nails). 2. Review of Resident #28's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the resident's annual MDS 3.0 assessment dated [DATE] indicated the resident usually understands others, usually makes himself understood, he had both short and long term memory impairment and his cognitive skills for daily decision making was modified independence. He was identified as being dependent on staff for personal hygiene. On 11/16/15 at 11:16 A.M., observation revealed the resident had a thick build up of a white substance on the resident's teeth. On 11/17/15 at 9:35 A.M., observation of Resident #28 revealed the resident's teeth continued to have a thick build up of a white substance. On 11/18/15 at 10:20 A.M., the resident was observed to have food and a thick white substance to his teeth. A foul odor to his breathe was also noted. On 11/18/15 at 10:15 A.M., interview with Resident #28 reported he did not have his teeth brushed by staff during his morning care. Resident #28 said he would like to have his teeth brushed twice a day. On 11/18/15 at 10:30 A.M., Licensed Practical Nurse (LPN) #34 verified Resident #28's teeth had a thick build up of a white substance on them. On 11/18/15 at 11:08 A.M., interview with the DON verified the resident's teeth had a thick build up of a white substance on his teeth and foul smelling breath. Review of the facility's mouth care policy last revised 10/10 revealed the purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth.

Based on observation, record review and interview the facility failed to provide dental services for Resident #76 and Resident #68. Actual harm occurred when the facility failed to accurately assess and ensure dental services were provided timely to Resident #76 and #68 which resulted in the need for emergency dental services, increased pain, and/or tooth decay beyond repair for the residents. This affected two residents (Resident #76 and #68) of four residents reviewed for dental services. Findings include: 1. Review of Resident #76 medical records revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #76's written dental consent dated 11/20/14 revealed Resident #76 agreed to by treated by the house dentist if the need arose including any type of dental that was warranted by the resident 's condition when the head nurse deemed necessary. Review of Resident #76 admission dental assessment dated [DATE] revealed the resident had natural teeth with no broken teeth, obvious cavities, or pain. Resident #76's teeth were noted to be clean with no debris. Further review revealed a notation that Resident #76 had all her natural teeth that were in good condition aside from some plaque noted on some of the teeth and a dental cleaning was scheduled. There was no evidence of any other comprehensive dental assessments performed for Resident #76 after this admission assessment. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had no broken natural teeth, cavities, or mouth pain. The assessment revealed the resident had a Brief Interview for Mental Status score of 15 which reflected the resident was cognitively intact. Record review revealed a current physician order, for the resident to have a dental consult yearly and as needed. Resident #76 primary insurance was Medicaid. Review of Resident #76 current dental care plan, revealed to offer dental examination annually and offer assistance and encouragement to perform good oral hygiene. Review of dental schedule from 04/2015 to present revealed no evidence Resident #76 was seen by in house dentist. Further review revealed Resident #76 was on the list to see the dentist in December 2015. Interview with Resident #76 on 11/16/15 at 2:19 P.M. revealed the resident reported she had several cavities, missing teeth, and had not had teeth cleaned since 2012. Resident #76 revealed she had reported dental concerns to staff and even stopped the dentist in the parking lot over the summer and requested an appointment. Resident #76 revealed she had reported to staff she would be willing to see a dentist outside the facility if her insurance would cover it. Interview and observation of Resident #76 on 11/18/15 at 2:03 P.M. revealed the resident had a few broken teeth on the bottom down past the gum line, two broken teeth on top, and plague build up. Resident #76 reported she had trouble chewing foods and she had been reporting dental concerns to staff since admission (11/20/14). Interview with SS #104 on 11/18/15 at 10:31 A.M. revealed Resident #76 had not seen a dentist since admission to the facility. SS #104 revealed he thought Resident #76 was seen at the last dental visit but her name was not on the list of residents that were seen. SS #104 verified Resident #76 had chased the dentist out to his car last Friday and requested an appointment with him. SS #104 revealed the dentist was coming tomorrow to fit a resident for dentures and he would ask the dentist to make an emergency visit. SS #104 revealed it was his responsibility to arrange dental appointments for the residents. Review of Resident #76 emergency dental notes dated 11/19/15 revealed Resident #76 presented for a problem focused exam regarding concerns with tooth number 6. Resident #76 reported pain and sensitivity in mouth with a pain scale of four (on scale of one to ten). Today tooth #4 and root #3 were extracted. The course of treatment included root #2 and tooth number #8, #9, #11, #13, #20, and #31 extract as needed for pain. Tooth #6, #7, and #10 would need restoration. Review of the dental policy dated 2001 and revised 12/13 revealed routine and emergency services are available to meet the resident 's oral health services in accordance with the resident's assessment and plan of care. Routine and emergency dental services are provided to the residents. Residents are permitted to select a dentist of their choice. Social services personnel will be responsible for assisting residents/family in making dental appointments and transportation arrangements as necessary. 2. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident was alert and oriented (cognitively intact). Resident #68's primary insurance was Medicaid. Review of a written dental consent dated 09/09/14 revealed Resident #68 agreed to be treated by the house dentist. Review of Resident #68's nutrition/dental care plan dated 09/11/14 revealed to provide consult with facility dentist as order. Review of Resident #68's outside dental note dated 11/28/14 revealed the dentist was unable to extract Resident #68's teeth and provide root canal. Further review revealed Resident #68 needed to see an oral surgeon. Interview with Resident #68 on 11/17/15 at 8:35 A.M. revealed he had three cavities and needed several teeth extracted. Resident #68 revealed he had not seen the facility dentist and it had been at least nine months since he last saw any dentist. Resident #68 reported home choice was trying to get him a new State identification card so he could see a dentist but had not heard back from them either. Interview with Social Service Employee (SS) #104 on 11/18/15 at 10:53 A.M. verified Resident #68 was on Medicaid and had signed consent to see the facility dentist on 09/09/14. SS #104 revealed Resident #68 had not seen the dentist and was not on the list to see the dentist next month. SS #104 revealed it was social service staff responsibility to arrange dental appointments for the residents. Interview and observation of Resident #68 on 11/18/15 at 10:58 A.M. with SS #104 present revealed Resident #68 had dental pain, two missing teeth on the bottom left side with one broken off at the gum line, one tooth on top left broken, one tooth on top right broken, and one tooth on right bottom broken. Resident #68 reported pain and difficulty chewing foods. Resident #68 reported he did see a dentist downtown last year after he had made his own appointment. Resident #68 reported that SS #104 was aware of the appointment and made transportation arrangements. Interview with SS #104 on 11/18/15 at 3:00 P.M. revealed he was unaware Resident #68 had seen an outside dentist and would attempt to obtain dental notes from 11/28/14. SS #104 revealed the facility had received orders from the outside dentist on 12/18/14 and no one followed up with the recommendations. Interview with Registered nurse (RN) #115 on 11/19/15 at 10:00 A.M. revealed the facility found a referral form from the outside dentist Resident #68 saw on 11/28/14 for medical clearance in Resident #68's over flow chart. RN #115 revealed the facility had to go to the dental office and pick up the actual dental notes from 11/28/14. Interview with SS #104 on 11/20/15 at 10:30 A.M. revealed he had made an appointment for Resident #68 to return back to the same outside dentist he seen on 11/28/14. SS #104 revealed the facility had an oral surgeon. Interview with Resident #68's outside dental office on 11/20/15 at 11:40 A.M. revealed they did not have an oral surgeon and that was the reason they had referred the resident to an oral surgeon in 2014. Interview with SS #104 on 11/20/15 at 2:00 P.M. revealed he called Resident #68's outside dentist and reconfirmed they did not have an oral surgeon so he canceled that appointment and rescheduled another appointment with an oral surgeon. Review of Resident #68's emergency dental notes dated 11/19/15 revealed Resident #68 was seen for a dental exam due to having some dental discomfort. The dentist reported after completing a comprehensive oral exam it was clear that Resident #68 would need several extractions. The dentist recommended a referral to an oral surgeon for all the extractions for the resident's comfort and safety. Further review of the oral referral report revealed Resident #68 needed tooth #4, #6, #13, #18, #30, and #31 extracted due to them being non-restorable. Additionally, review of Resident #68's medical record revealed the resident had not had a comprehensive dental assessment completed. Further review revealed on the resident's admission assessment staff were unable to examine the resident's oral/dental status. Review of the dental policy dated 2001 and revised 12/13 revealed routine and emergency services are available to meet the resident's oral health services in accordance with the resident ' s assessment and plan of care. Routine and emergency dental services are provided to the residents. Residents are permitted to select a dentist of their choice. Social services personnel will be responsible for assisting residents/family in making dental appointments and transportation arrangements as necessary.

Based on record review, review of the manufacturer's recommendations for the use of the Hoyer lift and interview the facility failed to ensure Resident #103 received adequate assistance during a Hoyer transfer. This resulted in harm to Resident #103, when she was dropped out of the Hoyer lift to the floor while being transferred by one State tested nursing assistant. The resident was transferred to the hospital where she required and received sutures to the laceration in the back of her head. This affected one resident (Resident #103) of three residents reviewed related to falls. The facility census was 79. Findings include: Review of Resident #103's medical record revealed a nurse's note dated 05/26/13 that indicated the resident had a fall that occurred on 05/26/13. An event report, dated 05/26/13 at 10:40 A.M. revealed the resident was observed by the nurse to be on the floor with her head on the Hoyer lift wheel. She was assessed to have sustained a head laceration to her posterior head that was bleeding. The fall occurred in her room during an assisted transfer. The event report listed only one witness to the fall. The investigation into the fall determined the fall occurred as a result of an employee using a Hoyer lift without the assistance of another staff member. A statement from the employee involved indicated he was trying to transfer the resident from the bed with the use of the Hoyer lift. As the resident was being lifted he noted that there was a problem with one of the straps slipping out. He attempted to push the resident back over the bed but by the time he was able to do that the resident slipped out. The resident was sent to the hospital where she required staples to the back of her head. The resident returned the same day with orders for treatment to the head laceration and orders to follow up with her physician in two days. An interview with Resident #103 on 07/11/13 at 9:05 A.M. verified she was dropped while being transferred by a staff member using the Hoyer lift. She stated she sustained a laceration to the back of her head that had to be stapled shut. She was aware of the staff member who transferred her and indicated he was the only staff member there at the time she fell . She stated there should always be two people present when the Hoyer lift was used but that time there was only one. Review of the manufacture's recommendations (for the Hoyer lift) revealed under the operation instructions it was recommended that two assistants should be used for all lifting preparations, transferring from and transferring to procedures. It indicated the equipment would permit proper operation by one assistant but the use of one should be based on the evaluation of the health care professional for each individual case. There was no written evaluation completed to indicate the resident could safely be transferred by one staff member using the Hoyer lift. An interview with the administrator on 07/11/13 at 11:15 A.M. verified Resident #103 had a fall that occurred while being transferred using a Hoyer lift. The administrator indicated the facility investigation determined a nursing assistant was using the Hoyer lift for the resident transfer without having any other help or staff present. The employee involved was eventually terminated as it was determined the unsafe transfer placed the resident at risk. This deficiency substantiates allegations contained in Complaint Number OH 781 and is an example of continued non-compliance from Complaint Number OH 511 investigated on 06/11/13.

Based on observation, review of the facility policy entitled Lifting Machine, review of staff education regarding the use of a mechanical lift, review of manufacturer's instructions for the lift and staff interview, the facility failed to ensure a safe transfer for two of two resident's who were transferred with the use of a mechanical lift (Resident's #23 and #34). The census was 83. Findings include: 1. Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care for Resident #34 revealed a mechanical lift was to be used for transfer from bed to chair. Review of the physician ' s orders for Resident #34 revealed the resident was to be transferred with a mechanical lift and two persons. Observation of a transfer on 08/09/13 at 10:15 A.M. by two State tested Nurse Aides (STNA) #4 and #5 revealed the resident was transferred into a wheelchair from the bed. During the transfer of Resident #34, staff placed the transfer sling under the resident, connected the sling to the mechanical lift and raised the resident off of the bed. The mechanical lift was rolled across the room to above the wheelchair and the resident was lowered down into the wheelchair. Review of the procedure with STNA 's #4 and #5 verified they failed to widen the legs of the mechanical lift and lock the brakes prior to raising the resident off of the bed. STNA's #4 and #5 verified the resident was rolled across the room to the wheelchair with the legs of the lift in the closed position. The lift was checked for allowance of the legs of the lift to remain in the widest open position while moving the device away from the bed and it was able to be moved away from the bed in the correct position once a storage box under the bed was removed. 2. Review of the medical record of Resident #23 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident, according to facility documentation weighed 281 pounds on 08/01/13. Review of the plan of care for the resident revealed it directed the resident was to be transferred to a wheelchair with two persons by a mechanical lift. Review of the physicians orders signed 07/13/13 instructed staff to transfer resident with two persons and a Hoyer lift. An observation of a mechanical lift transfer of Resident #23 at 11:25 A.M. on 08/09/13 revealed STNA's #1, #2 and #3 were in Resident #23 ' s room to transfer the resident from the bed to the wheelchair. The staff placed the resident on a transfer sling, connected the sling hoops to the mechanical lift and raised the resident off of the bed with the mechanical lift. The mechanical lift was moved away from the bed to place the resident in the wheelchair. The staff failed to spread the legs of the mechanical lift to the widest position and lock the legs in place before moving the mechanical lift away from the bed surface leaving the resident to dangle in the air. STNA #2, who was also a medical records person, then walked around the resident ' s bed and instructed STNA #1 and #3 that they forgot to widen the legs of the mechanical lift and lock them in place. The resident was then lowered down into the wheelchair without the wheelchair brakes locked. Interview of STNA's #1, #2 and #3 verified the legs of the lift device should have been widened to the widest position and locked in place prior to moving the mechanical lift away from the bed to prevent the device from tipping over and this action put Resident #23 at risk for injury. The three STNA ' s verified the device was used improperly and the legs of the device should have remained in a widened and locked position until Resident #23 was safely lowered into the wheelchair. The lift was checked for allowance of the legs of the lift to remain in the widest open position while moving the device away from the bed and it was able to be moved away from the bed in the correct position. This finding was verified by all three STNA ' s. Review of the staff education on the use of a mechanical lift presented on 05/26/13 revealed the instruction was to spread the legs of the lift to the widest open position and lock the wheels before raising the resident. Review of the mechanical lift manufacturing instruction revealed the device was model Reliant 600 and the manufacture instruction sheet includes necessary to widen the legs to the widest position and the shifter handle locked in place for optimum stability and safety. If necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. Review of the facility policy " Lifting Machine, Using a Portable " dated revised October 2010, revealed the wheelchair wheels were to be locked and open the leg of the lifting machine prior to lifting the resident off the bed. This deficiency is a recite to Complaint Number OH 913 completed on 07/11/13.

Based on record review, policy review, family and staff interview, the facility failed to provide adequate and necessary care and services to manage Resident #20's skin conditions. Actual harm occurred to Resident #20 with the deterioration and development of venous stasis [MEDICAL CONDITION], skin sloughing, [MEDICAL CONDITION], pain, and admission to the hospital. This affected one resident (Resident #20) of three residents reviewed. This affected one resident (Resident #20) of three residents reviewed. The facility census was 77. Findings include: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Weekly body audit sheets were reviewed as completed on 05/08, 05/12, 05/15, and 05/26/13. There was no mention of any [MEDICAL CONDITION] being present to the lower extremities at the time the audits were completed. The nurse's progress notes were reviewed from 05/07/13 to 05/29/13 and did not include any documentation of [MEDICAL CONDITION] being noted in the resident's lower extremities. A nurse's note dated 05/29/13 revealed the resident's daughter visited and voiced concern that the resident's lower extremities were more swollen and she had complaints of pain. The resident's physician was contacted and gave an order to send the resident to the emergency room for an evaluation. She was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. She received intravenous antibiotics and returned to the facility on [DATE] with antibiotics ordered by mouth for an additional 14 days. The re-admission orders [REDACTED]. The resident would also need compression wrapping on her lower extremities bilaterally in one week once her skin infection was resolved. The admission orders [REDACTED]. Record review revealed the orders were not put on the treatment administration record to show documented evidence these treatments were consistently being done. A weekly body audit completed on 06/04/13, upon the resident's return from the hospital indicated her bilateral lower extremities were swollen with blisters on the outer right ankle area. There was no indication at that time of the resident having a fluid filled blister to the outer aspect of her right lower leg just below the knee. Review of the nurses' notes between 06/04/13 and 06/10/13 revealed there were no comprehensive assessments of the resident's [MEDICAL CONDITION] of the lower extremities. Nursing documentation during that time only indicated that the resident continued to receive her antibiotics without adverse effects. There was no evidence that the nurse's were assessing the resident's legs for the presence of increased [MEDICAL CONDITION], if the [MEDICAL CONDITION] was pitting or non-pitting, or if there had been any redness or increased warmth noted with her lower extremities. There was also no documentation on the status of the fluid filled blisters that were noted on the resident's right outer ankle area that was present upon her re-admission to the facility. No concerns were noted by the facility nurses until 06/10/13 when the resident's daughter again visited the facility and reported that she had noted and was concerned with the increased swelling, open area to the outer aspect of the right lower leg and increased pain in her right leg. At the direction of the daughter the facility nurse contacted the resident's physician and was given the order to send the resident back to the hospital. An interview with Resident #20's family member on 06/10/13 at 12:40 P.M. revealed she was concerned that the resident was not receiving the care and assistance she needed in regards to her [MEDICAL CONDITION] of the lower extremities. She stated both times the resident had to be sent out to the hospital was at her request. She stated the facility staff had not updated her on the condition of the resident's legs when increased [MEDICAL CONDITION] with redness was noted, when she had increased pain or when the open area developed. She stated it did not seem like anyone was checking her or was concerned of the condition of her legs. She reported the resident was a diabetic and any issues she had with her lower extremities needed to be addressed promptly. Review of the facility's policy on change in a resident's condition or status that was revised April 2011 revealed it was the policy of the facility to promptly notify the resident, her attending physician, and representative of changes in the resident's medical condition. The nurse supervisor or charge nurse would notify the resident's attending physician if there was a significant change in the resident's medical condition or a need to alter the resident's medical condition significantly. An interview with STNA #5 on 06/10/13 at 2:35 P.M. revealed she had noted a fluid filled blister to the resident's outer right lower leg on Saturday 06/08/13. She stated she reported it to the nurse when it was noted. An interview with LPN #8 on 06/11/13 at 9:05 A.M. revealed he had worked the 3-11 shift on 06/08/12. He reported he did not typically work the hall where the resident resided so that was the first he had seen of her lower extremities. He indicated he had been given report from another nurse that the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] of the lower extremities. He stated he was only in the resident's room for a brief time on Saturday to give her medication. The resident was not in a good mood so he did not stay long. He denied that he had seen the fluid filled blister that was reported to have been seen by STNA #5. He denied that STNA #5 told him anything about a fluid filled blister she had noted on that shift. He did report there was weeping from the resident's right leg when he saw her on Saturday. He denied that it was a large amount but indicated it did saturate some of the sock she was wearing. He denied that he had updated the physician about the weeping drainage that came from the resident's right leg. He denied that he saw any type of open area at that time. The nurse's note for 06/08/13 did not include any documentation of a fluid filled blister being present on the outer aspect of the resident's right lower leg. There was also no documentation of the weeping drainage that was noted from the right leg. There was no evidence the physician or the family had been notified of the changes in the condition of the right lower extremity. A nurse's note dated 06/10/13 at 5:23 P.M. that was entered after the resident was sent to the hospital revealed the nurse had been notified of the blister on the resident's lower right extremity that morning. The nurse documented that an aide had reported it as being there over the weekend and was just told to be careful with it when dressing her. The resident was admitted to the hospital on [DATE] for more intravenous antibiotics. An emergency department encounter report dated 06/10/13 revealed the resident's chief complaint was leg pain. The leg pain was noted to have worsened and was not being controlled by the ordered pain medication. A family practice medical resident from the hospital, who was familiar with the resident from her prior admission, was asked to evaluate the status of her legs. The family practice medical resident indicated the legs were more red and were warmer to the touch than they previously were. A history and physical dated 06/10/13, that was completed at the hospital, revealed the [MEDICAL CONDITION] of the resident's lower extremity had shown improvement initially at the nursing facility but over the weekend became more swollen with worsening of her pain. The assessment of her legs indicated she had venous stasis [MEDICAL CONDITION], an erythemetous right lower extremity and skin that was sloughing off on the back side of her calf. Interview with the director of nursing (DON) on 06/11/13 at 8:10 A.M. confirmed there was no documentation from the nurses that reflected comprehensive assessments and monitoring of the resident's lower extremities when she was known to be receiving antibiotic treatment for [REDACTED]. She acknowledged there was no documentation in the nurse's notes of the facility updating the physician when the [MEDICAL CONDITION] had worsened. She agreed it should not have been the responsibility of the resident's daughter to monitor the condition of the resident's leg and insist when the resident's physician be contacted for treatment or transfers when the need arose. This deficiency substantiates Complaint Number OH 511.

Based on record review, staff interview, interview of the consultant Dietary Technician and review of the facility's Weight Assessment and Intervention Policy, the facility failed to ensure one of three residents reviewed for weight loss received nutritional supplements to support maintenance of his body weight and protein levels (Resident #202). The facility identified three residents with unplanned weight loss. The census was 74. Harm occurred when Resident #202's dietary supplements were not ordered or administered and the resident lost fifteen percent of his body weight in a two week period. Findings include: Record review for Resident #202 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS)assessment, dated 02/19/13, revealed a Brief Interview for Mental Status score of 15/15 (intact cognition). The MDS further revealed the resident required extensive assistance for activities of daily living, required supervision with eating, and had unhealed pressure ulcers (left knee stump site and left buttock). Review of the hospital Continuity of Care Transfer Form dated 02/12/13 revealed the resident was to receive a heart healthy diet and add two cans of Ensure (a high protein, high calorie nutritional supplement) daily. Review of the Individual Resident Care Plan dated upon admission 02/12/13, revealed in the area of nutritional status/special needs, Resident #202 was to receive Ensure (a high calorie, high protein supplement) two cans every day. Review of laboratory blood values drawn 02/14/13 revealed Resident #202 had a low total protein level of 5.9 grams per deciliter (g/dl) Normal values 6.0-8.3 g/dl and a low [MEDICATION NAME] level (protein indicator of nutritional status) of 2.7 g/dl. Normal values 3.5-5.5 g/dl. Review of a Certified Nurse Practitioner (CNP) Examination Form dated 02/19/13 revealed Resident #202 had a history of [REDACTED]. The exam further revealed the resident had a poor appetite/[MEDICAL CONDITION] and received [MEDICATION NAME] (an antidepressant often used also as an appetite stimulant). Review of a Comprehensive Nutritional assessment dated [DATE] revealed Resident #202 had a diet order for a low salt, high protein diet with a protein supplement (Prostat) 30 milliliters (ml) three times a day. The assessment documented the resident's weight as 113.2 pounds. The assessment revealed the resident triggered for an insidious weight loss of 5.3 pounds or 4.4% of his body weight since his hospitalization . The assessment identified the resident's meal intakes from 50-75% with the resident reporting he had no appetite. The assessment noted the resident had skin breakdown to his anal opening, left knee and right buttock. The assessment further revealed the resident has inadequate energy intake related to his current meal intakes and consultant Dietary Technician (DT) #1 recommended to decrease the Prostat to 30 ml. twice a day and add Med Pass 2.0 (a high calorie, high protein supplement) 120 ml twice a day for added support in weight stabilization as well as wound healing. Review of physician orders [REDACTED]. Further review of physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#202 had received any nutritional supplementation (either the Ensure from the hospital continuity admission record recommendations or the Med Pass 2.0 supplement as recommended by consultant DT #1 on 02/21/13. There was no evidence Resident #202 received the Prostat protein supplement twice a day as ordered. Review of the next dietary health status progress note, dated 02/27/13, revealed Resident #202 had a decline in meal intakes and was refusing meals, at most consuming 50% of his meals. The progress note further revealed the resident had multiple skin breakdown areas. The progress note revealed DT #1 was recommending to add Med Pass 120 ml three times a day and to continue to monitor. Phone interview with consultant DT #1 on 03/25/13 at 3:30 P.M. revealed she makes recommendation (related to diet changes/supplements) to the physician on a fax sheet and gives this to the unit nurse to fax to the physician. DT #1 further stated she could not say for sure or recall if she was aware Resident #202 had not been receiving any nutritional supplement (Ensure or the Med Pass 2.0) from his admission to the time of her second assessment and new recommendations on 02/27/13. Review of food intake records for Resident #202 from 02/13/13 through the breakfast meal on 02/28/13 revealed of 40 documented meal intakes Resident #202 consumed 100% of his meal on 3 occasions, 51-75% of his meal on 12 occasions, 26-50% of his meal on 13 occasions, refused his meal on 3 occasions and consumed 0% of his meal on 9 occasions. Review of the weight record for Resident #202 revealed he weighed 113.2 pounds the day after admission to the facility, 02/13/13. He refused to be weighed on 02/20/13 and weighed 96 pounds on 02/26/13, which was a loss of 17.2 pounds in 2 weeks. This weight loss indicated a 15% of the resident's body weight. Further record review revealed no evidence the facility had attempted again to re-weigh the resident after his refusal on 02/20/13. Interview with the Director of Nursing (DON) on 03/25/13 at 2:45 P.M. and 4:15 P.M. verified there was no evidence Resident #202 had received any Ensure or Med Pass 2.0 dietary supplementation from his admission on 02/12/13 through his discharge on 02/28/13. The DON further verified there was no evidence Resident #202 had received the Prostat as ordered by the physician on 02/13/13. The DON stated the dietary recommendation by the consultant DT #1 had been faxed to the physician and ordered. However, the facility did not receive the orders back from the physician before the resident's discharge on 02/28/13. The DON verified the facility did not follow up to the fax to ensure it was addressed by the physician. The DON further verified there was no evidence the facility attempted to obtain another weight on Resident #202 after his refusal on 02/20/13 and his next weight wasn't obtained until 02/27/13. Review of the facility Weight Assessment and Intervention Policy (Revised April 2012) revealed nursing staff would measure resident's weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns were noted at that point, weights would be measured monthly thereafter. Interventions for undesirable weight loss were to be based on careful consideration which included the use of supplementation.

Based on observation, staff interview, review of clinical records, review of Executive Director Documentation and facility investigation, and review of the facility's Abuse Policy, the facility failed to ensure residents were free from staff abuse. This affected one of 10 sampled residents (Resident #42) of the 79 residents residing in the facility. Harm occurred when Resident #42 sustained a [MEDICAL CONDITION] metacarpal, received a cast, and was medicated for pain after being physically abused by a facility staff member. Findings include: Review of the clinical record for Resident #42 revealed the resident was extremely hard of hearing and had a [DIAGNOSES REDACTED]. Review of progress notes dated 03/06/11 at 9:45 A.M., revealed the resident reported to Licensed Practical Nurse (LPN) #50, "He took my tray and hurt my hand" referring to state tested nurse aide (STNA) #30. The documentation noted no apparent injury. A second note at 2:03 P.M. by LPN #50 revealed the resident continued to state, "He hurt my hand." The note documented the right thumb with light blue and red bruising, was swollen, but the resident was able to move it. An x-ray was obtained, and the results returned on 03/06/11 at 5:05 P.M. revealed negative results for fracture. Review of a progress note dated 03/07/11 at 2:28 A.M. revealed Resident #42 was seated in a wheelchair and the resident's right hand was swollen. The dark blue bruising continued. The resident did not voice complaint of pain, but pulled hand away when the nurse attempted to touch. The resident continued to say, "He grabbed my hand when I was eating." Review of documentation dated 03/07/11 at 6:00 A.M. revealed the resident was up in the bathroom and requested a pain shot. The resident was administered Tylenol 650 milligrams (mg). She did not have orders at that time for stronger medication. Resident #42 was crying and holding her right hand. Documentation by LPN #80 on 03/07/11 at 7:00 A.M. clarified the left hand and thumb area remained swollen with bruising, not the right hand as previously documented. A progress note dated 03/07/11 at 3:54 P.M. by LPN #90 revealed bruising and swelling was present to left hand. The resident complained of pain when touched and pain to the left shoulder with movement. The certified nurse practitioner assessed Resident #42 and ordered an x-ray to the left shoulder, arm and hand; apply ice to area and [MEDICATION NAME] (opioid [MEDICATION NAME]) for pain. The x-ray was performed on 03/07/11 at 1:30 P.M. The note dated 03/07/11 at 11:48 P.M. by LPN #11 revealed the x-ray results were negative. According to LPN #11's assessment at that time the left hand was totally bruised and was red/purple in color with swelling. On 03/08/11 at 6:43 A.M., documentation by LPN #80 revealed the resident was seated in a wheelchair, was alert and oriented to time, date, and place, and was holding her left hand in her lap. Swelling and bruising continued to the left hand. Resident #42 would not let the nurse touch the area. On 03/09/11 at 2:23 P.M., Director of Nursing (DON) #103 documented an assessment of Resident #42's left hand. The resident's first knuckle of each finger was [MEDICAL CONDITION] (swollen) and red. The skin was shiny. The knuckles of her left hand were significantly [MEDICAL CONDITION]. The palm of the hand was significant for discoloration. The resident was unable to make a fist. DON #103's assessment was reported to the physician, who ordered Resident #42 be sent to the emergency room . The resident was transported to the emergency room at 3:55 P.M. Review of a progress noted completed by LPN #109 revealed Resident #42 returned to the facility on [DATE] at 7:15 P.M. with [DIAGNOSES REDACTED]. An appointment was arranged for an orthopedic consult on 03/11/11 at 9:20 A.M. On 03/11/11 at 1:56 P.M., documentation by LPN #90 revealed Resident #42 returned from the orthopedic appointment with a cast to the left hand. Review of the Executive Director Documentation revealed STNA #30 was terminated on 03/10/11 for suspicion of physical abuse. According to the facility's investigation, "it was determined that actual physical harm occurred to the resident as a result of (STNA #30's) actions." On 03/12/11 at 10:35 A.M., observation of Resident #42 revealed a cast was intact to the left hand/wrist area. Swelling of the fingers was noted. On 03/12/11 at 10:40 A.M., interview of STNA #20 revealed Resident #42 reported to her last Sunday (03/06/11) that STNA #30 twisted her arm. STNA #20 stated she immediately reported this allegation to the nurse. On 03/12/11 at 11:35 A.M., interview of LPN #40 revealed Resident #42 was a very reliable witness. LPN #40 verified she administered pain medication to Resident #42 at 11:35 A.M. on 03/12/11 for a pain level of 10 out of 10 to the left hand. On 03/12/11 at 1:00 P.M., the Administrator confirmed all information and copies provided regarding the investigation were correct. The Administrator confirmed STNA #30 was terminated on 03/10/11. Review of the facility's Resident Protection Policy and Procedure, dated June 2009, revealed the policy defined physical abuse included, but was not limited to, hitting, slapping, pushing and kicking. Physical abuse also included controlling behavior through corporal punishment.

Based on medical record review, observation, review of policy's and procedures, and staff interview, the facility failed to ensure the residential environment was free of accidental hazards as possible in regard to ill fitting shoes and sensor devices not being applied as ordered (Resident #50), improper oxygen storage on 100 Hall (Residents, #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11), failed to ensure chemicals were securely locked in the central bath between the 200-400 hall. This had the potential to affect 18 of 36 residents who were identified as independently mobile and cognitively impaired (Residents #12, #13, #14, #17, #18, #19, #22, #36, #37, #39, #40, #42, #43, #45, #46, #62, #64, and #84). The facility failed to ensure biohazardous waste and other chemical agents were contained and failed to ensure hot water temperatures were within an acceptable temperature range in the dining room. This had the potential to affect 24 of 85 residents who were identified as cognitively impaired and independently ambulatory (Residents #1, #3, #12, #13, #14, #17, #18, #19, #22, #26, #35, #36, #37, #39, #40, #42, #43, #45, #46, #62, #64, #77, #79, and #84). Harm occurred to Resident #50 on 04/05/10 when the facility failed to ensure the resident wore proper fitting shoes/slippers, which resulted in a fall, and Resident #50 suffered a fractured hip. Findings include: 1a. Record review for Resident #50 revealed the resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#50 had short-term and long-term memory deficits and had moderately impaired decision-making ability. The resident was identified as independent with walking and required supervision and set-up with dressing self. Review of Resident #50's Fall Risk assessment dated [DATE] revealed the resident scored a 15, which indicated the resident was at high risk for falls. Review of Resident #50's Falls plan of care with an initiation date of 08/31/09 revealed the resident had physical and cognitive limitations and had a history of [REDACTED]. The plan of care revealed the resident was at risk for injury related to falls. Interventions listed on the falls plan of care dated 03/31/09 directed to make sure resident footwear was appropriate prior to ambulation and transfers. Review of Resident #50's nurses' notes revealed a fall occurred on 04/03/10. The nurses' notes completed by Licensed Practical Nurse (LPN) #12 on 04/03/10 at 12:54 P.M., revealed the resident was observed by a State-tested nurse aide (STNA) lying on her left side. The resident's right shoe was off. The resident's wheelchair was in front of the resident. The nurse's note revealed the resident stated I was going to my room my foot caught here (pointing down to the carpet) and I fell . Review of Resident #50's Post Fall Investigation dated 04/03/10 revealed the resident had a fall. The resident was identified as alert, confused, and had poor vision. The investigation revealed the resident was not wearing appropriate foot wear. It stated the footwear was loose and oversized. The resident refused to take them off. The investigation revealed what most likely caused the fall was that the resident was observed not wearing her glasses. The investigation revealed the immediate intervention put into place specific to the cause of the fall, was patient education was provided to ensure glasses were worn at all times, and for the STNAs to report to the nurse if the patient refused to wear her glasses. Review of the investigation summary completed by the director of nursing (DON), dated 04/03/10, revealed the reason for the fall was that staff indicated Resident #50's slippers were loose. The intervention documented was that LPN #17 called Resident #50's family member regarding her shoes not fitting appropriately. Review of the nurses' notes dated 04/05/10 by LPN #17 at 5:00 P.M. revealed the resident fell . The resident landed on her buttocks beside her wheelchair. The resident complained of right hip pain, and had inward rotation of the right foot, and slight shortening of the right leg, with an abnormal bulge to the right outer hip. Nurses' notes dated 04/05/10 at 5:02 P.M. revealed the resident's doctor was notified and an order was obtained to sent out to the emergency room for evaluation. Review of the emergency room History and Physical dated 04/05/10 revealed the resident was noted to have a right intertrochanteric hip fracture. Review of Resident #50's Post Fall Investigation completed on 04/05/10 revealed the resident had a fall and the resident was confused. The investigation revealed the resident lost her balance and tripped on over-sized shoes. The investigation revealed that what most likely caused the fall was the resident stumbled in over-sized slippers and fell to the floor. Review of the investigation summary completed by the DON dated 04/05/10 revealed the reason for the fall was that staff indicated Resident #50's shoes were too big. It was noted under intervention the family would be notified again of shoes that Resident #50's slippers/shoes did not fit properly. It was noted under Additional Risk Factors that Resident #50 was identified as having shoes that were too large and LPN #17 called Resident #50's family to notify them of the shoes not fitting appropriately. It was noted the shoes were not removed from Resident #50's room. On 12/07/10 at 1:35 P.M., interview with the DON confirmed Resident # 50 had a fall on 04/03/10 and it was documented due to poor fitting shoes, and poor vision due to not wearing her glasses. The DON stated the family was notified that Resident #50's shoes did not fit appropriately. The DON confirmed the resident's shoes were not removed from the resident's room. The DON stated she was not sure why the shoes were not changed or removed; however, she stated it was the resident's right to keep them. The DON confirmed Resident #50 then had a fall on 04/05/10. It was noted the fall was related to shoes being oversized. Review of the facility's policy for Accident/Incident reports (dated September 1999) revealed at the time of an accident/incident, nursing was responsible for narrative notation in the medical record describe in the incident/accident as well as prompt follow up action and notification. 1b. Medical record review for Resident #50 revealed the resident had a physician's orders [REDACTED]. On 12/06/10 at 8:30 A.M. and 8:45 A.M., observation of Resident #50 revealed she was seated in her wheelchair in the dining room without a sensor alarm applied as ordered. On 12/06/10 at 8:45 A.M., interview with Activity Director #14 confirmed Resident #50 did not have a sensor alarm applied as ordered. 2. On 12/05/10 at 10:16 A.M., the surveyor observed an oxygen cylinder in Room 111 by Resident #33's wall. The oxygen cylinder was unsecured. On 12/05/10 at 10:16 A.M., this finding was verified during interview with LPN #3. This could potentially affect residents who resided on the 100 hall (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10). 3. On 12/05/10 at 1:43 P.M. the surveyor observed in the 200-400 hall central bath an unlocked closet that contained the following; a. One can of glass cleaner with a warning label that read keep out of reach of children. b. Sixteen bottles of after shave with a warning label that read keep out of reach of children. c. Four and a half boxes of deluxe twin blade razors. On 12/05/10 at 1:47 P.M., this finding was verified during interview of Registered Nurse (RN) #2. This could potentially affect independently mobile cognitively impaired residents (Residents #12, #13, #14, #17, #18, #19, #22, #36, #37, #39, #40, #42, #43, #45, #46, #62, #64, and #84). 4. On 12/08/10 at 9:05 A.M., during environmental rounds with Maintenance Supervisor (MS) #5, observation of an unlocked janitor's closet at the beginning of the 100 Hall revealed the following: a. Two black plastic totes containing biohazardous waste/filled sharps containers b. A 3.5 gallon plastic container of Mapi floor/wall tile adhesive labeled fatal if swallowed and caused eye/skin/respiratory irritation. At the time of the observation, MS #5 verified the above findings. 5. On 12/08/10 at 9:50 A.M., during environmental rounds with MS #5 and the administrator, the surveyor observed a sink in the unlocked main dining room. The hot water in the sink was 128 degrees Fahrenheit. At the time of the observation, MS #5 verified the hot water temperature. He turned the sink's individual 10-gallon water heater's temperature back and let the water run. On 12/08/10 at 9:55 A.M., the recheck of the hot water temperature was 119 degrees Fahrenheit. Interview with MS #5 revealed he did not routinely check the water temperature in the sink in the main dining room. This had the potential to affect 24 of 85 residents who were identified as cognitively impaired and independently ambulatory (Residents #1, #3, #12, #13, #14, #17, #18, #19, #22, #26, #35, #36, #37, #39, #40, #42, #43, #45, #46, #62, #64, #77, #79, and #84).