Every finding on record at Embassy of Logan

Based on observation, interview, record review, review of Centers of Disease Control (CDC) website and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) were implemented. This affected one resident (#49) of one residents observed for wound care. The facility census was 94.Findings include: Review of Resident #49's medical record revealed an admission date of 04/21/26 and diagnoses including asthma, atrial fibrillation, dementia, hypertension and hypothyroidism.Review of Resident #49's significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had severely impaired cognition, and was dependent on facility staff for all activities of daily living except eating.Review of Resident #49's nursing progress note dated 07/22/26 at 5:22 P.M. written by the Assistant Director of Nursing, revealed the resident returned from mohs surgery (procedure where the surgeon removes thin layers of cancer containing skin, one layer at a time, and examines them under a microscope until no cancer remains) to the left lower extremity (LLE).Review of Resident #49's physician orders reveled an order dated 08/07/26 for gentamicin sulfate external cream 0.1% apply to surgical site topically every shift for healing. Clean wound with wound cleanser and a clean cotton swab for debridement, cover with a non-stick dressing after application every shift until healed. Further review revealed no orders for EBP due to the resident's wound.Review of the resident's care plan revealed no care plan related to EBP.Review of Resident #49's non-pressure skin grid dated 08/17/26 revealed the resident had a surgical incision to her left lower leg that was 2 centimeters (cm) in length, 2.1 cm in width and 0.2 cm in depth.An observation of wound care on 08/20/26 at 11:30 A.M. revealed the surgical wound dressing was removed and the area cleansed and re-dressed as per physicians order by Registered Nurse (RN) #212. RN #212 wore gloves during the procedure but did not wear a gown. Further observation revealed no signage was observed outside of the resident's room or gowns available for staff to alert them of the need for EBP.In an interview on 08/20/26 at 11:30 A.M. RN #212 confirmed that she did not wear a gown during wound care and that Resident #49 was not on enhanced barrier precautions despite having a wound.Review of the facility policy titled Enhanced Barrier Precautions, date 07/13/22, revealed that residents with wounds would be placed on enhanced barrier precautions. Review of the cdc.gov website revealed Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation, interview and record review the facility failed to develop a comprehensive care plan to address Resident #6's chewing behavior. This affected one resident (#6) of seven residents reviewed for care planning. The facility census was 94.Findings include: Review of Resident #6's medical records revealed an admission date of 02/17/25 and diagnoses including Alzheimer's disease, dysphagia, hypothyroidism, and major depressive disorder.Review of Resident #6's behavior care plan initiated on 02/17/25 revealed no mention of the resident's behavior of chewing on objects in her near vicinity or her use of an oral motor tool (a safe object used for persons who chew on clothing or other objects).Review of Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and was dependent on facility staff assistance with all of her activities of daily livingAn observation on 08/19/26 at 3:30 P.M. revealed Resident #6 reclined in a Broda chair (special reclining chair with wheels) chewing on the edge of a bath blanket. Licensed Practical Nurse (LPN) #217 removed the blanket from the resident's mouth and noted the resident had a three-inch wide and two-inch-long part of the blanket edge in her mouth. LPN #217 held the resident's hands and provided one on one to the resident while other staff looked for her oral motor tool. While LPN #217 was holding the resident's hands, the resident tried to continually pull LPN #217's hand to her open mouth while making chewing movements with her mouth.In an interview at the time of the observation LPN #217 confirmed Resident #6 was pulling the LPN's hand toward her open mouth and stated that the resident was usually chewing on something. LPN #217 verified this was normal behavior for Resident #6. In an interview on 08/20/26 at 2:50 P.M. the Director of Nursing verified Resident #6 did not have a care plan addressing the sensory seeking behavior of chewing on objects.This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation, staff interview, and facility policy and procedure, the facility failed to prepare and serve food under sanitary conditions. This had the potential to affect the 92 of 92 residents who receive trays from the kitchen. The census was 92. Findings include: On 03/17/2026 at 10:33 A.M. Observation of the kitchen revealed the confection oven with food splatter and food crumbs. A container under the steam table with food debris, the wall behind the plate warmer with dust and dirt build up. The wall behind the table with the toaster with dried food splatter. 03/18/2026 at 2:20 P.M. observation of the kitchen with Dietary Manager #109 revealed the hanging electrical outlet over the serving line had a built up of dust hanging on it, and on the air conditioning unit. The trash can be beside the confection oven and in the dish washing area with no lid on them. The stove with dried food debris and splatter on it. The shelf under the tray line with crumbs and food debris on it. This was verified at the time of the observation with Dietary Manager #109. Review of Sanitary Conditions policy and procedure not dated revealed all equipment will be maintained in a clean and sanitary fashion. This deficiency represents non-compliance investigated under Complaint Number 2696142.

Based on interviews, observation, policy and audit reviews, the facility failed to ensure water temperatures did not exceed 120 degrees Fahrenheit (F) in the shower rooms on hallways 200 and 400. This had the potential to affect 42 residents (200 Hallway-Resident #51, Resident #27, Resident #64, Resident #39, Resident #15, Resident #33, Resident #89, Resident #41, Resident #45, Resident #85, Resident #34, Resident #79, Resident #08, Resident #54, Resident #01, Resident #40, Resident #23, Resident #36, Resident #12, and Resident #72. 400 Hallway-Resident #65, Resident #29, Resident #20, Resident #77, Resident #71, Resident #92, Resident #58, Resident #26, Resident #81, Resident #07, Resident #67, Resident #18, Resident # 74, Resident #93, Resident #101, Resident #75, Resident #48, Resident #80, Resident # 52, Resident #82, Resident #04, and Resident #69). The census was 92.Review of facilities audit conducted of water temperature log from January 2026-March 2026 revealed documented water temperatures were above 120 degrees F on 03/09/26, 03/02/26, 02/23/26, 02/19/26, 02/09/26, 02/02/26, 01/26/26, 01/19/26, 01/12/26 and 01/05/26 on multiple hallways. On 03/18/26 at 11:27 A.M. interview with Associate #178 confirmed documented water temperatures were above 120 degrees F. On 03/18/26 at 11:45 A.M. observation of shower room water temperatures taken by Associate #125 revealed that Hallway 100 temperature was 113.4 degrees F, hallway 200 was 131.0 degrees F, hallway 300 was 112.7 degrees F, hallway 400 was 122.8 degrees F, hallway 600 was 109.2 degrees F and hallway 700 was 115.0 degrees F.On 03/19/26 at 10:00 A.M. review of Safe Water Temperatures Policy dated 03/01/25 revealed water temperatures will be set to a temperature of no more than 120 degrees F.

Based on observation, medical record review and interview, the facility failed to maintain a complete and accurate medical record. This affected three residents (#5, #9 and #12) of 19 sampled residents. The facility census was 92. Findings Included:1. Review of the resident's medical record for Resident #9 revealed an initial admission date of 02/17/21 with the latest readmission date of 08/03/21 with the diagnoses including but not limited to polyneuropathy, chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, speech disturbances, anxiety disorder, schizophrenia, hyperlipidemia, dry eye syndrome, GERD, PTSD, major depressive disorder, BPH and insomnia. Review of the plan of care dated 11/28/25 revealed the resident had impaired skin integrity related to a skin tear to the left outer knee. Interventions included air mattress to promote skin integrity, check patency every shift, encourage resident to elevate feet while in chair, encourage to turn and reposition every two hours, evaluate wound related pain, pre-medicate prior to dressing changes as needed, notify physician if changes are noted to the wound, weekly wound measurements and documentation on wound appearance, drainage and surrounding tissue and wound treatment as ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was dependent on staff for activities of daily living (ADL). The assessment indicated the resident was at risk for skin breakdown and had skin tears. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problem, application of nonsurgical dressing other than to feet and application of ointments/medication to feet. Review of the progress note dated 11/28/25 at 2:00 P.M. revealed the resident was found to have a skin tear to the left lower anterior leg. The area has some redness and drainage measuring 2.0 centimeters (cm) by 1.5 cm by 0.1 cm. The resident was found to have caused the skin tear by moving his legs while sitting in a wheelchair. Review of the initial weekly non-pressure skin grid dated 11/28/25 revealed the resident was found to have a skin tear to the left anterior leg measuring 2.0 cm by 1.5 cm by 0.1 cm with a scant amount of drainage. The wound was described as resident has open area noted with some drainage. no signs/symptoms of infection noted, outer knee area. Review of the weekly non-pressure skin grid dated 12/01/25 revealed the skin tear to the left anterior shin measured 2.0 cm by 1.5 cm by 0.1 cm with some drainage. Review of the weekly non-pressure skin grid dated 12/08/25 revealed the skin tear to the left anterior shin measured 2.0 cm by 1.5 cm by 0.1 cm with some drainage. The facility determined the wound was unchanged. Review of the weekly non-pressure skin grid dated 12/11/25 revealed the skin tear to the left anterior shin measured 1.0 cm by 1.5 cm by 0.1 cm with some drainage. The facility determined the wound was unchanged. Review of the weekly Wound Nurse Practitioner (WNP) progress note from 12/19/25 to 03/11/25 documented the skin tear to the resident's left lateral leg on his right lateral leg. Review of the resident's monthly physician orders for March 2026 identified orders dated 03/06/26 cleanse left lower leg skin alteration with in-house wound cleanser or normal saline, pat dry, apply mupirocin, cover with calcium alginate and cover with dry clean dressing daily and as needed. On 03/17/26 at 2:12 P.M., an interview with Licensed Practical Nurse (LPN) #114 verified the resident's skin tear was on the left lateral leg and not on the right lateral leg. She verified the WNP documentation was not accurate to reflect the actual location of the skin tear being treated. On 03/18/26 at 9:02 A.M., observation of LPN #112 and #114 provide the physician ordered treatment to Resident #9's skin tear to his left outer leg revealed a quarter size wound with a reddish wound bed. No concerns were observed with the dressing change. 2. Review of the medical record for Resident #12 revealed an initial admission date of 04/11/24 with the diagnoses including but limited to cerebrovascular accident, diabetes mellitus, dementia, hyperlipidemia, obesity, gout, major depressive disorder, carotid artery syndrome, osteoarthritis, osteoporosis, peripheral vascular disease, hammer toes, chronic pain, schizoaffective disorder, bipolar type, generalized epilepsy, hypothyroidism, anxiety disorder, anemia and Rheumatoid arthritis. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had no issues with her teeth. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had no mouth or facial pain, discomfort or difficulty chewing. Review of the medical record revealed the resident had refused dental services on 09/19/24. Review of the medical record revealed the resident had no documented evidence the resident was seen by a dentist since being admitted to the facility. Review of the plan of care dated 03/17/26 revealed the resident is at risk for dental or chewing problems related to poor dental hygiene. Interventions include apply lip balm/ moisturizer to lips as needed, arrange for periodic dental consult, assist as needed with oral hygiene, including denture care if applicable, diet as ordered by the physician, discuss food preferences and attempt to incorporate them in the special diet, encourage resident to report any oral discomfort, follow up visits by dentistry as scheduled and as needed with coordinating pain management if needed and may use dental swabs if unable to tolerate toothbrush. Review of the dental visit provided by the facility contracted dental assistant revealed the resident was seen on 07/17/25 for her annual visit. The resident's teeth were cleaned and a silver diamine fluoride was applied to several teeth with the intent to arrest decay and prevent further decay. A follow-up appointment would be based on insurance. On 03/18/26 at 2:00 P.M., an interview with the Licensed Social Worker (LSW) #216 revealed the 07/17/25 was probably in an email somewhere. She verified the dental progress noted was not on the resident's medical record. 3. Review of the medical record for Resident #5 revealed an admission date of 10/31/25 and diagnoses of cerebral infarction, unspecified and unspecified asthma, uncomplicated. Resident #5 was admitted to Buckeye Hospice on 02/05/26. On 03/17/26 at 3:00 P.M. interview with Associate #178 confirmed hospice documentation is not uploaded in resident medical record. Associate #178 confirmed hospice documentation is available in email. Email request sent at 3:11 P.M. Hospice documentation provided. On 03/18/26 at 8:40 A.M. interview with Associate #157 confirmed medical records position was eliminated and there are resident documents in emails that have not been uploaded to medical records. On 03/19/26 at 10:14 A.M. interview with Associate #178 revealed no medical records policy addressing completeness of medical records exists. This deficiency represents non-compliance investigated under Complaint Number 2629172.

Based on interviews, and record review, the facility failed to follow up on appropriate and timely completion regarding correct eyeglass prescription. This affected one resident (Resident #11) of two residents reviewed for activities of daily living. The census was 92.Review of the medical record for Resident #11 revealed an admission date of 04/30/25. Diagnoses include schizoaffective disorder and chronic obstructive pulmonary disease (COPD). Further review of the medical record revealed Resident #11's eyeglasses were obtained while at the facility and added to Resident #11's inventory sheet on 09/19/25. Glasses adjustment by 360 Care completed on 11/04/25.On 03/16/26 interview with Resident #11 revealed eyeglasses are not the correct prescription, and I have told someone about this. On 03/17/26 at 2:10 P.M. interview with Associate #216 revealed 360 Care was supposed to be out 03/11/26 to see resident. Associate #216 presented documentation from 360 Care on 03/11/26 and glasses were adjusted. Resident said that he can't see out of the bifocal very well was documented in the note. Associate #216 confirmed there was no next step regarding Resident #11 eyeglasses.

Based on medical record review, interview and policy review the facility failed to follow physician recommended parameters for medication. This affected one resident (Resident #5) of five residents reviewed for unnecessary medication. The census was 92. Review of the medical record for Resident #5 revealed an admission date of 10/31/25 and diagnoses of cerebral infarction, unspecified and unspecified asthma, uncomplicated. Review of medical orders revealed an order from 01/30/26 for Metoprolol Tartrate Oral Tablet 25 milligrams (MG) oral tablet 25 MG (Metoprolol Tartate). Give 1.5 tablet by mouth two times a day for hypertension (HTN). Hold if static blood pressure (SBP) below 110 or heart rate (HR) below 60. Review of the medical administration record revealed no documented SBP or HR from 01/30/26-02/26/26. On 02/26/26 pharmacy recommended to give 1.5 tablet by mouth two times a day for hypertension (HTN). Hold if static blood pressure (SBP) below 110 or heart rate (HR) below 60. On 03/18/26 at 11:36 A.M. interview with Associate #114 confirmed medication should have been held on 03/10/26 evening dose and 03/11/26 morning and evening doses. On 03/19/26 at 1:56 P.M. interview with Associate #157 confirmed no SBP/HR documented from 01/30/26-02/26/26. On 03/19/26 review of Medication Administration Policy dated 08/22/22, revealed the facility is to obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. This deficiency represents non-compliance investigated under Complaint Number 2696141.

Based on interview, record review and policy review the facility failed to show documented evidence of resident and family participation in the care planning process. This affected one resident (#50) of one sampled for care planning. The facility census was 92. Findings include:Review of Resident #50's medical record revealed an admission date of 09/26/24 and diagnoses including dementia with behaviors, morbid obesity, diabetes, cirrhosis of the liver, hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of two out of 15 indicating the resident was severely cogitatively impaired. Further review of the MDS revealed Resident #50 used a wheelchair for mobility, required set up for eating, and was dependent on facility staff for all other activities of daily living.Further review of Resident #50's medical record revealed an undated invitation to a care conference on 12/16/25 at 10:00 A.M. However, no evidence of the care conference being held was present in the medical record.In an interview on 03/16/2026 at 10:37 A.M. Resident #50's husband revealed he did not remember having a care conference meeting with the facility at least once a quarter.In an interview on 03/17/2026 at 2:10 P.M. the Administrator revealed the care conference summary in the electronic health care record was not opened for the scheduled 12/16/25 care conference, so the facility had no evidence of care conference being held.Review of the policy titled Care Planning - Resident Participation undated revealed the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. Further review of the policy revealed the facility will obtain a signature from the resident and/or the resident's representative after discussion or viewing of the care plan.

Based on observation, medical record review, and interview, the facility failed to ensure the physician ordered treatment was implemented. This affected one resident (#9) of three residents reviewed for skin conditions. The facility census was 92. Findings Include:Review of the resident's medical record for Resident #9 revealed an initial admission date of 02/17/21 with the latest readmission date of 08/03/21 with the diagnoses including but not limited to polyneuropathy, chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, speech disturbances, anxiety disorder, schizophrenia, hyperlipidemia, dry eye syndrome, GERD, PTSD, major depressive disorder, BPH and insomnia. Review of the plan of care dated 11/28/25 revealed the resident had impaired skin integrity related to a skin tear to the left outer knee. Interventions included air mattress to promote skin integrity, check patency every shift, encourage resident to elevate feet while in chair, encourage to turn and reposition every two hours, evaluate wound related pain, pre-medicate prior to dressing changes as needed, notify physician if changes are noted to the wound, weekly wound measurements and documentation on wound appearance, drainage and surrounding tissue and wound treatment as ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was dependent on staff for activities of daily living (ADL). The assessment indicated the resident was at risk for skin breakdown and had skin tears. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problem, application of nonsurgical dressing other than to feet and application of ointments/medication to feet. Review of the progress note dated 11/28/25 at 2:00 P.M. revealed the resident was found to have a skin tear to the left lower anterior leg. The area has some redness and drainage measuring 2.0 centimeters (cm) by 1.5 cm by 0.1 cm. The resident was found to have caused the skin tear by moving his legs while sitting in a wheelchair. Review of the initial weekly non-pressure skin grid dated 11/28/25 revealed the resident was found to have a skin tear to the left anterior leg measuring 2.0 cm by 1.5 cm by 0.1 cm with a scant amount of drainage. The wound was described as resident has open area noted with some drainage. no signs/symptoms of infection noted, outer knee area. Review of the weekly non-pressure skin grid dated 12/01/25 revealed the skin tear to the left anterior shin measured 2.0 cm by 1.5 cm by 0.1 cm with some drainage. Review of the weekly non-pressure skin grid dated 12/08/25 revealed the skin tear to the left anterior shin measured 2.0 cm by 1.5 cm by 0.1 cm with some drainage. The facility determined the wound was unchanged. Review of the weekly non-pressure skin grid dated 12/11/25 revealed the skin tear to the left anterior shin measured 1.0 cm by 1.5 cm by 0.1 cm with some drainage. The facility determined the wound was unchanged. Review of the initial weekly Wound Nurse Practitioner (WNP) progress note dated 12/18/25 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 1.5 cm by 1.0 cm by 0.1 cm and described as 50% granulation and 50% slough. The wound had a moderate amount of serosanguinous exudate. The treatment was cleanse with normal saline, apply Medihoney and cover with bordered gauze dressing daily and as needed. Review of the weekly non-pressure skin grid dated 12/25/25 revealed the skin tear to the left anterior shin measured 1.0 cm by 1.2 cm by 0.1 cm with some drainage. The facility determined the wound had improved. Review of the weekly WNP progress note dated 12/31/25 revealed the WNP had documented the wound to the resident's right lateral lower leg measured 3.5 cm by 3.0 cm by unable to determine (UTD) and described as 20% granulation and 80% slough. The wound had a moderate amount of serosanguinous exudate. The WNP documented the wound had increased in size since the last visit and appeared devitalized with poor vascularization. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 3.6 cm by 3.2 cm by UTD. The treatment was cleanse with normal saline, apply Medihoney and cover with bordered gauze dressing daily and as needed. Review of the weekly WNP progress note dated 01/08/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measured 3.5 cm by 3.0 cm by UTD and described as 20% granulation and 80% slough. The wound had a moderate amount of serosanguinous exudate. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 3.6 cm by 3.0 cm by UTD. The treatment was cleanse with normal saline, apply Medihoney, apply calcium alginate and cover with bordered gauze dressing daily and as needed. Review of the weekly WNP progress note dated 01/15/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 4.0 cm by 3.0 cm by UTD and described as 20% granulation, 40% slough and 40% necrotic tissue. The wound had a moderate amount of serosanguinous exudate. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 4.2 cm by 3.2 cm by UTD. The treatment was changed to cleanse with normal saline, apply Mupirocin ointment then calcium alginate and cover with bordered gauze dressing daily and as needed. Review of the weekly WNP progress note dated 01/22/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 4.0 cm by 3.0 cm by UTD and described as 20% granulation, 40% slough and 40% necrotic tissue. The wound had a moderate amount of serosanguinous exudate. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 4.2 cm by 3.2 cm by UTD. The treatment was cleanse with normal saline, apply Mupirocin ointment then calcium alginate and cover with bordered gauze dressing daily and as needed. Review of the weekly WNP progress note dated 01/29/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 4.0 cm by 3.0 cm by UTD and described as 40% granulation, 20% slough and 40% necrotic tissue. The wound had a moderate amount of serosanguinous exudate. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 4.1 cm by 3.1 cm by UTD. The treatment was cleanse with normal saline, apply mupirocin ointment then apply calcium alginate and cover with bordered gauze dressing daily and as needed. Review of the weekly WNP progress note dated 02/05/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 4.5 cm by 4.2 cm by 0.2 cm and described as 70% granulation and 30% slough. The wound had a moderate amount of serosanguinous exudate, and the peri-wound was reddened. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 4.1 cm by 2.6 cm by 0.1 cm. The treatment was cleanse with normal saline, apply mupirocin ointment then apply calcium alginate and cover with bordered gauze dressing daily and as needed. Review of the weekly WNP progress note dated 02/12/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 3.5 cm by 2.0 cm by 0.2 cm and described as 70% granulation and 30% slough. The wound had a moderate amount of serosanguinous exudate and the peri-wound was reddened. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 3.6 cm by 2.2 cm by 0.2 cm. The treatment was cleanse with normal saline, apply mupirocin ointment then apply calcium alginate and cover with bordered gauze dressing daily and as needed. The facility determined the wound had improved/healing. Review of the weekly WNP progress note dated 02/19/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 3.5 cm by 2.0 cm by 0.2 cm and described as 70% granulation and 30% slough. The wound had a moderate amount of serosanguinous exudate and the peri-wound was reddened. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 3.6 cm by 2.2 cm by 0.2 cm. The treatment was cleanse with normal saline, apply mupirocin ointment then apply calcium alginate and cover with bordered gauze dressing daily and as needed. The facility determined the wound was unchanged. Review of the weekly WNP progress note dated 02/26/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 3.5 cm by 2.5 cm by 0.2 cm and described as 80% granulation and 20% slough. The wound had a moderate amount of serosanguinous exudate, and the peri-wound was reddened. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 3.6 cm by 2.6 cm by 0.1 cm. The facility implemented a new treatment of cleanse with normal saline, apply mupirocin ointment then start applying silver alginate and cover with bordered gauze dressing daily and as needed. The facility determined the wound was unchanged. Review of the weekly WNP progress note dated 03/05/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 3.0 cm by 2.0 cm by 0.2 cm and described as 80% granulation and 20% slough. The wound had a moderate amount of serosanguinous exudate, and the peri-wound was reddened. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 3.0 cm by 2.2 cm by 0.2 cm. The treatment was cleanse with normal saline, apply mupirocin ointment then apply silver alginate and cover with bordered gauze dressing daily and as needed. The facility determined the wound had improved/healing. Review of the weekly WNP progress note dated 03/11/26 revealed the WNP had documented the wound to the resident's right lateral lower leg measuring 3.0 cm by 2.0 cm by 0.2 cm and described as 80% granulation and 20% slough. The wound had a moderate amount of serosanguinous exudate and the peri-wound was reddened. A sharp/excisional debridement was performed by the WNP using a curette for removal of slough with post debridement measurements 3.0 cm by 2.1 cm by 0.2 cm. The treatment was cleanse with normal saline, apply mupirocin ointment then apply silver alginate and cover with bordered gauze dressing daily and as needed. The facility determined the wound was unchanged. Review of the weekly WNP progress note dated 03/18/26 revealed the WNP had documented the wound to the resident's left lateral lower leg measuring 2.5 cm by 1.2 cm by 0.2 cm and described as 100% granulation. The wound had a moderate amount of serosanguinous exudate, and the peri-wound was reddened. The treatment was cleanse with normal saline, apply mupirocin ointment then apply silver alginate and cover with bordered gauze dressing daily and as needed. The facility determined the wound was improving. Review of the resident's monthly physician orders for March 2026 identified orders dated 03/06/26 cleanse left lower leg skin alteration with in-house wound cleanser or normal saline, pat dry, apply mupirocin, cover with calcium alginate and cover with dry clean dressing daily and as needed. On 03/17/26 at 2:12 P.M., an interview with the Director of Nursing (DON) verified the facility had not implemented the treatment cleanse with normal saline, apply mupirocin ointment then apply silver alginate and cover with bordered gauze dressing daily and as needed as ordered by the WNP. An interview with Licensed Practical Nurse (LPN) #114 verified the resident's skin tear was on the left lateral leg and not on the right lateral leg. She verified the WNP documentation was not accurate to reflect the actual location of the skin tear being treated. On 03/18/26 at 9:02 A.M., observation of LPN #112 and #114 provide the physician ordered treatment to Resident #9's skin tear to his left out leg revealed a quarter size wound with a reddish wound bed. No concerns were observed with the dressing change.

Based on record review, interview and facility policy review, the facility failed to document treatments completed on two pressure ulcers for one resident (#111) of three residents reviewed. The facility census was 96. Findings include: Review of the medical record for Resident #111, revealed an admitted [DATE]. Diagnoses included but were not limited to schizophrenia, other reduced mobility pressure ulcer of left buttock stage IV (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) and dependence on other enabling machines and devices. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated cognitive intactness. The resident was assessed to require dependence on toilet hygiene, partial/moderate assistance with transfers and independent with bed mobility. The resident was also assessed to have two stage IV pressure ulcers on readmission/reentry with no refusal of care behaviors. Review of Resident #111's active care plans revealed a focus of an actual area of skin impairment related to stage IV pressure to left and right ischial with interventions including but not limited to: treatment order to left and right ischial changed per Nurse Practitioner and treatment as ordered. Review of physician's orders dated for 04/16/24 with a discontinued date of 05/06/24 for Resident #111 revealed two wound orders: cleanse wound to left ischium with normal saline, irrigate wound, pat dry, pack wound with collagen sheet, follow with packing and gauze and secure twice a day and as needed every shift for wound care and cleanse wound to right ischium with normal saline, irrigate wound, pat dry, pack wound with collagen sheet, follow with packing and gauze and secure twice a day and as needed every shift for wound care. Further review of this resident's physicians orders dated for 05/07/24 with a discontinuation date of 06/10/24 revealed two orders: Mupirocin external ointment 2 % apply to left ischium topically every shift for wound care cleanse wound to left ischium with normal saline (irrigate) pat dry, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed and Mupirocin external ointment 2 % apply to right ischium topically every shift for wound care cleanse wound to right ischium with normal saline (irrigate) pat dry, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed. Residents #111's Treatment Administration Record (TAR) for May 2024 revealed for both wound orders dated 04/16/24 had missed treatments for day shift for: 05/04/24, 05/05/24 and 05/07/24. Further review revealed for both wound orders dated 05/07/24 had missed treatments for day shift for: 05/23/24, 05/24/24, 05/28/24, and 05/031/24. Review of active physicians orders dated for 06/10/24 for Resident #111' revealed two wound orders: Mupirocin external ointment 2 % apply to left ischium topically every shift for wound care cleanse wound to left ischium with normal saline (irrigate) pat dry, drop 2-3 drops of Tetracyte into wound bed, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed and Mupirocin external ointment 2 % apply to right ischium topically every shift for wound care cleanse wound to right ischium with normal saline (irrigate) pat dry, drop 2-3 drops of Tetracyte into wound bed, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed. Resident #111's TAR for June 2024 revealed for both wound orders dated 05/07/24 had missed treatments for day shift for: 06/01/24, 06/07/24 and 06/10/24. Further review revealed for both wound orders dated 06/10/24 had missed treatments for day sift for: 06/11/24, 06/12/24, 06/14/24, 06/16/24, 06/17/24, 06/21/24, 06/23/24, and 06/30/24. On 07/02/24 at 9:45 A.M., Resident #111 refused to interview and refused to have his dressing change observed to his right and left ischium. Interview on 07/02/24 at 9:45 A.M. with the Director of Nursing (DON) verified Resident #111 had missed treatments for multiple orders for the left and right ischium for May and June 2024 on the TAR. Interview on 07/02/24 at 10:13 A.M. with Licensed Practical Nurse (LPN) verified Resident #111 had missed treatments for multiple orders for the left and right ischium for May and June 2024 on the TAR and stated, I am the nurse who takes care of him during the week most days and I religiously change it when he lets me. Also verified unable to document late entries for the missed treatments due to the resident does refuse as well and no form of confirmation for what days it was completed and what days he refused. Review of the facility policy titled Medication and Treatment Orders dated 03/01/2022 stated treatment orders .will be documented in PCC and on the TAR. This deficiency represents non-compliance investigated under Master Complaint Number OH00155246.

Based on observation and staff interview, the facility failed to ensure residents' rooms were maintained in a safe, functional, and sanitary manner. This affected six residents (Resident #6, #21, #53, #62, #63, and #152) of 32 that were observed for room conditions. The facility census was 98. Findings include: 1. Review of Resident #6's room on 04/01/24 at 11:39 A.M. revealed the overbed light had a bulb that was burning out in the front of the overbed light. The light would turn on, but shined a pinkish-red color and was not fully lit. The resident's wall next to her bed had chipped paint and was in need of being painted. The entry door on the inside was noted to have chipped paint and was in need of being painted. On 04/04/24 at 8:23 A.M., a follow up observation was made of Resident #6's room and her room remained in disrepair. In addition to the above findings, the vent and surrounding ceiling area was noted to be covered in dust. Findings were verified by Maintenance Director #22. 2. Review of Resident #21's room on 04/01/24 at 10:02 A.M. revealed the floor tile next to her bed had a long crack in it. The inside door frame to the room had chipped paint. The vent in the ceiling and the surrounding ceiling was noted to have dust build up on it. On 04/04/24 at 8:25 A.M., a follow up observation was made of Resident #21's room and her room remained in disrepair. In addition to the above findings, the tile floor between bed A and B was noted to have black marred areas and gouges in it in front of resident in bed B's recliner. Findings were verified by Maintenance Director #22. 3. Review of Resident #53's room on 04/01/24 at 10:02 A.M. revealed the floor had cracked tile. Her inside door frame and door was noted to have chipped paint and was in need of being painted. The vent in the ceiling and the surrounding ceiling area had dust build up on it and was in need of being cleaned. On 04/04/24 at 8:26 A.M., a follow up observation of Resident #53's room revealed it remained in disrepair. The vent and the surrounding ceiling still had dust build up present. Findings were verified by Maintenance Director #22. 4. A review of Resident #62's room on 04/01/24 at 1:43 P.M. revealed the residents's wall around the recessed area where her wardrobe was placed was damaged. The dry wall compound had fallen off exposing the metal strip that was used to make a straight edge. The sink in her bathroom had constant running water and could not be shut off. On 04/04/24 at 8:28 A.M., a follow up visit to Resident #62's room revealed it remained in disrepair. The sink was noted to still have water running from it. Findings were verified by Maintenance Director #22. 5. A review of Resident #63's room on 04/01/24 at 2:15 P.M. revealed the recessed wall where her wardrobe was placed had damage to it where the door knob to the entry door had hit it. The metal strip was exposed from where the dry wall compound had come off and there was metal edge strips exposed in other areas across the top of that recessed wall. On 04/04/24 at 8:29 A.M., a follow up observation of Resident #63's room noted it remained in disrepair. Findings were verified by Maintenance Director #22. 6. A review of Resident #152's room on 04/01/24 at 10:53 A.M. revealed there had been two separate areas in which the wall had been patched over wallpaper. The patched areas was on each side of a bulletin board that was hanging on the wall above the resident's bed. There was also an area on the ceiling in which a leak had occurred above the window that had flaking ceiling paint. The recessed wall where the wardrobe was placed had damage to the corner where the door knob had hit it. On 04/04/24 at 8:30 A.M., a follow up observation of Resident #152's room revealed it remained in disrepair. Findings were verified by Maintenance Director #22. On 04/04/24 at 8:24 A.M., an interview with State tested Nursing Assistant (STNA) #130 revealed they were to report any issues they noted with the facility's environment to the maintenance department. They were able to enter those issues into the computer when repairs were needed. She denied she had reported any environmental issues. On 04/04/24 at 8:31 A.M., an interview with Maintenance Director #22 confirmed any environmental concerns identified by the staff were to be put into the computer. He denied he had any work orders that had been placed for the environmental issues noted above. He claimed he also made daily rounds throughout the building to check in with the staff to see if anything needed fixed. He denied he had been made aware of any of the environmental concerns identified on the 400 hall.

Based on record review ,staff interview, and facility policy review, the facility failed to ensure the physician was notified after a change in condition of a new wound or the worsening of a current wound. This affected four residents (#3, #74, #89, and #93) of seven reviewed for skin impairments. Facility census was 98. Findings include: 1. Review of the medical record for the Resident #89 revealed an admitted [DATE]. Diagnoses included depression, heart failure, diabetes, end stage renal disease, and absence of left leg below the knee. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively intact and required supervision touching assistance for personal hygiene and activities of daily living. Review of the plan of care dated 01/2024 revealed Resident #89 was at risk for skin impairments with interventions to inspect for reddened areas during daily care, weekly skin assessments, charge nurse to notify wound nurse, physician and family of any new areas, and wound care practitioner to eval and treat as indicated. Review of the skin observation assessment dated [DATE] revealed a new red area on the left knee. Facility had no evidence of physician notification of this new skin impairment. Review of the skin grid non-pressure assessment dated [DATE] revealed a new skin impairment was noted of a red area blister to knee. Facility had no evidence of physician notification of this new skin impairment. Review of the skin grid non-pressure assessment dated [DATE] revealed multiple scabs to distal finger joints (date acquired 9/22). Facility documented physician was notified 09/25/23, three days after new skin impairments were identified. Review of the skin observation assessment dated [DATE] revealed a previously identified area was present. The area included scabs on the right hand and fingers and a scab on the left knee. It did not indicate how many scabs, specific locations or sizes. Several of these scabs were not identified on several previous skin observations or assessments. Facility had no evidence the physician was notified. Review of the skin grid non-pressure assessment dated [DATE] revealed bruising to left knee. Facility had no documentation of physician being notified. Review of the skin observation assessment dated [DATE] identified scabs to right fingers. Facility did not have evidence of the physician being notified to new skin impairment. Review of the skin observation assessment dated [DATE] identified scabbed areas on right hand fingers and a bruise on the abdomen. Facility had no evidence of the physician being notified of skin impairment or bruising. Review of the skin observation assessment dated [DATE] identified a scabbed area on the back of the left hand. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] identified a scabbed area on the left hand. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Facility had no evidence of the physician being notified. Review of the skin observation assessment dated [DATE] identified scabbed areas to right hand. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Facility had no evidence of the physician being notified. Review of the skin observation assessment dated [DATE] identified hand blisters. Facility had no evidence of the physician being notified of the skin impairments. Review of the skin observation assessment dated [DATE] identified scabbed areas to bilateral fingers. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] identified scabbed areas to the right hand fingers. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Facility had no evidence of the physician being notified. Review of the skin observation assessment dated [DATE] identified scabbed areas to right and left hands. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] identified scabbed areas to right hand fingers. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] identified scabbed areas to fingers of right and left hands. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] identified scabbed areas to right hand fingers. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin grid non-pressure assessment dated [DATE] identified a skin tear that occurred at the device check appointment. This assessment was updated to state the tear was healed on 02/28/24. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] identified an area to LFA and scabbed areas to right fingers. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Facility had no evidence of the physician being notified. Review of the skin grid non-pressure assessment dated [DATE] identified a bruise to the top of the scalp. The assessment revealed this wound was identified at 02/13/24. Review of the skin observation assessment dated [DATE] stated skin was intact with no impairments, but also stated left fingers wound treatments were in place. Facility had no evidence of the physician being notified. Review of the skin grid non-pressure assessment dated [DATE] identified a bruise was acquired on 02/13/24. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin grid non-pressure assessment dated [DATE] identified scabs on the right fingers. Facility had no evidence of the physician being notified. Review of the skin grid non-pressure assessment dated [DATE] identified scabs on his right fingers. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Facility had no evidence of the physician being notified. Review of the skin grid non-pressure assessment dated [DATE] identified scabs on his right fingers. Facility had no evidence of the physician being notified of the skin impairment. Interview on 04/03/24 at 2:30 P.M. with Director of Nursing (DON) confirmed facility had an order for the wound practitioner to evaluate and treat as necessary dated 03/2024 and confirmed the wound provider saw resident but had no recommendations and did not document any assessment or findings. 2. Review of the medical record for the Resident #3 revealed an admitted [DATE]. Diagnoses included diabetes type 1, respiratory failure, metabolic encephalopathy, heart failure, vascular disease and kidney failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and required substantial maximum assistance for lower body dressing, showering and moderate assistance for hygiene and upper body dressing. Review of the plan of care dated 11/16/23 revealed Resident #3 was at risk for alteration in skin integrity with interventions for wound care practitioner to evaluate and treat as indicated. The care pan also stated the resident had an actual area of skin impairment of pressure ulcer to left knee amputation stump with interventions to indicate wound treatment, nursing to observe the wound dressing. Observe and document the character of wound weekly, observe for clinical changes and complete skin observations on bath/shower days. Review of the skin grid non-pressure assessment dated [DATE] identified bruising to the neck. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin grid non-pressure assessment dated [DATE] identified redness to the back of the right hand. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin grid non-pressure assessment dated [DATE] identified redness to the back of left hand. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin grid non-pressure assessment dated [DATE] identified a surgical incision to the left illiac crest. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified. The assessment revealed the left knee had an open area. The assessment did not include any descriptions or measurements. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified. The assessment revealed a skin tear to the left forearm with treatment in place. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was marked as intact, but also marked with previous areas noted. The assessment identified a scabbed area to the left knee and scabbed area to the right foot. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed a toe skin impairment. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact, marked with previous areas noted. The assessment identified a scabbed area to the left knee. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact. The assessment did not include any areas listed or descriptions of wound impairments. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact. The assessment did not include any areas listed or descriptions of wound impairments. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin observation assessment dated [DATE] revealed skin was not intact. The assessment identified a scabbed area to the left knee. Facility had no evidence of the physician being notified of the skin impairment. 3. Review of the medical record for the Resident #74 revealed an admitted [DATE]. Diagnoses included respiratory failure, diabetes, dysphagia, muscle weakness, encephalopathy, and pulmonary embolism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was cognitively impaired and was rarely if ever understood and was dependent for activities of daily living. Review of the plan of care dated 03/04/24 revealed Resident #74 was at risk of skin impairments. Review of the skin grid non-pressure assessment dated [DATE] identified a new skin impairment of scabs to the left toes, also identified on 10/24/23. The assessment marked the wound as improved and marked as declined on 10/24/23. Facility had no evidence of the physician being notified. Review of the skin observation assessment dated [DATE] revealed skin was intact with no new areas, dressing and treatment were not applicable. The assessment identified a left toe(s) impairment with great toenail ingrown with treatment in place. Facility had no evidence of the physician being notified of the skin impairment. Review of the skin grid non-pressure assessment dated [DATE] identified redness and scab to left toes around the toenail bed. Facility had no evidence of the physician being notified. Interviews on 04/04/24 from 2:30 P.M. to 3:15 P.M. with DON confirmed Residents #3, #74 and #89 had numerous wounds and also confirmed facility had no evidence of the physician being notified of these skin impairments. 41271 4. Review of the medical record for Resident #93 revealed an admitted [DATE]. Diagnoses included delirium, vascular dementia, hemiplegia affecting the left non-dominant side, and a history of falling. Review of Resident #93's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating a severely impaired cognition for daily decision making abilities. Resident #93 was noted to display disorganized thinking, inattention, rejection of care and delusions. Resident #93 was noted to to experience impairment to one upper and one lower extremity and required substantial to maximal assistance for bed mobility and turning from side to side. Per assessment, Resident #93 was noted to be incontinent of bowel and bladder function and noted to one stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) that was not present upon admission to the facility. Review of the plan of care dated 11/02/23 and revised 02/14/24 revealed Resident #93 had the potential for alteration in skin integrity related to incontinence. Interventions included to report to physician for evaluation and treatment as indicated. Review of the Skin Grid Pressure assessment dated [DATE] revealed Resident #93 was noted to have a area to the coccyx noted to measure 1.2 centimeter(cm) in length by 1.2 cm in width by 0.1 cm in depth described as a stage two pressure. No evidence was noted to indicate the physician was notified of this newly identified pressure wound. Review of progress notes from 01/14/2023 through 01/31/2024 revealed no evidence of the physician being notified of the newly identified pressure wound identified for Resident #93. Interview on 04/04/24 at 10:13 A.M. with Charge Nurse, Licensed Practical Nurse (LPN) #50 verified Resident #93 had a stage two pressure wound that was newly identified per nurses notes on 01/14/24 and per Skin Grid Pressure assessment dated [DATE]. Charge Nurse, LPN #50 also verified there was no evidence noted in the nurses progress notes or skin assessment that the physician had been notified of the newly identified pressure wound. Charge Nurse, LPN #50 claimed the wound physician was notified the following week when the physician was onsite to complete wound treatments for other residents but not notified immediately when the pressure wound was identified. Review of the facility policy titled Notification of Change, dated 08/22/22 revealed, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as b. Clinical complications or development of a stage two pressure injury.

Based on record review, staff interview, and facility policy review, the facility failed to ensure skin and wound assessments were completed thoroughly, accurately, and timely for three residents (#3, #74 and #89) of four reviewed for non-pressure wounds. The facility census was 98. Findings include: 1. Review of the medical record for the Resident #89 revealed an admitted [DATE]. Diagnoses included depression, heart failure, diabetes, end stage renal disease, and absence of left leg below the knee. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively intact and required supervision touching assistance for personal hygiene and activities of daily living Review of the plan of care dated 01/2024 revealed Resident #89 was at risk for skin impairments with interventions to inspect for reddened areas during daily care, weekly skin assessments, charge nurse to notify wound nurse, Physician and family of any new areas, and wound care practitioner to eval and treat as indicated. Review of the skin observation assessment dated [DATE] revealed a new red area on the left knee. Review of the skin grid non-pressure assessment dated [DATE] revealed a new skin impairment was noted of a red area blister to knee. Review of the skin observation assessment dated [DATE] revealed no areas identified. It did not indicate if prior redness and blistering had healed. Review of the skin grid non-pressure assessment dated [DATE] revealed multiple scabs to distal finger joints (date acquired 9/22). The assessment marked the wounds as unchanged but identified skin impairments had not been previously assessed or identified. Review of the skin observation assessment dated [DATE] revealed a previously identified area was present. The area included scabs on the right hand and fingers and a scab on the left knee. It did not indicate how many scabs, specific locations or sizes. Several of these scabs were not identified on several previous skin observations or assessments. Review of the skin grid non-pressure assessment dated [DATE] revealed resident had bruising to the left iliac crest. This bruising was marked as unchanged, but skin impairment had not been previously identified or assessed. Review of the skin observation assessment dated [DATE] revealed bruising to left illiac crest. Review of the skin grid non-pressure assessment dated [DATE] revealed bruising to left knee. None of the recent previous skin assessments mentioned concerns of bruising to the left knee. Review of the skin observation assessment dated [DATE] identified scabs to right fingers. Assessment did not provide details of the scabs including amount and sizes. Review of the skin observation assessment dated [DATE] identified scabbed areas on right hand fingers and a bruise on the abdomen. Review of the skin observation assessment dated [DATE] identified a scabbed area on the back of the left hand. Review of the skin observation assessment dated [DATE] identified a scabbed area on the left hand. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Review of the skin observation assessment dated [DATE] identified scabbed areas to right hand. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Review of the skin observation assessment dated [DATE] identified hand blisters. The assessment did not specify which hand, how many, or the size of the blisters. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] identified scabbed areas to bilateral fingers. Review of the skin observation assessment dated [DATE] identified scabbed areas to the right hand fingers. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Review of the skin observation assessment dated [DATE] identified scabbed areas to right and left hands. Review of the skin observation assessment dated [DATE] identified scabbed areas to right hand fingers. Review of the skin observation assessment dated [DATE] identified scabbed areas to fingers of right and left hands. Review of the skin observation assessment dated [DATE] identified scabbed areas to right hand fingers. Review of the skin grid non-pressure assessment dated [DATE] identified a skin tear that occurred at the device check appointment. This assessment was updated to state the tear was healed on 02/28/24. Review of the skin observation assessment dated [DATE] identified an area to LFA and scabbed areas to right fingers. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Review of the skin grid non-pressure assessment dated [DATE] identified a bruise to the top of the scalp. The assessment revealed this wound was identified at 02/13/24. Review of the skin observation assessment dated [DATE] stated skin was intact with no impairments, but also stated left fingers wound treatments were in place. Review of the skin grid non-pressure assessment dated [DATE] identified a bruise was acquired on 02/13/24. The assessment included no information on description location or size of the bruise. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin grid non-pressure assessment dated [DATE] identified scabs on the right fingers that were marked as unchanged, gave no date of when they were acquired and no description or size. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin grid non-pressure assessment dated [DATE] identified scabs on his right fingers. The assessment was marked as unchanged and provided no date the wound was acquired. Review of the skin observation assessment dated [DATE] stated a previous area had been identified and provided no information on which site or description of the skin impairment it was referring to. Review of the skin grid non-pressure assessment dated [DATE] identified scabs on his right fingers. The assessment was marked as unchanged and provided no date the wound was acquired or any size or description of the wound. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Observation and interview on 04/02/24 at 8:56 A.M. with Resident #89 revealed he had several visible wounds on his bilateral hands with a grayish scab on the right middle finger and several additional red colored blisters on his bilateral fingers. Resident stated he had blisters on his hands for several months and also revealed the large grey scab like wound had been there for several months. He revealed it started as a blister and believed it to be caused by his dialysis port causing issues with blood flow to his hand. Interview on 04/03/24 at 2:20 P.M. with Director of Nursing (DON) confirmed facility had an order for the wound practitioner to evaluate and treat as necessary dated 03/2024 and confirmed the wound provider saw resident but had no recommendations and did not document any assessment or findings. 2. Review of the medical record for the Resident #3 revealed an admitted [DATE]. Diagnoses included diabetes type 1, respiratory failure, metabolic encephalopathy, heart failure, vascular disease and kidney failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and required substantial maximum assistance for lower body dressing, showering and moderate assistance for hygiene and upper body dressing. Review of the plan of care dated 11/16/23 revealed Resident #3 was at risk for alteration in skin integrity with interventions for wound care practitioner to evaluate and treat as indicated. The care pan also stated the resident had an actual area of skin impairment of pressure ulcer to left knee amputation stump with interventions to indicate wound treatment, nursing to observe the wound dressing. Observe and document the character of wound weekly, observe for clinical changes and complete skin observations on bath/shower days. Review of the skin grid non-pressure assessment dated [DATE] identified bruising to the neck. The assessment had marked this finding as new but did not include the date acquired or description. Review of the skin grid non-pressure assessment dated [DATE] identified redness to the back of the right hand. The assessment did not include description or measurements. Review of the skin grid non-pressure assessment dated [DATE] identified redness to the back of left hand. The assessment did not include description or measurements. Review of the skin grid non-pressure assessment dated [DATE] identified a surgical incision to the left illiac crest. The assessment had marked this healed on 11/29/23 and it was included in any other assessments. Review of Physician orders dated 11/16/23 to 11/30/23 to monitor incision cite to left groin each shift for signs of infection. The wound to the left groin was never marked or included in any skin observation assessments or skin grid non-pressure assessment. Another order dated 11/16/23 to 04/01/24 revealed an order for right second toe to cleanse wound with wound cleanser or normal saline, apply betadine, and leave open to air daily. The wound on the second right toe was not documented in the skin assessments. Review of the skin grid non-pressure assessment dated [DATE] identified bruising to the neck. The assessment had marked this finding as new again but did not include the date acquired or description. The assessment also stated the impairment was improved but also that Physician was notified of the decline in skin a few days prior. Review of the skin grid non-pressure assessment dated [DATE] identified redness to the back of the right hand. The assessment had marked this finding as new again but did not include description or measurements. The assessment also stated the impairment was improved. Review of the skin grid non-pressure assessment dated [DATE] identified redness to the back of the left hand. The assessment had marked this finding as new again but did not include description or measurements. The assessment also stated the impairment was unchanged but also that it was healed. Review of the skin grid non-pressure assessment dated [DATE] identified a surgical incision to the left illiac crest. The assessment had marked this finding as new again but did not include description or measurements. The assessment also stated the impairment was unchanged but also that it was healed. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment revealed a left knee wound of amputation stump wound. The assessment did not include any descriptions or measurements. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment revealed a left knee wound of amputation stump wound had an open area. The assessment did not include any descriptions or measurements. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified. The assessment revealed a left knee had an open area. The assessment did not include any descriptions or measurements. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified. The assessment revealed a skin tear to the left forearm with treatment in place. The assessment did not include any measurements. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Review of the skin observation assessment dated [DATE] revealed skin was marked as intact, but also marked with previous areas noted. The assessment identified a scabbed area to the left knee and scabbed area to the right foot. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment identified a toe skin impairment but did not include any description or details including if it was the right or left, which toe and what the injury actually was (cut, bruise, scab ect). Review of the skin observation assessment dated [DATE] revealed skin was not intact, marked with previous areas noted. The assessment identified a scabbed area to the left knee. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Review of the skin observation assessment dated [DATE] revealed skin was not intact, previous areas identified, dressing and treatment in place. The assessment did not include any areas listed or descriptions of wound impairments. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Physician order dated 03/13/23 revealed wound care practitioner to evaluate and treat as indicated. The order did not specify any specific wounds and assessments before and after the order stated no skin impairments. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] revealed skin was not intact, and marked with previous areas noted. The assessment identified a scabbed area to the left knee. Review of the skin grid non-pressure assessment dated [DATE] identified a an other wound measuring 0.5 by 0.5 and a scab on the second right toe. The assessment had marked this finding as healed but did not specify if both wounds were healed (one had measurements). Review of wound practitioner notes dated 01/15/24, 01/22/24, 01/29/24, 02/05/24, 02/19/24, 02/26/24, 03/04/24, 03/11/24, 03/18/24, 03/25/24, and 04/01/24 revealed the wound practitioner observed and made recommendations regarding the stump pressure wound but had no documentation of assessing any other skin impairments. Review of the Skin grid assessment listing found Resident #3 had not had a skin grid assessment from 11/01/23 to 03/13/24 and then none after 03/13/23. Interview and observation on 04/01/24 at 11:38 A.M. with Resident #3 revealed resident had several visible wounds and scabs on his bilateral lower extremity as well as dried blood on his pillow and a bloody bandage on the floor. Resident revealed he had consistently had various wounds on his legs and feet with scabs and skin tears. 3. Review of the medical record for the Resident #74 revealed an admitted [DATE]. Diagnoses included respiratory failure, diabetes, dysphagia, muscle weakness, encephalopathy, and pulmonary embolism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was cognitively impaired and was rarely if ever understood and was dependent for activities of daily living. Review of the plan of care dated 03/04/24 revealed Resident #74 was at risk of skin impairments. Review of the skin grid non-pressure assessment dated [DATE] identified a new scab on the left toes also noted to be an abscess. The assessment marked this finding as unchanged while also marked as worsened with physician notification on 10/24/23 and also marked as healed but gives measurements of 0.5 by 0.5. Review of the skin grid non-pressure assessment dated [DATE] identified a new skin impairment of scabs to the left toes, also identified on 10/24/23. The assessment marked the wound as improved and marked as declined on 10/24/23. Review of the skin observation assessment dated [DATE] revealed skin was intact with no new areas, dressing and treatment were not applicable. The assessment identified a left toe(s) impairment with great toenail ingrown with treatment in place. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin grid non-pressure assessment dated [DATE] identified redness and scab to left toes around the toenail bed. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin observation assessment dated [DATE] revealed skin was intact and no areas of skin impairment were identified. Review of the skin grid assessments revealed resident was missing several skin grid non-pressure assessments. Observations and interview dated 04/01/24 at 10:52 A.M. with Resident #74's representative and Resident #74 revealed resident had wounds to his toes and had a dressing in place. Resident Representative revealed resident had an ingrown toe that was causing issues to his skin around the nailbed. Resident Representative revealed resident had a wound on his toe for the last several weeks and they had not fully healed. Interviews on 04/04/24 from 2:30 P.M. to 3:15 P.M. with DON confirmed wound assessments did not contain thorough information of what wounds were present and when. The assessments also did not contain descriptions of the wounds and document when they were discovered and when they were healed. DON revealed facility had previously identified an issue with nursing assessment documentation not being accurate and detailed and revealed they had completed education on 02/2024 and 03/2024. DON confirmed issues were still present in documentation after the trainings had been completed. DON revealed skin grid assessments non pressure assessments should be completed when a new wound was identified and then weekly thereafter until the wound was healed and confirmed several skin grid assessments were not completed and also skin observation assessments should be completed weekly regardless of wounds being present or healing status. Review of the facility policy titled Licensed Nurse Skin Condition Documentation, dated 03/01/22 revealed it was the practice of the facility to complete weekly wound observations and provide weekly documentation of any wound area in order to identify progress or lack of progress in a wound area. The assessments would include identification of the type of wound and description including color, size/measurements, location and exudate if present. The nurse shall document on forms and place in medical record and will notify physician of any changes.

Based on medical record review, staff interview, and policy review, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #6) of one residents reviewed for PASRR documents. The facility census was 98. Findings Include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with agitation/ mood disturbance, anxiety disorder, major depressive disorder (MDD), and delusional disorder. Review of Resident #6's Preadmission Screening and Resident Review (PASRR) Identification Screen dated 11/30/23 revealed under Section (D.) the resident was identified as having a diagnosis of dementia. Under Section (E.) Indications of Serious Mental Illness, the resident was identified as having the diagnosis of a mood disorder and anxiety. Delusional disorder was not marked despite that being a diagnosis the resident was known to have upon admission. Review of a request for a Level of Care Review dated 01/02/24 revealed the facility sent the review request to the Central Ohio Area Agency on Aging for a nursing facility to nursing facility transfer as the resident was admitted to the facility from another nursing facility in Ohio. The Request for a Level of Care Review did not required the facility to include the resident's mental illness diagnoses only an instrumental activities of daily living to show how much assistance the resident needed in areas such as shopping, meal preparation, and laundry/ housekeeping activities. Review of a Pre-Admission Screen Determination dated 01/03/24 revealed it was not applicable. An in-person assessment was indicated not to be required. The comment section indicated it was for a delayed exempt and the resident was approved for transfer. On 04/03/24 at 3:26 P.M., an interview with Social Worker #216 revealed she had been the facility's social worker since just after their last annual survey. She reviewed PASRR's upon a resident's admission for accuracy and to ensure the appropriate diagnoses were added to the PASRR. She acknowledged Resident #6 had the diagnosis of delusional disorder that was not included on her PASRR they received from the transferring facility. She confirmed she received the PASRR from the transferring facility and assumed it had been completed accurately. She further confirmed she did not review it for accuracy. She acknowledged there could have been the possibility of the resident triggering for a Level II review if the prior PASRR had been completed accurately. She further acknowledged any such services that could have been required through a Level II review would not have been provided to the resident timely, if the resident required them. Review of the facility's policy on Resident Assessment- Coordination with PASARR Program revised 01/01/24 revealed the facility coordinated assessments with the preadmission screening and resident review (PASARR) program under Medicaid (MCD) to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs. All applicants to the facility would be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's MCD rules for screening. The social services director would be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. Any resident who exhibited a newly evidence or possible serious mental disorder, intellectual disability, or a related condition would be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

Based on medical record review, staff interview, and policy review the facility failed to ensure all resident Pre-Admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #6) of one residents reviewed for PASRR documents. The facility census was 98. Findings Include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with agitation/ mood disturbance, anxiety disorder, major depressive disorder (MDD), and delusional disorder. Review of Resident #6's Preadmission Screening and Resident Review (PASRR) Identification Screen dated 11/30/23 revealed under Section (D.) the resident was identified as having a diagnosis of dementia. Under Section (E.) Indications of Serious Mental Illness, the resident was identified as having the diagnosis of a mood disorder and anxiety. Delusional disorder was not marked despite that being a diagnosis the resident was known to have upon admission. Review of a request for a Level of Care Review dated 01/02/24 revealed the facility sent the review request to the Central Ohio Area Agency on Aging for a nursing facility to nursing facility transfer as the resident was admitted to the facility from another nursing facility in Ohio. The Request for a Level of Care Review did not require the facility to include the resident's mental illness diagnoses only an instrumental activities of daily living to show how much assistance the resident needed in areas such as shopping, meal preparation, and laundry/ housekeeping activities. Review of a Pre-Admission Screen Determination dated 01/03/24 revealed it was not applicable. An in-person assessment was indicated not to be required. The comment section indicated it was for a delayed exempt and the resident was approved for transfer. On 04/03/24 at 3:26 P.M., an interview with Social Worker #216 revealed she had been the facility's social worker since just after their last annual survey. She reviewed PASRR's upon a resident's admission for accuracy and to ensure the appropriate diagnoses were added to the PASRR. She acknowledged Resident #6 had the diagnosis of delusional disorder that was not included on her PASRR they received from the transferring facility. She confirmed she received the PASRR from the transferring facility and assumed it had been completed accurately. She further confirmed she did not review it for accuracy. She acknowledged there could have been the possibility of the resident triggering for a Level II review if the prior PASRR had been completed accurately. She further acknowledged any such services that could have been required through a Level II review would not have been provided to the resident timely, if the resident required them. Review of the facility's policy on Resident Assessment- Coordination with PASARR Program revised 01/01/24 revealed the facility coordinated assessments with the preadmission screening and resident review (PASARR) program under Medicaid (MCD) to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs. All applicants to the facility would be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's MCD rules for screening. The social services director would be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority.

Based on record review and staff interview, the facility failed to ensure laboratory tests were completed as ordered by the physician. This affected one (Resident #62) of five residents reviewed for unnecessary medications. The facility census was 98. Findings include: Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included mood disorder, bipolar disorder, and major depressive disorder. Review of Resident #62's physician's orders revealed the resident had an order to receive Depakote (an anti-convulsant also used in the treatment of bipolar disorder) Delayed Release (DR) 500 milligrams by mouth (po) twice a day for mood disorder. The order had been in place since 10/29/20. Her physician's orders also included the need to obtain a Depakote level every six months and as needed. That order had been in place since 01/20/22. Further review of Resident #62's electronic medical record (EMR) revealed it was absent for evidence a Depakote level had been drawn every six months as ordered. Findings were verified with the Licensed Practical Nurse (LPN) #50. On 04/04/24 at 3:00 P.M., an interview with LPN #50 revealed the last Depakote level they could find for Resident #62 was collected on 08/18/22. She confirmed the resident's physician's orders indicated a Depakote level was to be done every six months. She reported their laboratory system they used for entering a lab test did not allow them to enter it outside the current year they were in. The need to obtain a Depakote level on the resident every six months fell through the cracks, after it was last obtained in August 2022.

Based on record review and staff interview, the facility failed to ensure a resident receiving a narcotic pain medication ordered on an as needed basis (prn) had parameters ordered from the physician on when to administer the medication. This affected one (Resident #6) of five residents reviewed for unnecessary medications. The facility census was 98. Findings include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, opioid use, and a history of a displaced fracture of the upper end of the left humerus with routine healing. A review of Resident #6's physician's orders revealed she had an order to received Norco (Acetaminophen and Hydrocodone) 5-325 milligrams (mg) one half tablet by mouth (po) twice a day on a scheduled basis beginning on 02/21/24. Her orders also included the use of Norco 5-325 mg one half tablet po every six hours as needed for pain. There was no direction for the nurses to know when to administer the prn Norco such as for moderate to severe pain or for pain levels of 4 to 10 on a 1-10 scale. The resident also had an order to receive Acetaminophen (Tylenol) 650 mg po with instructions to administer every six hours as needed for general discomfort. Her pain was to be monitored every shift for medication monitoring. Review of Resident #6's medication administration record (MAR) for January 2024 revealed the resident was given Norco 5-325 mg one half tablet 18 times that month. She received it less than daily but somedays was given two doses. The nurses administering the prn Norco did not specify what the resident's pain level was when she received it, but did indicate the medication was effective when administered. In addition to the prn Norco, the resident received Acetaminophen 650 mg po as ordered every six hours prn for general discomfort twice that month. The nurses administering the Acetaminophen did include a pain level and recorded the resident's pain level as a 1 and 3 when the Acetaminophen was given. Both doses were indicated to be effective when given. The MAR also documented the resident's pain level each shift when assessed. She denied any pain 50 of the 55 shifts her pain was assessed. She complained of a pain level of 1 out of 10 twice, a 2 out of 10 once, and a 3 out of 10 only two times. Review of Resident #6's MAR for February 2024 revealed the resident began receiving a scheduled dose of Norco 5-325 mg one half tablet po twice a day on 02/21/24, after it had been ordered. She received four doses of the Norco 5-325 mg one half tablet on a prn basis for pain. The nurses administering those prn doses of Norco did not specify what the resident's pain level was at the time the prn medication was given. All four doses were indicated to have been effective. She was not given any of the Acetaminophen 650 mg tablets on a prn basis despite that medication being recorded as having been effective in managing the resident's pain the previous month. Her pain level continued to be monitored every shift as ordered and she was not indicated to have had any pain when assessed. On 04/04/24 at 10:50 A.M., an interview with the Director of Nursing (DON) confirmed Resident #6's physician's orders for the use of prn Norco did not include parameters to direct the nurses on when it should be given. She acknowledged the resident had an order for Acetaminophen 650 mg to be given every six hours prn for general discomfort and the medication was documented as being effective in managing the resident's pain when it was given. She further acknowledged the resident had been given four doses of the prn Norco in February 2024, without the Acetaminophen being used at all on a prn basis for pain. She also confirmed the pain assessment that was being completed every shift as ordered in February 2024 revealed the resident had no complaints of pain when assessed each shift the entire month. She stated she would contact the physician to obtain further orders for parameters on when to use the prn Norco.

Based on medical record, skin assessment review, staff interview, and facility policy review, the facility failed to properly document a newly identified pressure wound. This affected one (Resident #93) of the seven residents reviewed for skin assessment accuracy. The facility census was 98. Findings include: Review of the medical record for Resident #93 revealed an admitted [DATE]. Diagnoses included delirium, vascular dementia, hemiplegia affecting the left non-dominant side, and a history of falling. Review of Resident #93's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating a severely impaired cognition for daily decision making abilities. Resident #93 was noted to display disorganized thinking, inattention, rejection of care and delusions. Resident #92 was noted to to experience impairment to one upper and one lower extremity and required substantial to maximal assistance for bed mobility and turning from side to side. Per assessment, Resident #93 was noted to be incontinent of bowel and bladder function and noted to one stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) that was not present upon admission to the facility. Review of the plan of care dated 11/02/23 and revised 04/01/24 revealed Resident #93 has an actual area of skin impairment related to pressure area to coccyx. Interventions included to observe the area for clinical changes and document findings and notify the physician. Review of the completed Weekly Skin Observation dated 01/12/24 revealed Resident #93 had no skin issues and skin was intact. Review of the progress note dated 01/14/24 at 11:41 A.M. created by Licensed Practical Nurse (LPN) #220 revealed, Treatment applied to open area to crack of buttocks resident tolerated well. Encouraged turning and repositioning while in bed. Turns back on his back, non-compliant with recommendations. Review of a completed Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #93 was noted to have a new skin problem, abrasion, acquired 01/22/24 to the coccyx measuring 0.5 centimeters (cm) in length, by 1 cm in width, by 0 cm in depth, no staging noted. Review of the progress note dated 01/27/24 at 6:56 P.M. created by LPN #220 revealed, Encouraged turning and repositioning while in bed. Patient non-compliant, moves body even with his left sided weakness (status post stroke with left upper and lower weakness) off his side/ either side he is place on and turns back onto back/ buttocks. Treatment in place and continues to coccyx. Encouraged turning and repositioning. Review of the Skin Grid Pressure assessment dated [DATE] revealed Resident #93 was noted to have a newly identified area to the coccyx noted to measure 1.2 centimeter(cm) in length by 1.2 cm in width by 0.1 cm in depth described as a stage two pressure. No evidence was noted to indicate the physician was notified of this newly identified pressure wound. Interview on 04/04/24 at 10:13 A.M. with Charge Nurse, Licensed Practical Nurse (LPN) #50 verified Resident #93 had a stage two pressure wound that was newly identified per nurses notes on 01/14/24 and per Skin Grid Pressure assessment dated [DATE]. Charge Nurse, LPN #50 also verified there was no evidence noted in the nurses progress notes or skin assessment that the physician had been notified of the newly identified pressure wound. Charge Nurse, LPN #50 claimed the wound physician was notified the following week when the physician was onsite to complete wound treatments for other residents but not notified immediately when the pressure wound was identified. Interview on 04/04/2024 10:52 A.M. with Charge Nurse LPN #220 revealed skin assessment could not be located related to the progress note entered 01/14/23 indicating that a treatment to the coccyx was in place. No skin assessment was noted to have been completed until 01/24/24 and should have been completed when the area was first identified. Review of the facility policy titled Notification of Change, dated 08/22/22 revealed, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as b. Clinical complications or development of a stage two pressure injury. Review of the facility policy titled Licensed Nurse Skin Condition Documentation, dated 03/01/2022 revealed, It is the practice of the facility to complete weekly wound observation and provide weekly documentation of any pressure area(s) and wound area(s) in order to identify progress or lack of progress to any wound area.

Based on record review, interviews and facility policy review, the facility failed to prevent the misappropriation of Resident #16's power wheelchair. This affected one resident (#16) of one resident reviewed for misappropriation. The facility census was 90. Findings Include: Review of the medical record for Resident #16 revealed an initial admitted [DATE] with the latest readmission of 01/22/22 with diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome, dependence on wheelchair, alcoholic cirrhosis, bradycardia, chronic respiratory failure, hypertension, mood disorder, edema, major depressive disorder, carpal tunnel syndrome left upper limb, dysphagia, anxiety disorder, constipation and anemia. Review of the plan of care dated 11/26/14 revealed the resident had impaired physical mobility related to utilize electric wheelchair for mobility related to generalized muscle weakness, impaired vision and use of psychotropic medications. Interventions included ambulation with front wheelchair walker, encourage to turn and reposition with care rounds, encourage to use self-releasing seat belt while utilizing motorized wheelchair, non-skid footwear at all times and trapeze bar to bed. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required supervision with bed mobility, transfers and locomotion on/off the unit. The assessment indicated the resident utilized both a walker and wheelchair for mobility. Review of the monthly physician orders for July 2023 revealed an order (initiated 01/22/22) to encourage use of self-releasing seat belt while utilizing motorized wheelchair, verify able to self release every shift while using. On 07/28/23 at 8:25 A.M., interview with the Administrator revealed Resident #16 had received a new power chair and the resident's old power chair was being stored on the 300 hallway (for several months). The Administrator revealed a roll off dumpster was brought in to clean out the 300 hallway for re-opening and during the clean out the resident's chair was discarded in the dumpster. On 07/28/23 at 9:00 A.M., interview with Resident #16 revealed permission was not given to the facility to discard the power wheelchair and he was not provided the opportunity to remove the chair from the facility. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, last revised 10/2020 revealed the facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident property. 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. This deficiency represents non-compliance investigated under Complaint Number OH00144749.

Based on observation, record review, interview and facility policy review, the facility failed to maintain acceptable infection control practices to prevent cross contamination of two Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) pressure ulcers during an observed dressing change for Resident #44. This affected one resident (#44) of three residents reviewed for pressure ulcers. The facility census was 90. Findings Include: Review of the medical record for Resident #44 revealed an initial admitted [DATE] with the latest readmission of 09/22/21. Diagnoses including schizophrenia, low back pain, Stage IV pressure ulcer to left buttocks, morbid obesity, anxiety disorder, hyperlipidemia, Vitamin D deficiency, hypothyroidism, bipolar disorder, tremor, anemia, major depressive disorder, insomnia, epilepsy, carpal tunnel syndrome, asthma, gastroesophageal reflux disease (GERD), osteoarthritis (OA), lumbar spina bifida, diabetes mellitus, hypertension and left below the knee amputation. Review of the plan of care dated 01/26/23 revealed the resident had an actual area of skin impairment related to Stage IV pressure ulcer to left ischial and right ischial, Interventions included encourage resident to lay down throughout the day to relieve pressure, air mattress as ordered, encourage to relieve pressure to wound areas, evaluate pain and provide pain relieving interventions as ordered, followed by Nurse Practitioner (NP) and wound care consultants, initiate wound treatment, continue wound treatment as ordered, nursing to observe dressing daily to ensure that the dressing remains intact and there are no signs/symptoms of infection or increased drainage, observe for clinical changes, resident prefers to use scooter without ROHO cushion, refer to dietician to determine need/no need for dietary interventions and skin observation and document on bath/shower days. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two for bed mobility and toilet use and dependent on two for transfers. The assessment indicated the resident has an indwelling urinary catheter and was frequently incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had one unhealed Stage IV pressure ulcer that was present on admission. Review of the monthly physician orders for July 2023 revealed an order (initiated 03/15/23) to pack wound to left ischium with half strength Dakins soaked Kerlix roll, cover with bordered dressing and change daily and cleanse wound to right ischium with half strength Dakins', pat dry, pack with half strength soaked gauze daily and as needed. Review of a weekly pressure skin grid dated 07/24/23 revealed the resident had a Stage IV pressure ulcer to the right ischium measuring 2.0 centimeters (cm) by 1.0 cm by 3.0 cm. The wound had tunneling at 12 o'clock measuring 2.8 cm. The wound had attached wound edges and macerated peri-wound with a moderate amount of serous drainage. The wound was determined to have been unchanged. Review of the weekly pressure skin grid dated 07/24/23 revealed the resident had a Stage IV pressure ulcer to the left ischium measuring 1 0 cm by 3.0 cm by 4.0 cm with 100% granulation bed, unattached edges, macerated edges and moderate serosanguinous drainage. The wound had tunneling around the clock measuring 4.0 cm. On 07/28/23 at 10:30 A.M., observation of Licensed Practical Nurse (LPN) #110 and #124 provide the physician ordered treatment to Resident #44's Stage IV pressure ulcer to the right and left ischium revealed the LPN's washed their hands and set up the required supplies on a barrier after sanitizing the bedside table. LPN #124 cleansed hands and donned gloves. LPN #124 cleansed the wound to the right ischium with wound cleanser and drain sponge, then dried the wound using a drain sponge. LPN #124 then cleansed the wound with wound cleanser and drain sponge, then dried the wound using a drain sponge. LPN #124 then sanitized her hands and donned gloves. LPN #124 cut two pieces of Kerlix and placed in one half Dakins' solution. LPN #124 then packed the Dakins' soaked packing in the wound to the right ischium using a Q-tip. LPN #124 then obtained another Q-tip and packed the wound to the left ischium with the Dakins' soaked Kerlix. LPN #124 sanitized her hands and donned a pair of gloves. LPN #124 then covered the right ischium wound with a bordered gauze. LPN #124 then covered the wound to the left ischium with a boarded gauze dressing. LPN #124 verified the dressing changes to the two Stage IV pressure ulcers were completed together instead of separate to prevent potential cross contamination. Review of the facility policy titled, Pressure Injury Prevention and Management, dated 08/22/22 revealed the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. This deficiency represents non-compliance investigated under Complaint Number OH00144381.

Based on observation, record review and interview the facility failed to maintain the outside physical environment in a safe manner to prevent Resident #2 from sustaining a fall with injury. Actual harm occurred on 03/25/23 when Resident #2, who was independent with the use of a motorized (power) wheelchair sustained a fall in the parking lot, when his wheelchair fell into a pot hole resulting in a proximal humerus fracture to his right arm. The resident had increased pain to the area and was unable to use the motorized wheelchair for independent mobility for a period of time following the incident/injury. This affected one resident (#2) of five residents reviewed for accidents. The facility census was 98. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including quadriplegia, peripheral vascular disease, neuralgia, neuritis, depression, chronic pain, wheelchair dependent and on 03/26/23 a diagnosis of fracture of upper end of right humerus. Review of a power wheelchair mobility indoor driving assessment and experience check list dated 12/20/22 revealed Resident #2 was able to safely maneuver the wheelchair including backing up and rate of speed. No updated assessment for the use of the power wheelchair had been completed between this assessment and 03/25/23. Review of a nursing progress note, dated 03/25/23 at 2:14 P.M. revealed a change in surface in the parking lot at 1:30 P.M. (resulting in a resident fall). A full nursing assessment was completed and the resident was assisted back to an upright position. Resident #2 was complaining of pain. The physician was notified and gave an order to send Resident #2 to the emergency room for evaluation and treatment of his injuries. The resident's guardian was notified. Review of the local emergency department notes dated 03/25/23 revealed Resident #2 had an x-ray of right upper extremity that showed a right proximal humerus fracture. Review of the imaging report from the local hospital dated 03/25/23 revealed the resident had an impacted angulated fracture of the anatomic neck of the proximal right humerus. New orders were provided to continue with pain management, ice the area and use a sling to right arm. Review of the facility incident report/investigation, dated 03/26/23 at 1:53 P.M. revealed Resident #2 was witnessed by a staff member tipped forward in his power wheelchair after hitting a pot hole in the (facility) parking lot. The resident was transported to local emergency department for evaluation. Resident #2 returned with diagnosis of right proximal humerus closed fracture injury that was identified as non-surgical. Resident #2 had a follow appointment with an orthopedic physician on 03/29/23. Resident #2 stated at the time of the incident, he was driving backwards due to the wind because he thought he was going to lose his hat. Interventions included to assess the wheelchair for damage and physical therapy services to assist with alternate mobility device until Resident #2 was released by physician to operate power wheelchair independently. The report also noted the power wheelchair representative was to be in the facility on 03/29/23 for assessment of damages to accessory applications to the chair and an order was received to place use of the power wheelchair on hold until the resident was medically cleared for use as the resident operated the wheelchair from the right side and currently had a right arm injury. A new power wheelchair assessment was to be initiated for indoor and outside of the facility when the resident was medically cleared to operate. The assessment revealed predisposing factor related to an uneven surface, physiological factors included pain and immobility and propelling in wheelchair without assistance. A nursing note dated 03/26/23 at 6:53 P.M. revealed Resident #2 returned from the hospital at 12:30 P.M. The Certified Nurse Practitioner (CNP) documented in the progress notes on 03/27/23 at 12:00 A.M. Resident #2's x-ray results from local hospital revealed he had a fracture of right humerus and to follow up with orthopedic physician. The CNP noted per the facility staff, Resident #2 was on leave of absence on 03/25/23 and was riding backwards in his motorized wheelchair. Resident #2 hit a pothole, fell out of his chair and was evaluated at local emergency department. Resident #2 complained of moderate to severe pain of right upper extremity with movement (following the incident). A nursing progress note dated 03/29/23 at 6:27 A.M. revealed the Interdisciplinary Team (IDT) reviewed Resident #2's fall that occurred while he was utilizing his power wheelchair. The IDT was in agreement with immediate interventions of therapy referral, hold independent power wheelchair usage until medically cleared, staff to assist Resident #2 in regular wheelchair for mobility, require power wheelchair mobility operation assessment with therapy and review of safety compliance agreement. Review of the plan of care for Resident #2 dated 03/29/23 revealed potential risk for falls related to decreased physical function and use of a power wheelchair with a goal to be free from significant injury thought next review date. Interventions included encourage the resident to participate in therapy as ordered, ensure call light in reach at all times, a left grab bar to residents bed, use a mechanical lift for all transfers, observe for changes in ability to complete activities of daily living and adjust assistance provided accordingly, power wheelchair use on hold until medically cleared, encourage the resident to utilize alternative mobility chair with staff providing assistance for locomotion on and off the unit until medically cleared to use power wheelchair and therapy interventions to ensure safe usage of power wheelchair. Review of the orthopedic physician note dated 03/29/23 revealed Resident #2 was a quadriplegic who fell from his wheelchair after getting stuck in a pot hole several days ago and fell (out of the chair) on to his right shoulder. The resident was seen at local emergency department and radiographs showed a proximal humerus fracture. The resident was placed in a sling as the fracture was inoperable. Resident #2 complained of pain in the right shoulder area with movement. The orthopedic plan was to increase pain medications, use ice intermittently and wear sling. Review of the resident's pain assessments and medication administration records for March and April 2023 revealed Resident #2 had increased pain after the fall on 03/25/23 rating his pain a six on a scale of one to ten. On 03/27/23 Resident #2's pain level was rated a 10 out of 10 on the day shift and nine out of 10 on evening shift. On 03/28/23 Resident #2's pain level was rated a seven out of 10 on the day shift and nine out of 10 on the evening shift. On 03/29/23 Resident #2's pain level was rated a four out of 10 on day shift and eight out of 10 on the evening shift. As a result of the increased pain a new physician order was given to increase the resident's routine pain medication from Percocet 7.5 milligrams (mg)/325 mg by mouth two times daily to Percocet 10 mg/325 mg by mouth two times daily from 03/30/23 through 04/01/23. Resident #2 also received an extra dose of Percocet 10 mg/325 mg by mouth in the afternoon from 03/30/23 through 04/01/23 for uncontrolled pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/23 revealed Resident #2 was cognitively intact and required total dependence from two persons for bed mobility, transfers, toileting and bathing. Resident #2 required supervision with locomotion and had impaired range of motion to bilateral upper and lower extremities. Resident #2 used a wheelchair for mobility. An interview on 06/11/23 at 2:20 P.M. with Resident #2 revealed he had an incident in the parking lot/driveway of the facility back in March (2023) while in his power wheelchair. The resident stated as he was returning to the facility and the wind (it was a windy day) started to blow his hat off. Resident #2 stated he could only use one arm, that arm and hand was operating the wheelchair, so he stopped, and was backing up to turn his wheelchair when the wheelchair went in to one of those deep pot holes in the parking lot and flipped him over. The resident stated he broke his arm near his shoulder. Resident #2 stated when he returned from the hospital, he was not able to operate his wheelchair safely due to his right arm fracture and the pain medications he was on. Resident #2 stated he was seen by an orthopedic physician, and around the first of May 2023, the orthopedic physician released him to be able to use his power wheelchair if he passed a safe driving course. Resident #2 stated he passed the safe driving course and was now able to use his chair again to get out of his room. An interview on 06/12/23 at 3:45 P.M. with Physical Therapist (PT) #22 revealed all residents who have a power wheelchair have to complete an indoor safety evaluation and test and if the resident wanted to go outside or in the community, they had to pass the community outdoor evaluation and test. PT #22 revealed Resident #2 passed his first test when he came in to the facility a couple of years ago. PT #22 revealed Resident #2 had an incident recently outside of the building in the parking lot/driveway. Resident #2 was coming back towards the facility, it was a windy day, and his hat was blowing off. Resident #2 stated he had stopped and tried to change direction of the wheelchair and in doing so backed up into one of the huge pot holes out there in the driveway/parking lot area. The chair flipped him over resulting in a broken right humerus to the only good and usable limb the resident had. PT #22 stated the physician had written an order the resident was not safe to drive the power wheelchair and the resident was not allowed to be up in his chair; his only independence. PT #22 revealed some time passed and the doctor gave a new order for the resident to use the chair again. At that point, PT #22 completed the indoor and outdoor safety evaluations for Resident #2, who passed both tests. An interview on 06/13/23 at 8:30 A.M. with the Director of Nursing (DON) revealed the facility had three residents, Resident #2, Resident #31 and Resident #22 who were assessed to be able to go outside in their wheelchairs independently. Outside included the parking lot and driveway area per the DON. An observation on 06/13/23 at 8:40 A.M. revealed the facility driveway had 17 large pot holes from the facility sign to the the facility/building itself. There was a sign indicating to please drive slow and look out for our residents. An interview on 06/13/23 at 3:20 P.M. with the Administrator revealed he was aware of the large pot holes and poor surface of the driveway. The Administrator stated the Maintenance Director had received a few bids on repairing the driveway/parking lot area and when the companies were called only one stated they could actually complete the repairs. The Administrator stated it was still a work in progress. However, on this date (06/13/23), the Maintenance Director purchased several 50 pound bags of asphalt to fill the holes until it can be paved. An observation on 06/13/23 at 3:41 P.M. revealed the Maintenance Director was filling the pot holes with the bags of asphalt.

Based on record review, staff interview and policy review the facility failed to implement a comprehensive and individualized restorative nursing ambulation program to ensure Resident #40 received the assistance needed for ambulation to maintain the resident's highest level of functioning ability. Actual Harm occurred for Resident #40 when the resident experienced a decline in functional ability, from only requiring minimum staff assist with the ability to ambulate 50 feet to requiring maximum staff assist with the ability to only ambulate five feet four months after her physical therapy ended and she was referred to a restorative maintenance program for ambulation that was not implemented. This affected one resident (#40) of five residents reviewed for restorative nursing services. Findings include: A review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #40's physical therapy discharge summary for dates of service between 12/10/20 and 01/05/21 revealed the resident required contact guard assist (CGA) at the time of her discharge on 01/05/21 and was able to ambulate 50 feet. Her prognosis at the time of her discharge to maintain her current level of function was indicated to be good with consistent staff follow through. Her discharge recommendations included a functional maintenance program/ restorative nursing program and assistive device for safe functional mobility. A restorative nursing program was recommended to facilitate the resident to maintain her current level of function and in order to prevent a decline. The development of an instruction in a restorative nursing program that included ambulation and transfers was to be implemented. A review of a therapy discharge recommendation sheet for Resident #40 dated 01/05/20 informational provided instructions for the nursing staff to ambulate the resident up to 50 feet with one person assist and another person to follow with a wheelchair. The resident was to use a front wheeled walker when ambulating. A review of Resident #40's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for PT was given on 05/18/21. Resident #40's medical record was absent for any evidence of her receiving restorative nursing services for transfers and ambulation between 01/05/21 when she was initially discontinued from PT and 05/18/21, when PT was ordered again. A review of Resident #40's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had adequate hearing and vision. Her speech was clear and she was usually able to make herself understood and was usually able to understand others. Her cognition was severely impaired. Physical behaviors occurred four to six days of the assessment period and verbal behaviors directed at others occurred daily. No rejection of care was noted. She required the extensive assist of two staff for bed mobility, transfers and ambulation in her room. Ambulation in the hall only occurred once or twice and she was a one person assist during those times. There was no indication of her receiving any therapy at that time. The end date of her occupational therapy was 02/03/21 and the end date for PT was 01/05/21. The MDS did not indicate the resident received any restorative nursing services during the look back period of the MDS assessment. A review of Resident #40's care plans revealed she had a care plan in place for activities of daily living (ADL) self care performance deficit and physical mobility deficit related to muscle weakness, difficulty in walking, muscle contracture of the lower leg, tremors, reduced mobility, and an extrapyramidal and movement disorder. Interventions included walking with the assistance of one and a walker and PT/ OT evaluation and treatment as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her care plans did not include anything regarding her receiving restorative nursing services for ambulation. A review of Resident #40's documentation of walking in her room or corridor for the past 30 days located under the task tab of the electronic health record (EHR) revealed ambulation was not attempted due to the resident's medical condition or safety concerns. There was no evidence of any referrals to physical therapy prior to 05/18/21 when staff deemed the resident's medical condition did not allow them to ambulate her or there were safety concerns. A review of Resident #40's PT evaluation and plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Her prior level of function was indicated to be a minimum assist for transfers, minimum assist for level surfaces and a distance level surface of 50 feet with the use of a front wheeled walker. She had been more shaky and declined with the ability to transfer/ ambulate with less safety and two falls. She had been able to safely transfer with minimum staff assist and walk with one assist prior with the use of a front wheeled walker (FWW). Her functional assessment at the time of the evaluation revealed she was a moderate assist with sit to stand transfers, maximum assist with stand pivot, maximum assist with level surfaces and her distance level surfaces was five feet using a FWW. On 05/24/21 at 10:57 A.M., an interview with State tested Nursing Assistant (STNA) #72 revealed she had been employed by the facility since February 2021 and was familiar with Resident #40. She reported the resident had required limited assist of one for transfers and was able to ambulate to the bathroom with a one person assist. She denied she used a walker when ambulating the resident. She reported the resident shook and her legs were unstable so they had to keep a hold of her. She denied the resident was part of a restorative nursing program in which they ambulated her on a regular basis. She stated they had walked her a few times with a two person assist when the resident asked them to. She was able to ambulate short distances like from the TV area to the nurses station but again stated they had no routine or program they were following. She speculated the resident may ask to walk maybe one or two times a week. She denied a walker was used when walking the resident in the hall either. She reported the resident's ability to ambulate hadn't really changed from her perspective but felt if therapy worked with her more she would be able to walk better. On 05/24/21 at 11:43 A.M., an interview with Registered Nurse (RN) #37 revealed the facility did not have a restorative nursing program. RN #37 revealed he had been employed for a few months and denied they had a restorative program during that time. He felt Resident #40 would benefit from an ambulation program. He also denied he had ever seen a walker in the resident's room or known her to use one when going to the bathroom or ambulating for any other reason. A review of the facility's restorative nursing services policy revised August 2018 revealed a restorative nursing program was utilized to assist residents to achieve and/ or maintain their optimal functional level consistent with their capabilities, goals and preferences. Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitative services. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives were individualized and resident centered, and were outlined in the resident's plan of care.

Based on record review, review of a self reporting incident (SRI), staff interview and policy review, the facility failed to ensure a resident received timely care and services following a change in condition. This affected one (Resident #100) of four residents reviewed in three separate SRI's. Actual Harm occurred for Resident #100 when she complained of extreme pain in her left hip and was noted to have swelling the morning of 02/06/21. The physician was not notified until approximately eight hours later and x-rays were not obtained until later that evening showing she had a dislocated hip. Resident #100 required treatment at the hospital for a [MEDICAL CONDITION]. Findings include: A review of Resident #100's medical record revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #100's Minimum Data Set (MDS) assessment for a modification of a significant change dated 01/12/21 revealed the resident did not have any speech or hearing problems. She was able to make herself understood and was able to understand others. Her cognition was severely impaired. She was known to have physical and verbal behaviors directed at others and other behaviors not directed at others. She was also known to reject care. She required an extensive assist of two for bed mobility and transfers. Ambulation did not occur and she was not known to have had any falls since her last assessment. A review of Resident #100's nurses' progress notes revealed a nurse's note dated 02/06/21 at 6:00 P.M. that indicated the resident complained of extreme pain and discomfort. She was continuously screaming out in pain and guarding herself from being touched. She complained of bilateral hip and pelvis pain. She was not known to have had any recent falls or injuries noted/ reported or documented. Multiple staff attempted to assess the resident but she would hardly allow them to complete a thorough assessment to her hip and pelvis area. She was offered pain medication but refused per her normal self. The physician assistant was notified and a stat bilateral hip and pelvis x-ray was ordered. X-ray was indicated to have been notified at 5:36 P.M. and was to be in the facility to complete the x-ray within two hours. X-rays done at 8:53 P.M. showed a left hip dislocation. The physician assistant was notified and a new order was received to send her to the emergency room for a reduction. The resident was transported to the local emergency room at 10:40 P.M. A nurse's progress note dated 02/07/21 at 3:18 A.M. revealed the facility was made aware the hospital was unable to do the reduction of her dislocated hip and had to send the resident to OSU Medical Center's emergency room to attempt a reduction. If not successful the resident would have to have surgery. A nurse's progress note dated 02/07/21 at 8:37 A.M. revealed the facility spoke with OSU Medical Center staff and was informed the resident would be staying awhile. Her hip was dislocated with a fracture. The physician at OSU indicated the fracture could have very well happened when the local hospital was attempting to put the hip back into place. A review of Resident #100's hospital records from the local hospital revealed she was seen for the chief complaint of hip pain. The resident reported it happened during the night. Her hip replacement was found to be out of socket per report. The facility nurse didn't know what had happened or when it may have occurred. The history of present illness indicated it was uncertain as to when the injury occurred. She was non-ambulatory and they suspected the injury may have happened sometime in the past four days. She had no signs of head trauma or any other bodily injury. An x-ray done at the hospital on [DATE] at 11:59 P.M. showed a left hip prosthesis, superior dislocation of the left hip, and no fracture. Reduction attempts were made on 02/07/21 at 12:59 A.M. and again at 1:18 A.M. Reduction attempts were stopped at 1:23 A.M. when they were unsuccessful. On 02/07/21 at 1:52 A.M. another x-ray of the left hip was done. The x-ray showed a persistent superior dislocation of the left hip prosthesis. An age-indeterminate [MEDICAL CONDITION] femoral diaphysis was noted. It was possibly old but not discernible on the prior left hip radiographs given differences in positioning. A review of Resident #100's hospital records from OSU revealed the resident arrived at their emergency roiagnom on [DATE] at 4:21 A.M. She arrived with a dislocated hip and was noted to have tenderness and bony tenderness present. She also had decreased range of motion. Prior to her hospitalization , she had two reduction attempts that had been unsuccessful. It was believed the resident may have had several days where her hip had been dislocated. An orthopedic consult was obtained and it was determined the resident would need a revision of her total hip arthroplasty. A review of a SRI # 8 for an injury of unknown origin dated 02/07/21 revealed Resident #100 had a past medical history of [REDACTED]. On 02/06/21, the resident started to complain of increased hip pain. The nurse contacted the physician's assistant for orders to x-ray the hip. The x-rays showed a dislocated hip. The resident was unable to tell them any details. Staff were allegedly interviewed for the previous 72 hours and denied knowledge of any falls or potential injuries. The resident was said to have been immediately sent to the local hospital where they attempted a reduction but was unsuccessful. She was then sent to OSU and a repeated x-ray showed she also had a fracture. The OSU emergency room doctor indicated the fracture most likely occurred while they were attempting to reduce the dislocation at the prior hospital. The facility unsubstantiated the allegation and did not feel abuse or neglect occurred. They indicated there was no evidence of injury or wrong doing at that time. Staff were said to have responded appropriately to the resident's complaints of pain and appropriate staff were notified. A review of the written witness statements obtained by the facility as part of their investigation into the injury of unknown origin revealed the obtained statements from the nurse on duty at the time Resident #100 first complained of hip pain and was noted to have swelling present. They also obtained written witness statements from the two aides that were on duty who the resident first reported her complaints to. A review of a written witness statement from State tested Nursing Assistant (STNA) #23 revealed she and STNA #19 heard Resident #100 screaming her leg was broken. They responded to her room to complete a bed check and found the resident in tears. They noticed her left upper leg was swollen to they notified the nurse Licensed Practical Nurse (LPN) #26 who came in to assess the resident. The resident informed STNA #23 that the other girls were very rough on her when changing and turning her. A review of a written witness statement from LPN #26 revealed Resident #100 complained of pain in the morning of 02/06/21. The nurse indicated the resident had a small amount of swelling to the back of her left thigh. STNA #23 alerted her to that. The nurse had the aides move the resident to her recliner calming her down and allowing her to rest until the next bed check. The nurse indicated she noted the resident's left hip jutted out. Swelling was reported to have gone down. The physician assistant was notified and a new order was received to obtain an x-ray. On 02/24/21 at 3:12 P.M., an interview with LPN #12 revealed she was asked to assess Resident #100's hip by LPN #26 on 02/06/21 after she had been noted to have complaints of pain and swelling. She stated she was working with RN #15 and they both looked at it at the request of LPN #26. She indicated it was reported Resident #100 complained of her hip hurting that morning by the aides (STNA #19 and #23) when they got her up. She reported her and the other nurse were just up front when LPN #26 asked them to look at it. She stated when she looked at it, the hip appeared to be dislocated. It was hard and bulging. The resident said it was broke but did not elaborate to her how it happened. She was a little unclear as to when they looked at the resident's hip but verified by looking at her phone that the physician assistant was not notified until 4:40 P.M. On 02/25/21 at 10:32 A.M., an interview with LPN #26 revealed she was the nurse on duty on 02/06/21 when Resident #100 complained of left hip pain and was found to have a dislocated hip. She confirmed she had two other nurses (LPN #12 and RN #15) to assess the resident's left hip after it was reported to her that she had some pain and swelling. She reported she was certain RN #15 assessed it as she was in there when she checked the resident's range of motion. She was not sure if LPN #12 looked at it or not. She confirmed the resident's complaints of her left hip pain started in the morning as she had started her medication pass and the aides entered her room for their morning rounds. She did note some swelling in the back of the resident's left thigh and the resident did complain of pain but stated that was normal for her. She confirmed the swelling was new for the resident and not something she was known to have. She stated they sat the resident in her recliner and her swelling did seem to go down. The resident went to sleep when in her chair. When they checked on her at the next bed check or two, the resident pelvis looked like it was out of alignment. She continued to complain of pain then too. She reported the physician assistant was notified sometime between the noon and the 4:00 P.M. medication pass. They received an order for [REDACTED]. When she left at 7:30 P.M., the x-ray still had not been completed. She denied she had notified the physician assistant of the resident's swelling and complaints of pain at the time it was first noted. She stated she just wanted to monitor it. She stated it was not as bad when she was in her chair and the pain was no more than normal for the resident after she had been placed in her chair. She reported it was not until the next bed check or two that they noted her left hip looked like it jutted out. She denied she initially checked the resident's range of motion in her left lower extremity when the swelling was first noted. She thought the swelling was just from her lying in bed. They did assess her range of motion when her hip was noted to jut out but the resident had limited range of motion anyway. The resident did complain of increased pain with range of motion so that was why they notified the physician. The resident had been known to complain of pain in her legs when moved and would complain of legs being broke in the past. She did not initially have any concerns the swelling the resident had was related to a fracture or a dislocation. On 02/25/21 at 11:21 A.M., an interview with STNA #23 revealed she was one of the two aides that cared for Resident #100 on 02/06/21 and reported her complaints of pain and swelling in her left hip. She reported the resident started complaining of the pain around 8:00 A.M. They heard her complaining of pain when they were doing their rounds so they went in to check on her. She stated she had informed LPN #26 of the resident's complaints of hip pain and of the swelling she had in her hip area. She reported LPN #26 did come in and check on her. The swelling was on her left upper outer leg between her knee and hip area. She denied the swelling was there when she last cared for the resident on the prior Wednesday. LPN #26 did talk with the resident about getting in her recliner and she instructed the aides to help her transfer. The resident screamed a little during the transfer but did seem more comfortable once they got her in her recliner. She thought LPN #26 had notified the physician immediately when it was first reported to her between 8:00 A.M. and 9:00 A.M. They checked on the resident again around lunch time and she wanted to remain in her recliner. She stated it was then around 2:30 P.M. and 2:45 P.M. that they placed the resident back into bed because she was going to have an x-ray done. She reported she worked until 7:00 P.M. and by the time she left the x-ray still had not been done. On 02/25/21 at 2:05 P.M., an interview with the facility's Interim Director of Nursing (DON) revealed the administrative staff was not made aware of Resident #100 being sent out with a dislocated hip until 02/07/21. She reported LPN #52 received a voicemail on her work phone informing her that the resident was sent out. LPN #52 did not get her message until she came in to work on 02/07/21 (Sunday) as a weekend manager. She was not told of the incident until LPN #52 and the Administrator (who also came into work on 02/07/21) notified her on that day. The facility initiated their investigation for an injury of unknown origin on 02/07/21. On 02/25/21 at 2:15 P.M., an interview with the Administrator confirmed she had not been made aware of Resident #100 being sent out to the hospital for a dislocated hip until 02/07/21, when she came into the facility. She confirmed how LPN #52 had been notified of the incident via voicemail. She reported LPN #52 completed the incident report when she had been made aware and they started their investigation. Findings were verified with the Administrator regarding Resident #100's delay in treatment/ evaluation following her increased complaints of pain in her left hip and new onset of swelling she was noted to have in the morning of 02/06/21. It was not clear as to why the physician assistant was not notified sooner after the change was noted or that a stat x-ray was obtained timelier than what it was. She provided a copy of the order for a stat x-ray of the bilateral hips and pelvis due to extreme pain and discomfort. The order was dated for 02/06/21 at 5:40 P.M. She also provided an email from the mobile x-ray company that showed the order for the x-ray was created in their system on 02/06/21 at 5:38 P.M. around the time the order was received. The x-ray tech was not in transit to complete the x-ray until 7:23 P.M. and images were not received until 8:51 P.M. She also provided a copy of an employee counseling sheet that was given to LPN #26 on 02/07/21. The counseling sheet indicated the nurse was instructed to please notify the ADON or DON when a resident was experiencing unusual pain and obtaining an x-ray. A review of the facility's change in condition notification protocol, undated, revealed when identifying a change in condition for a resident the following was to be implemented and/ or carried out prior to notifying the attending physician and interested family member. The facility had adopted the Interact Version 4.0 Change in Condition Tool (SBAR) as the resource for reporting a change in condition to the physician and/ or physician assistant/ nurse practitioner. As soon as the nurse had been made aware of a change in condition by an employee of the facility and once the nurse had been able to access the resident, the nurse would initiate an SBAR. The nurse would gather pertinent information as directed by the SBAR prior to making a phone call to the physician. The facility would inform the resident, consult with the resident's physician, and if known, notify the resident's representative when there was an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention, a significant change in the resident's physical/ mental/ or psychosocial status, a need to alter treatment significantly or a decision to transfer a resident from the facility. The facility would complete notification to the resident's physician to discuss the resident's status and the care for the resident. The licensed nurse was to use the physician notification pathway in determining when notification was an immediate situation. Immediate notification would include significant changes in the resident's condition. This deficiency was cited as an incidental finding to Complaint Number OH 030.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC) , observations, record reviews, review of the facility's undated isolation unit policy, review of isolation precautions policy revised February 2019, review of Triage and Quarantine Management policy revised [DATE], review of facility COVID-19 tracking forms, and interviews with staff and the local health department, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures and the appropriate use of personal protective equipment (PPE) to prevent the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy when four residents (Residents #32, #48, #57, and #73 ) who tested negative for COVID 19 remained or were placed on a COVID positive unit with six residents who tested positive for COVID-19 resulting in Resident #73 testing positive for COVID-19 six days later. Two residents (Residents #1 and #118) remained on the COVID positive unit after the negative PCR test resulting in Resident #118 testing positive for COVID-19 three days later. Two residents (Residents #78 and #100) were not moved to the designated COVID-19 unit for three days after a positive COVID-19 test result was received. Observations on [DATE] and [DATE] revealed staff not utilizing PPE appropriately and/or not completing proper hand sanitizing. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 126 residents at risk for the likelihood of harm, complications and/or death and specifically affected Residents #1, #22, #27, #95, #114, #73, #32, #48, #57, #118, #1, #78, #9, #100, #111, #56, #125, #50, #92, #117, #102, #66, #47, #76, #113, #63, #42, #67, #29, #96, #107, #55, #93, #81, and #71. The facility census was 126. On [DATE] at 3:00 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when four residents (Residents #32, #48, #57, and #73 ) who tested negative for COVID-19 remained or were placed on a COVID positive unit with six residents (Residents #1, #22, #27, #95, #114, and #118) who tested positive for COVID-19. Resident #73 then tested positive for COVID-19 six days later. Additionally, two residents (Residents #1 and #118) tested positive initially with a rapid test, then tested negative with a PCR test three days later. Residents #1 and #118 remained on the COVID positive unit after the negative PCR test. Resident #118 then tested positive for COVID-19 three days later. Furthermore, two residents (Residents #78 and #100) were not moved to the designated COVID-19 unit for three days after a positive COVID-19 test result was received. Observations on [DATE] and [DATE] revealed staff not utilizing PPE appropriately and/or not completing proper hand sanitizing. The facility's failure to effectively implement infection control practices likely contributed to the COVID-19 outbreak that spread throughout the facility infecting 44 residents with COVID-19 resulting in two deaths. As of [DATE] the Immediate Jeopardy remains ongoing. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) memo QSO ,[DATE]-ALL dated [DATE] revealed the Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of the CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of the Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations We expect facilities to use this new process, in conjunction with the latest guidance from CDC to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 . We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80 (a)(2)(i) and (ii)). 1. Review of the facility COVID-19 tracking form revealed Residents #1, #22, #27, #95, #114, and #118 all tested positive for COVID-19 on[DATE] and [DATE]. These six residents already resided on the 600 unit or were moved to the 600 unit on [DATE] when it was made the COVID positive unit. Between [DATE] and [DATE] the facility had 34 additional residents test positive for COVID-19. Two residents (Residents #22 and #111) who were positive for COVID-19 expired. The facility had 19 staff test positive for COVID-19 between [DATE] and [DATE]. Interview with Corporate RN #200 on [DATE] at 11:00 A.M. revealed that all but seven (7) residents had tested positive for COVID (the original census was 126). She stated she did not know how many staff had tested positive or how many deaths there were. 2 (a). Review of Resident #73's medical record revealed she was admitted to the facility on [DATE] and resided in a room on the 600 unit. The resident had a negative COVID-19 test on [DATE]. The facility made the 600 unit the COVID positive unit on [DATE]. Resident #73 remained on the COVID positive unit (after testing negative on [DATE]) with six residents who were positive for COVID-19. Review of facility COVID-19 tracking forms revealed Resident #73 then tested positive for COVID-19 on [DATE]. Observations on [DATE] between 3:10 P.M. and 3:50 P.M. revealed Resident #73 did reside on the COVID-19 unit. Interview with the Administrator on [DATE] at 12:25 P.M. confirmed Resident #73 had been negative for COVID-19 but had resided on the COVID positive unit. Six days later on [DATE] Resident #73 tested positive for COVID-19. The Administrator stated the positive results had been confirmed with a PCR test. 2 (b). Review of the medical records for Residents #32 and #48 revealed they tested negative for COVID-19 on [DATE]. Resident #32 resided on the COVID positive unit and Resident #48 was moved to the COVID positive unit on [DATE]. Resident #32 and Resident #48 remained on the COVID positive unit with six residents who were positive for COVID-19 until [DATE]. Residents #32 and #48 tested negative for COVID-19 on [DATE]. Observations on [DATE] between 3:10 P.M. and 3:50 P.M. revealed Residents #32 and #48 did reside on the COVID positive unit. Interview with the Director of Nursing on [DATE] at 2:40 P.M. revealed she did not think the facility had a policy regarding where COVID positive residents and residents who require quarantine but are negative are to be placed in the facility. She confirmed residents who were negative for COVID-19 were on the same unit with residents who were positive for COVID-19. 2 (c). Review of the medical record for Resident #57 revealed she was re-admitted to the facility on [DATE] from the hospital. Resident #57 was tested for COVID-19 at the hospital prior to readmission and was negative. Resident #57 was readmitted to the facility and placed in a room on the COVID positive unit that housed six residents who were positive for COVID-19. Resident #57 remained on the COVID positive unit until she was moved on [DATE]. The resident had a negative COVID-19 test on [DATE]. Observations on [DATE] between 3:10 P.M. and 3:50 P.M. revealed Resident #57 did reside on the COVID positive unit. Interview with Corporate Registered Nurse (RN) #200 on [DATE] at 4:35 P.M. revealed Resident #57 was placed on the COVID positive unit after readmission because that had been her room previously. 3 (a). Review of Resident #118's medical record revealed the resident was admitted to the facility on [DATE]. Resident #118 was tested for COVID-19 with a rapid test on [DATE]. The rapid test results were positive. Resident #118 was moved to the COVID positive unit on [DATE]. A PCR COVID test was conducted on [DATE]. The results were obtained on [DATE] and were negative. However, Resident #118 continued to reside on the COVID positive unit. Observations on [DATE] between 3:10 P.M. and 3:50 P.M. revealed Resident #118 did reside on the COVID positive unit. Review of the facility COVID-19 tracking form revealed Resident #118 was tested for COVID-19 on [DATE] and tested positive. Interview with the Administrator on [DATE] at 12:25 P.M. confirmed Resident #118 continued to reside on the COVID positive unit after negative PCR test results on [DATE] and then tested positive for COVID-19 with a rapid test on [DATE] and a follow up PCR test done after the rapid test on [DATE] also resulted in positive results. 3 (b). Review of Resident #1's medical record revealed the resident was admitted to the facility [DATE]. The resident was tested for COVID-19 with a rapid test on [DATE]. The rapid test results were positive. The resident was moved to the COVID unit on [DATE]. A PCR COVID-19 test was conducted on [DATE]. The results were obtained on [DATE] and were negative. Observations on [DATE] between 3:10 P.M. and 3:50 P.M. revealed Resident #1 did reside on the COVID positive unit. Resident #1 continued to reside on the COVID positive unit until [DATE] when she was moved to the quarantine unit due to the [DATE] negative PCR results. Interview with Licensed Practical Nurse (LPN) #201, who was also the facility Infection Prevention Nurse, on [DATE] at 7:30 A.M. confirmed Resident #1 had negative COVID test results on [DATE] but remained on the COVID positive unit. 4 (a). Review of the medical record for Resident #78 revealed an admission date of [DATE]. Record review revealed the resident had a negative rapid COVID test on [DATE]. However, an order was obtained to do a PCR COVID test. Review of the treatment administration record revealed during monitoring for symptoms of COVID, the resident was found to have a cough on [DATE]. Record review revealed Resident #9 was moved into the room with Resident #78 on [DATE]. Resident #9 had tested negative for COVID-19 on [DATE]. These residents were not on the COVID positive unit. Interview with the DON on [DATE] at 2:15 P.M. revealed the PCR COVID test for Resident #78 was ordered due to the resident's cough, to rule out COVID. Record review revealed before the PCR results were received for Resident #78, another rapid COVID test was completed on [DATE] and was positive. The positive results were documented in the nurses notes on [DATE] at 12:18 P.M. Resident #78 was moved to another room on a unit with negative residents (not the COVID positive unit) on [DATE] and was placed in a room with Resident #100 (who had tested positive on [DATE]). Review of a room change list revealed Resident #78 was moved to the COVID positive unit on [DATE]. Interview with RN #203 on [DATE] at 1:45 P.M. revealed Resident #78 was positive for COVID and Resident #9 was not. She stated both residents were on quarantine guidelines which included wearing gown, gloves, mask over N95 mask, shoe covers, and eye protection when entering room. Interview with LPN, Infection Prevention Nurse #201 on [DATE] at 2:20 P.M. revealed Resident #78 was positive for COVID and was on isolation precautions. However, Resident #9, her roommate, was not on any type of isolation or quarantine precautions. Observations on [DATE] at 2:50 P.M. revealed Resident #78 (who was COVID-19 positive) still residing in the room with Resident #9, (not on COVID positive unit). Observations at that time revealed State tested Nursing Assistant (STNA) #202 entered Resident #78's room. STNA #202 was wearing an N95 mask and eye protection goggles with gown, gloves, and shoe covers. She provided care for Resident #78. When she came out of the room, STNA #202 stated she assisted the resident with her oxygen tubing. STNA #202 removed the gown, gloves, and shoe covers prior to exiting the room. She then removed the eye protection goggles and placed them down, lens side down, on the PPE cart outside the room. She was not observed to clean the goggles and left them laying on the PPE cart. She used hand sanitizer. She did not change the N95 mask and proceeded to Resident #3's room (this resident was COVID-19 negative) and asked that resident if she was ready to go to bed. Observations on [DATE] at 6:30 A.M. and interview with LPN #214 revealed Resident #9 was not on quarantine/isolation precautions at this time, even though this resident was exposed to Resident #78, her roommate, who tested positive for COVID-19 on [DATE]. Observations on [DATE] at 6:40 A.M. revealed Resident #78 (who was COVID-19 positive) and Resident #100 in a room together on the 300 unit (not the COVID unit). This was a unit where all the other residents were negative for COVID-19. 4 (b). Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE]. Review of nurse's notes dated [DATE] at 2:30 P.M. revealed the resident was complaining of nausea, myalgia, and decreased taste. An order was obtained for a COVID-19 test. The rapid test on [DATE] was negative. There was no evidence the resident was placed on quarantine/isolation precautions due to symptoms. On [DATE] at 12:44 A.M. the resident had a temperature of 101.8. On [DATE] at 3:32 P.M. a rapid COVID test was positive. The resident remained on a unit with negative residents. Resident #100 was placed on quarantine on [DATE] and another positive resident (Resident #78) was moved into her room on [DATE]. Resident #100 did not have a roommate prior to [DATE]. On [DATE] the facility received a positive PCR COVID test result and the Resident #100 was moved to the COVID positive unit. Observations on [DATE] at 6:40 A.M. revealed Resident #100 was in a room on the 300 unit (not the COVID unit). This was a unit where all the other residents were negative for COVID-19. Interview with LPN, Infection Prevention Nurse #201 on [DATE] at 7:30 A.M. revealed Resident #100 had a cough and fever on [DATE] so a rapid COVID test was done. LPN #201 confirmed the test was positive. She confirmed Resident #100 was not on the COVID positive unit. The LPN confirmed there were four residents on the COVID unit who were negative for COVID-19. She stated she did not know what the facility policy was regarding having a COVID unit or a quarantine unit. LPN #201 confirmed the facility did not have a quarantine unit and residents who were on quarantine were spread throughout the facility. The LPN confirmed Resident #100 was not on isolation precautions during the time she was having symptoms of COVID-19. 5 (a). Observations on [DATE] at 12:45 P.M. on the 100 unit revealed a sign on the door of Resident #56 and Resident #125's room to see the nurse before entering. Interview with LPN #206 on [DATE] at 12:45 P.M. revealed Resident #125 was on contact/droplet precautions due to having been out of the facility for a physician appointment and possibly being exposed to COVID-19. However, she confirmed the resident did not have a physician's orders [REDACTED].#56 was on isolation precautions or not. She confirmed Resident #56 did not have an order either for isolation precautions. She stated she thought he was on precautions or he would not be in a room with Resident #125. Observations on [DATE] at 12:46 P.M. revealed STNAs #204 and #205 went into Residents #125 and Resident #56's room. Neither STNA applied any eye protection prior to entering the room. They wore N95 masks but did not change the masks when leaving the room. STNA #204 proceeded to the kitchen to obtain something for a resident and STNA #205 proceeded to the 200 unit to pick up meal trays wearing the same N95 masks that was worn in Residents #125 and #56's room. 5 (b). Observations on [DATE] at 12:55 P.M. revealed a sign on the door of Residents #50 and #92's room to see the nurse before entering. LPN #207 and RN #208 were observed in the room. LPN #207 was observed standing next to Resident 50's bed and a syringe was observed in her hand. LPN #207 was not observed wearing a gown, gloves, or eye protection. She only had on a N95 mask. RN #208 was standing next to her and later indicated she was in orientation. RN #208 also did not have on a gown, gloves, or eye protection. She only had on a N95 mask. On [DATE] at 1:00 P.M. during interview, LPN #207 stated she was administering a bolus tube feeding to Resident #50. She confirmed she was not wearing gloves. She stated Resident #50 was not on isolation precautions. She stated only the roommate was on isolation precautions (Resident #92). LPN #207 stated Resident #92 was on isolation precautions as he had been out of the facility for [MEDICAL CONDITION]. Record review revealed neither Resident #50 nor Resident #92 had physician orders [REDACTED]. Interview with LPN, Infection Prevention Nurse #201 on [DATE] at 7:30 A.M. revealed both Residents #50 and #92 were on isolation precautions due to being new admissions to the facility. She stated the facility did not have a producible tracking system for residents on isolation precautions to determine why they were on it or when it started or when it ended. Interview with the DON on [DATE] at 2:45 P.M. confirmed Residents #114, #95, #27, #22, #78, #100, and #111 did not have physician orders [REDACTED]. On [DATE] at 9:30 A.M. during interview the DON stated the facility had put up signage the night before to instruct staff on how to apply and remove PPE. She stated this had not been up prior for residents on isolation precautions. 5 (c). Observations on [DATE] at 3:30 P.M. on the COVID positive unit revealed STNA #210 came out of Resident #22's room (positive for COVID-19). STNA #210 took off her gown and gloves. She was not observed to sanitize her hands. She then put on a gown and gloves and entered Resident #95's room (positive for COVID-19). On [DATE] at 3:52 P.M. STNA #210 was observed coming out of a resident room on the COVID positive unit. She removed her gown and gloves and, without sanitizing her hands, got a packet of new isolation shoe covers, opened it, and placed the shoe covers in the PPE containers at resident doors. She then pushed the clean linen cart down the hall and placed linens in the linen closet. Interview with STNA #210 on [DATE] at 3:40 P.M. confirmed staff on the COVID positive unit wear the same N95 mask all shift for COVID positive residents and COVID negative residents. Interview with RN #209 on [DATE] at 3:50 P.M. revealed the staff on the COVID positive unit wear the same N95 mask the whole shift. She stated they wear the same N95 mask into the rooms of residents who are positive and the rooms of residents who are negative. She stated she only cleans her face shield at the end of her shift, not after each resident contact. Interview with LPN, Infection Prevention Nurse #201, on [DATE] at 10:00 A.M. confirmed all staff wear the same N95 masks all shift and do not change between residents. She stated staff should use bleach wipes to clean eye protection after each resident contact. 5 (d). Observations on [DATE] at 9:40 A.M. revealed STNA #212 came out of Resident #117's room. RN #213 identified the resident as being on isolation precautions due to his previous roommate being positive for COVID-19. STNA #212 removed her gloves and gown; used hand sanitizer; removed her face shield and laid it on the bedside table inside the room with the outside of the shield facing down. She removed her surgical mask which was over her N95 mask. She then put on gloves and cleaned the face shield. She then hung the clean face shield on the doorknob of the room door. She stated there are supposed to be hooks inside the room and on the outside of the door. The hook inside the room is to hang the dirty face shield on until you can clean it. The hook on the outside of the door is to hang the clean face shield on after you clean it. She confirmed she had to lay the dirty face shield on the bed side table as there were no hooks in the room. She was not observed to clean the bedside table prior to leaving the room. Interview with Corporate RN #200 on [DATE] at 9:55 A.M. confirmed there were no hooks inside or on the door for Resident #117's room and there should have been. 5 (e). Observations on [DATE] at 10:00 A.M. revealed five residents in the outside smoking area. STNA #212 was with the residents while they were smoking. When Resident #102 was done smoking her cigarette, she handed it to STNA #212. (Resident #102 was COVID negative at that time). STNA #212 took the cigarette in her ungloved hand and touched the part that went in the resident's mouth with her fingers. She then put the cigarette on the ground, stomped it out, picked it up again, and put it in a plastic cup she was holding. She then, without sanitizing her hands, went over to the keypad on the outside of the door entering the facility, and punched in the code to allow a resident to go inside the building. Interview with STNA #212, at that time, confirmed she did not sanitize her hands after handling the part of the cigarette that had went in Resident #102's mouth with her bare hands. She confirmed she touched the keypad, that any staff or resident could touch, without sanitizing her hands. 5 (f). Observations on [DATE] at 10:45 A.M. revealed RN #213 leaving a room on the 100 unit, this room had been identified housing a resident on quarantine due to potential COVID-19. She removed her PPE and was observed cleaning the face shield she had removed without wearing any gloves. She then hung the clean face shield on the room door. The facility provided documentation that stated staff were educated beginning [DATE] to remove PPE when exiting a quarantine/isolation room in the following order: remove gloves, wash hands, put on new gloves, remove face shield, gown, and surgical mask, clean face shield and place on clean hook, remove gloves, and clean hands. Interview with RN #213 on [DATE] at 11:50 A.M. confirmed she was not wearing gloves when she cleaned her soiled face shield and should have. She stated this was an error on her part. She stated that the signage in the room gave instructions on how to remove PPE but did not include instructions on how to clean the face shield. 6. Interview with the Administrator and Director of Nursing on [DATE] at 11:15 A.M. revealed they had been in contact with the local health department regarding the positive cases of COVID-19 for residents and staff. They stated the local health department was aware they had residents negative for COVID-19 on the COVID positive unit. The Administrator stated the local health department contact told them not to move the COVID negative residents off the COVID positive unit. She further stated the local health department was aware they had COVID positive residents on a unit with negative residents. She stated the local health department did not have a problem with this. Interview with Local Health Department Nurse #211 on [DATE] at 2:10 P.M. revealed she was not aware the facility had COVID-19 negative residents on the COVID positive unit and that this should not happen. She also stated she was not aware the facility had COVID-19 positive residents on a unit with negative residents. She stated this had not been discussed with her by the facility. 7. On [DATE] at 11:26 A.M. five resident meal trays were observed on a cart outside the COVID-19 unit. A staff from the COVID-19 unit was observed to open the door and pull the cart in the unit. A concealed metal tray cart was left outside the COVID-19 unit on [DATE] at 11:43 A.M. and staff from the COVID-19 unit were observed to open the door to the unit and pull the tray delivery cart inside. On [DATE] at 1:20 P.M., a large metal tray cart was observed sitting in the hallway adjacent to the nurse's station on the COVID-19 unit. On [DATE] at 11:17 A.M. during interview the Administrator reported that dietary staff take the tray carts to the door of the COVID-19 unit and notify staff the carts are there. Staff from the COVID unit then come to the door and pull the carts inside the unit and pass the trays. The Administrator stated when the carts are to be returned to the kitchen, staff notify the kitchen and push the tray carts outside the unit and the dietary staff take the trays to the kitchen where they are cleaned. On [DATE] at 1:15 P.M. during interview LPN #201 stated the meal cart was brought outside of the COVID unit and dietary called to let them know it was there. LPN #201 stated staff would go to the double door and wheel the carts on the unit. When they were finished with the carts, staff would push the empty cart outside the unit doors and kitchen staff would take the cart to the kitchen and clean the cart. LPN #201 confirmed the cart was not cleaned on the unit and was taken down a common hallway before entering the kitchen service area to be cleaned. On [DATE] at 3:32 P.M. during an interview with Dietary Manager (DM) #309 she reported kitchen staff obtained the meal carts from the hallway outside the COVID unit and the carts are taken to the dining room where kitchen staff wash each cart with soap and water, rinse and then spray with a sanitizing solution. DM #309 reported when the carts are taken into the kitchen for the next meal, they are sanitized again, just to ensure no transmission. DM #309 reported she was not aware of any type of cleaning or sanitizing nursing staff performed before they removed the carts from the COVID unit. 8. Observations on [DATE] at 12:20 P.M. revealed STNA #205 put on PPE to enter the room of a resident on quarantine (room [ROOM NUMBER]). STNA #205 had on an N95 mask and goggles. She put on a gown, surgical mask over the N95 mask, gloves and face shield prior to entering the room. She delivered the meal tray to the resident. When she was done, she removed the gloves and face shield. She hung the dirty face shield on the doorknob of the room door without cleaning it after use. She removed her gown and surgical mask and washed her hands. STNA #205 then put on a different face shield to deliver a tray to Resident #92 who was on quarantine. When she exited the room, she took off the face shield and laid it down on top of a box of gloves on the PPE caddy in the hallway without cleaning it. Interview with STNA #205 on [DATE] at 12:40 P.M. revealed there were no hooks in the rooms to hang the face shield on after use. She stated there was supposed to be a hook inside the room to hang the dirty face shield on until it was cleaned. Also, there was supposed to be a hook on the door to hang the face shield on after it was cleaned. She confirmed she did not clean the face shields prior to hanging the first one on the doorknob or prior to laying the second one on the PPE cart. Observations on [DATE] at 12:40 P.M. revealed STNA #223 put on the face shield that had been worn by STNA #205 but had not been cleaned. 9. Interview with Resident #66 on [DATE] at 12:43 P.M. revealed she had just been moved to the room she was in (on the 200 unit) from the COVID unit. She stated that none of her personal belongings had been brought to the room and she wanted them. She stated her purse, wheelchair, and pictures had not been moved to her new room. However, observations on [DATE] at 12:43 P.M. revealed that there were items in the room with Resident #66 including a water pitcher with straw, snack items (bags of chips), flowers, and pictures on the wall. Additional interview with Resident #66 on [DATE] at 12:43 P.M. revealed that these items belonged to the resident who resided in the room prior to her. Interview with STNA #205 on [DATE] at 12:50 P.M. confirmed the personal items in the room with Resident #66 belonged to Resident #47, who had resided in the room prior to Resident #66. Interview with STNA #223 on [DATE] at 12:50 P.M. revealed that residents were being moved to new rooms without taking their personal belongings with them. Therefore, residents were being placed in rooms with personal items that did not belong to them. She confirmed Resident #66 was placed in a room with Resident #47's personal belongings. She stated the STNAs have to try to clean the room before a new resident moves in. However, she stated staff could not clean the room when another resident's personal belongings were still in the room. She confirmed the food and water pitcher on Resident #66's side of the room belonged to Resident #47. Interview with LPN #207 on [DATE] at 1:05 P.M. confirmed Resident #66 was moved into a room with Resident #47's personal belongings still on the that side of the room. Review of the medical record for Resident #47 revealed the resident was moved from that room on [DATE]. Record review also revealed she tested negative for COVID 19 on [DATE]. Review of the medical record for Resident #66 revealed the resident was moved from the COVID unit to the 200-unit room on [DATE]. Record review also revealed she tested positive for COVID 19 on [DATE]. 10. Observation on [DATE] at 12:05 P.M. of the memory care unit/400-hall revealed room [ROOM NUMBER] had a quarantine cart outside the door and a note posted on the door that read Please see nurse before entering. It was noted that Resident #76 who currently resided in the room was placed in quarantine on [DATE] due to her former roommate testing positive for COVID-19. Continued observation revealed Resident #113 who was COVID negative, laying in the roommate bed in room [ROOM NUMBER] Resident #63 was observed entering room [ROOM NUMBER] and proceeding to 401 B and touching Resident #76's feet and bed side table. Resident #63 then proceeded to exit room [ROOM NUMBER] and enter room [ROOM NUMBER] and lay in bed. Resident #113 was then observed getting out of the bed in 401 and exiting the room and entering room [ROOM NUMBER], going into the bathroom in room [ROOM NUMBER], opening the closet door and touching clothing in the closet and then laying down on the bed in room [ROOM NUMBER] . Interview on [DATE] at 12:25 P.M. with STNA #520 confirmed room [ROOM NUMBER] was a quarantine room and Resident #113 and Resident #63 were noted entering room [ROOM NUMBER] and touching multiple items in that room along with lying in bed, then proceeding to enter additional rooms that were not their own rooms thereby potentially spreading the COVID-19 virus. 11. Interview on [DATE] at 3:30 P.M. with STNA #506 revealed Resident #42, who had tested positive for COVID-19 on [DATE], was transferred to the COVID unit on [DATE]. Prior to being transferred to the COVID unit, there was another resident who had resided in that room. STNA #506 revealed the room was not cleaned prior to the facility transferring Resident #42. 12. Observation on [DATE] at 9:30 A.M. of the memory care unit/400-unit revealed there were COVID-19 positive residents residing in the same rooms with COVID negative residents. Resident #67 who had tested COVID-19 positive on [DATE] and was residing in a room with Resident (TRUNCATED)

Based on observation, record review, interviews, review of staffing policies, and facility's assessment, the facility failed to ensure adequate staffing to meet the needs of residents related to medication administration, falls, abuse, smoking, prompt response to call lights, and assistance for other activities of daily living for dependent residents. This resulted in Immediate Jeopardy on 11/02/20 when one nursing assistant was not able to timely deliver meal trays to residents on the 300-quarantine unit where approximately 23 residents resided, resulting in cold food. In addition, the lack of adequate staffing resulted in delayed medication administration, including insulin and antihypertensive medication, affecting 25 residents, (Residents #1, #5, #6, #8, #23, #27, #30, #31, #37, #53, #54, #62, #66, #70, #73, #74, #84, #85, #88, #101, #106, #110, #114, #126, and #127), delayed assistance in getting requested ice water, affecting Resident #101, delayed assistance getting out of bed for a dependent resident affecting Resident #83, delayed assistance with smoke breaks affecting Residents #4, #92, and #125, lack of proper supervision resulting in falls, affecting Resident #42, lack of supervision resulting in sexual abuse, affecting Residents #2, and #115, and delayed call light response, affecting Resident #66. The lack of adequate staffing placed all residents at risk for the likelihood for serious harm, serious injury, or death. The facility census was 126. On 11/09/20 at 5:25 P.M. the Regional Executive Director of Operations #501 and the Director of Nursing (DON) were notified that a situation of Immediate Jeopardy was present starting 11/02/20 when the facility failed to ensure enough staff was available to meet the care needs of its residents. This included adequate number of nurses and state tested nursing assistants (STNAs) to provide assistance with activities of daily living, medication administration, prompt response to call lights, and supervision to prevent falls and sexual abuse. As of 11/13/20 the Immediate Jeopardy remained ongoing. Findings include: 1. During an interview with the Administrator on 11/02/20 at 11:17 A.M. she stated the normal staffing pattern for the 300 unit was one STNA and one nurse. The Administrator reported when two STNAs were assigned to the 300 unit she would normally find one sitting at the nurses' station. The Administrator stated she felt one STNA and one nurse would be sufficient at this time when the 300 unit was also being utilized for the COVID-19 quarantine unit. At the time, there were approximately 23 residents on the 300 unit. On 11/02/20 at 11:20 A.M. noon meal trays for Residents #8 and #23 were observed left on a cart near the 300 unit nurses' station. STNA #303 was observed on 11/02/20 at 12:21 P.M. taking the noon tray to Resident #8 (a full hour after it had been delivered to the floor). STNA #303 was observed setting the meal tray up. Resident #8 did not respond when the tray was set up. STNA #303 reported he did not know if Resident #8 would eat anything or not, she appeared to be tired today. STNA #303 confirmed he did not attempt to assist Resident #8 with the meal at this time because he was the only one answering lights and giving resident care. Occupational Therapy Assistant (OTA) #307 reported on 11/02/20 at 11:45 A.M. Resident #8 and #23's meal trays were delivered before the cart trays because they needed assistance with their meal. On 11/02/20 at 11:30 A.M. the call light for room [ROOM NUMBER] was on. The call light was answered by STNA #303 on 11/02/20 at 11:47 A.M. (17 minutes later). The call light for room [ROOM NUMBER] was observed to be triggered on 11/02/20 at 11:32 A.M. STNA #303 was observed to enter the room on 11/02/20 at 11:46 A.M. and assist Resident #106 with a bedpan. (12 minutes later). The call light for room [ROOM NUMBER] was observed to be triggered on 11/02/20 at 11:35 A.M. On 11/02/20 at 11:54 A.M. (19 minutes later), STNA #303 entered the room and upon exit reported Resident #127 needed a riser for the toilet and left the floor to find a toilet riser for the resident. STNA #303 stated on 11/02/20 at 11:38 A.M. that he was working as an STNA today, however he was the Housekeeping Supervisor. STNA #303 stated he and Registered Nurse (RN) #203 were the only staff assigned to the 300 unit. STNA #303 stated if two STNAs were working on the floor, resident care, answering call lights and passing trays would be timelier. On 11/02/20 at 12:05 P.M. Resident #106's call light was observed to trigger. RN #203 was observed to answer the call light on 11/02/20 at 12:21 P.M. (16 minutes later) and assisted the resident off the bedpan. Resident #106 stated she did not think it would take that long to get the bedpan and it was uncomfortable. On 11/02/20 at 12:10 P.M. the 300 unit cart with noon meal trays was brought to the unit. STNA #303 and RN #203 were working on the 300 unit. STNA #320, whose normal job was in the business office had been pulled to work on the 300 unit, was observed donning personal protective equipment (PPE) on 11/08/20 at 12:30 P.M. and delivered the first tray from the meal cart to Resident #41 on 11/08/20 at 12:36 P.M. (26 minutes after the cart was delivered to the floor). The second tray from the meal cart was removed on 11/08/20 at 12:43 P.M. and delivered to Resident #12. STNA #320 reported on 11/08/20 at 12:47 P.M. she was waiting for someone to bring the size gloves she wore to the floor before she could deliver anymore trays. On 11/02/20 at 12:52 P.M., STNA #320 delivered Resident #57 her dinner tray. STNA #303 had been providing resident care while STNA #320 was delivering meal trays and on 11/02/20 at 12:53 P.M. STNA #303 started delivering meal trays to resident rooms. On 11/02/20 at 1:04 P.M. the surveyor requested Dietary Manager (DM) #309 to take temperatures of food which had been on the cart since arrival to the floor at 12:10 P.M. Pork cutlet was 99 degrees (*) Fahrenheit (F), Brussel Sprouts were 99.3*F and potatoes were 88.5*F. The oranges, which were to be served cold, were 72.8*F. DM #309 reported temperatures ranged from 190*F to 204*F for hot food and the oranges were 38*F when leaving the kitchen. On 11/02/20 at 1:08 P.M. STNA #320 confirmed the trays were being delivered to residents after sitting on the meal cart for an extended time. STNA #320 stated no staff was available to hand the tray into a resident room after she had donned the PPE and this was also taking more time, however, felt even without the PPE, it would be difficult for one STNA to pass trays, provide care and answer call lights on the 300 unit. Corporate RN #200 confirmed on 11/02/20 at 1:12 P.M. during observation of meal delivery that staffing had been an issue with timely delivery of the noon meal. The Administrator stated she had just informed staff that if a resident would like another tray from the kitchen to let them know and they would get the resident warm food. RN #200 and the Administrator confirmed that they had not offered to assist STNA #303 and #320 with delivery of the noon meal. On 11/02/20 at 1:13 P.M. RN #203, who was working on the 300 unit, stated she had just finished the medication administration and observation of the noon meal delivery did not appear efficient and with the number of staff, they were not able to pass trays in a timely manner. On 11/02/20 at 1:15 P.M. upon entering the Covid-19 unit, five call lights were observed on. LPN #312 and #201 were observed talking at the nurses' station. LPN #201 stated it was almost time to take residents outside to smoke and she needed to see which residents wanted to go out to smoke. LPN #312 remained at the nurses' station. On 11/02/20 at 1:24 P.M. STNA #316 was observed performing housekeeping duties. STNA #316 reported nursing staff on the Covid-19 unit were currently responsible for housekeeping and activities. STNA #316 stated two other STNAs were working the unit today, however, did not know where they were at this time and did not think they were inside the building. STNA #316 was observed to answer the first call light that had been on since 1:15 P.M. at 1:47 P.M. LPN #201 stated on 11/02/20 at 1:50 P.M. call lights should be answered with 10 minutes. 2 (a). Interview with LPN #216 on 11/03/20 at 1:45 P.M. revealed she was the only nurse on duty for the 600 and 700 units with 37 residents who were all COVID positive. On 11/03/20 at 2:00 P.M. she stated there were nine residents (Residents #27, #37, #53, #66, #70, #73, #110, #114, and #126) who had not received their morning medications due between the time window of 7:00 A.M. and 11:00 A.M. which included insulin for Resident #110 and blood pressure medication for Resident #66. In addition, she stated Resident #31 was due to receive pain medication ([MEDICATION NAME]) at 12:00 P.M. which had not been given as of 2:00 P.M. She stated it was impossible for one nurse to administer medications for both the 600 and 700 units. Review of the Medication Administration Records (MAR) on 11/03/20 at 2:00 P.M. confirmed the medications were past due for Residents #27, #31, #37, #53, #66, #70, #73, #110, #114, and #126. The MARs for November 2020 for Residents #27, #31, #37, #53, #66, #70, #73, #110, #114, and #126 were requested from the facility. However, the facility failed to provide the records. Interview with Residents #27, #31, #37, #73, #114, and #126 confirmed medications were late. (b). Observation on 11/04/20 at 11:10 A.M. revealed the Minimum Data Set 3.0 (MDS) Nurse #221 was still administering Rise medication to the 300 unit. MDS Nurse #221 confirmed she still had the back half of the 300 unit to administer medication to which included 15 Residents (#1, #5, #6, #8, #23, #30, #54, #62, #74, #84, #85, #88, #101, #106, and #127), Medication not yet administered included blood pressure medication for Resident #54. Interview on 11/04/20 at 11:15 A.M. with MDS Nurse #221 revealed that due to the originally scheduled nurse calling off she was pulled from her normal position as MDS nurse to work as a floor nurse, and this was something she did not normally do and was falling behind. MDS Nurse #221 also confirmed that when a medication was assigned to be administered at Rise in the resident's electronic Medication Administration Record [REDACTED]. The MAR for November 2020 for Residents #1, #5, #6, #8, #23, #30, #54, #62, #74, #84, #88, #101, #106, and #127 were requested from the facility. The facility failed to provide the records. Review of the facility's medication administration times revealed medication that was noted to be administered every morning, every day, every other day, twice a day, three times a day, and four times a day, the first dose for the day would be administered between 7:00 A.M. and 11:00 A.M. Review of the facility's policy titled Medication Administration and Documentation-Education, revised on 07/2018, revealed under Documentation of Medication Administration number 4. Medications may be given up to 60 minutes before or after the designated administration time unless ordered at specific time. Under number 6. If medications are given outside of the scheduled administration times, the physician will be notified, and every effort made to return to the established schedule. Under number 7. Any omission or delay in medication administration requires a brief explanation. Review of the facility's assessment, revised on 03/12/20, revealed under Part 2: Services and Care We Offer Based on Our Residents' Needs, under General Care Medication, Awareness of any limitations of administering medications, administration of medication that residents need by route: oral, nasal, [MEDICATION NAME], sublingual, topical, subcutaneous, rectal, intravenous, intramuscular, inhaled, vaginal, ophthalmic, etc. 3. Observation on 11/04/20 at 11:20 A.M. revealed Resident #101 asking staff for some ice water because her water pitcher was empty. STNA #524 and STNA #220 were both observed telling Resident #101 that they would get her some fresh water in a few minutes. STNA #524 proceeded to enter another resident's room to obtain vital signs and STNA #220 entered another resident's room while holding a meal tray to assist with feeding. Continued observation revealed Resident #101 did not receive fresh ice water until 12:30 P.M. Interview with STNA #220 confirmed they were not able to get Resident #101's ice water in a timely manner due to not having enough time to meet everyone needs nor having enough staff to help out. 4. Observation on 11/04/20 at 2:30 P.M. revealed staff exiting Resident #83's room after assisting him out of bed into his wheelchair. Interview on 11/04/20 at 2:31 P.M. with Resident #83 revealed he had asked the staff if he could get up out of bed around 6:30 A.M. Resident #83 revealed the staff told him they were too busy to get him up at that time and it would have to be later on. Resident #83 confirmed that 2:30 P.M. was the first time he had been out of bed for that day. Interview on 11/04/20 at 2:40 P.M. with STNA #212 confirmed Resident #83 requested to get out of bed earlier that morning but due to there only being one nursing assistant providing care on that unit for 18 residents , they were not able to get Resident #83 out of bed till later on that day. 5 (a). Observation on 11/04/20 at 1:26 P.M. revealed Residents #4, #92, and #125 sitting by the 100 and 200 unit nurses station, waiting for a staff member to come and take them outside for their scheduled smoke time, which was at 1:30 P.M. Continued observation revealed these residents did not go outside to smoke until 1:50 P.M. Interview on 11/04/20 at 1:45 P.M. with STNA #212 revealed it was the responsibility of the 100 unit or 200 unit staff members to take the residents out for their scheduled smoke breaks. STNA #212 revealed she had asked Licensed Practical Nurse (LPN) Infection Preventionist (IP) #201 to ask for someone else to do this task because aides did not have time to do it and LPN IP#201 was the only nurse for both the 100 unit and 200 unit until 2:00 P.M. Observation on 11/09/20 at 9:30 A.M. revealed Residents #4, #92, and #125 sitting by the 100 and 200 unit nurses station, waiting for a staff member to take them outside for their scheduled smoke time which was at 9:30 A.M. Continued observation at 10:32 A.M. revealed the same mentioned residents still sitting by the nurses station waiting to go outside to smoke. At 10:38 A.M. Residents #4, #92, and #125 were assisted outside to smoke. Interview on 11/09/20 between 9:36 A.M. and 9:45 A.M. with Residents #4, #92, and #125 confirmed having to wait for staff to find time to take them outside to smoke happened all the time. It was rare for smoke breaks to occur at the scheduled times. Interview on 11/09/20 at 9:50 A.M. with LPN #207, revealed she was still currently administering morning medication and the STNAs were busy providing resident care. Observation on 11/09/20 at 9:52 A.M. revealed Scheduler #525 approached LPN #207 and informed her that it was time for the residents to go out for their scheduled 9:30 A.M. smoke break. LPN #207 informed Scheduler #525 that the floor staff was too busy and did not have enough help to do this right now. (b). Observations on 11/03/20 at 9:38 A.M. revealed Resident #102 sitting in the hallway on the 100 unit asking for staff to come and supervise outside smoking. STNA #212 was observed providing care to a resident. Interview with STNA #212 on 11/03/20 at 9:38 A.M. revealed staff on the 100 unit were assigned to supervise outside smoking. She stated she was the only nursing assistant scheduled to work on the 100 unit, making it difficult to supervise outside smoking and provide care to the residents. 6. Review of Resident #42's medical record revealed a progress note dated 11/07/20 at 6:57 P.M. by RN #225 revealed Writer called to the 600 (unit) for resident lying on floor with puncture wound/ laceration to posterior head. Moderate amount bright red active bleeding observed. Upon assessment writer noted resident's skull visible through gaping head wound. Resident also noted to have skin tear to right elbow. Nurse Practitioner #502 made aware of resident's fall with injuries, writer given instruction to send to the emergency room for eval of head wound and possible need for sutures. Interview on 11/09/20 at 11:52 A.M. with STNA #526 revealed she was working the COVID unit on 11/07/20 when Resident #42 had his fall. STNA #526 claimed she was in another resident's room when she heard the code falling star being called. When she came out of the resident's room, she saw two nurses holding the back of Resident #42's head and trying to keep him calm. STNA #526 said she approached the resident in attempts to calm him down as well and keep him from getting up. STNA #526 also revealed that on that day there was only one nurse and one STNA on the 600 unit and one nurse and one STNA on the 700 unit for 38 residents which both were COVID units, and felt they were not adequately staffed to provide care and supervision for residents. STNA #526 also revealed that she felt Resident #42's fall may have been prevented if there were more staff on the units and there would have been more staff available to keep a closer eye on this resident. Review of the facility's policy titled Fall Management, dated 01/29/20, revealed the facility will identify each resident who is at risk for falls and will develop a Plan of Care and implement interventions to manage falls. The facility will provide an environment that is free from potential hazards. The licensed nurse will perform a Fall Risk Assessment immediately if the resident is deemed to be at risk. Review of the facility's assessment, revised on 03/12/20, revealed under Part 2: Services and Care We Offer Based on our Residents' Needs revealed a general care area of Mobility and fall/fall injury prevention, Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself. 7. Review of a self-reported incident form submitted to the State Survey Agency by the facility on 11/09/20 revealed it was dated 11/09/20 and date of discovery listed as 11/09/20. The allegation was sexual abuse. The alleged perpetrator was listed as another resident. The initial source of allegation was listed as staff. Involved residents were listed as Resident #115 and Resident #2. The incident form stated both residents had dementia, and neither were able to provide any meaningful information. The date, time, and location of the occurrence were blank on the form. The narrative summary of the incident and witness statements were blank. Interview with STNA #219 on 11/09/20 at 11:00 A.M. revealed she had been assigned to work on the dementia unit (400 unit) last night, 11/08/20 from 7:00 P.M. to 7:00 A.M. on 11/09/20. However, she was pulled to work on the 300 unit. She stated STNA #218 was working on the dementia unit by herself at the time an incident regarding Resident #115 happened. She stated STNA #218 came off the dementia unit and reported that Resident #115 had gone in Resident #2's room and put his hand under her gown in the chest area. Resident #2 was crying and STNA #218 got him out of her room. STNA #218 went back and saw that Resident #2 was wet and Resident #115 had urinated on her. Resident #2 was still upset. Resident #2's gown was wet at the top but her incontinence brief was dry. STNA #219 stated when there was only one staff on the dementia unit, you couldn't keep an eye on 21 residents, especially when in a room providing care. She stated the week prior; the nurse was only able to be on the dementia unit about two hours per shift because of working on another unit also. STNA #219 stated Resident #115 had a history of [REDACTED]. She stated he won't sit down and wandered up and down the unit going in other resident rooms. She stated there was nothing they could do when they were short staffed and only had one or two staff on the unit. She stated she felt Resident #115 knew when the staff were busy and that was when he went in female resident rooms. She stated there were residents who required assistance from two staff so even when there were two staff, they could both be in a resident room providing care. Interview with LPN #217 on 11/09/20 at 10:10 A.M. revealed she was the nurse assigned to work on the dementia unit (400 unit) beginning at 7:00 P.M. on 11/08/20 through 7:00 A.M. on 11/09/20 with 21 residents. However, she stated she was also assigned to cover the 300 unit, for that shift with 19 residents. She stated that around 8:30 P.M. on 11/08/20 STNA #218 reported to her that, after being in a resident room providing care on the dementia unit, she was unable to find Resident #115 in his room. STNA #218 then looked for him and found him in female Resident #2's room. She reported that Resident #115 had his hands under Resident #2's gown near her breast area. She reported that Resident #2's gown was wet up the front. LPN #217 stated that STNA #218 presumed Resident #115 had urinated on Resident #2 as her disposable underwear was dry. LPN #217 stated Resident #2 was unable to verbally express what happened but STNA #218 said Resident #2 seemed irritated and was moaning at the time of the incident. LPN #217 stated that STNA #218 indicated Resident #115 tended to follow the female residents around and be friendly with them. LPN #217 stated she was working on the 300 unit (outside of the secured doors of the dementia unit) at the time of the incident. She stated she had never worked on the dementia unit before and did not know how to handle the incident. When asked what was done as a result of the incident, LPN #217 stated they separated Resident #115 from Resident #2 and then got Resident #2 cleaned up. She stated Resident #115 then went to bed and the STNA kept an eye on him. Interview 11/15/20 at 11:45 A.M. with STNA #218 revealed the Dementia Unit had one staff working the unit on 11/08/20 when Resident #2 was sexually assaulted by Resident #115. The Dementia Unit had 21 residents at the time. STNA #218 revealed her co-worker was pulled to another unit at 7:00 P.M., the beginning of their 12-hour shift. The nurse was responsible for two other units beside the Dementia Unit and normally did not arrive on the Dementia Unit until approximately 11:00 P.M. On 11/08/20 at 8:30 P.M. Resident #115 was observed sexually assaulting Resident #2. STNA #218 was on the unit herself. STNA #218 opened the double door leading to the adjoining unit and told the staff why she needed the nurse. No one came to the unit until approximately 11:30 P.M. Resident #2 had what appeared to be urine from the perpetrator over the top part of her gown. STNA #218 transferred the resident into a wheelchair and showered her. STNA #218 included the resident was a two person assist but she was the only one on the unit, and there was urine all over her and she needed to bathe her. STNA #218 verified the unit was unsupervised when she was in the shower with Resident #2. STNA #218 indicated the unit holds 23 residents. Review of the 10/02/20 Significant Change MDS revealed Resident #2 was a two assist for bed mobility and transfers. Resident #2 was a two-person physical assist for bathing. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation of Resident Property Policy revised 10/2020 revealed under Prevention and Identification the deployment of staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents care needs. 8. Observations on 11/09/20 at 12:20 P.M. revealed Resident #66's call light on. There were two nursing assistants working on the unit (STNAs #205 and #223) at the time who were passing the lunch meal trays. At 12:43 P.M. Resident #66's call light remained on (23 minutes later). The surveyor asked the resident if there was something she needed. She stated she had been moved to this room today without any of her personal belongings (including purse, wheelchair, pictures) and she wanted these items in her room. On 11/09/20 at 1:00 P.M. STNA #223 verified she answered and turned off Resident #66's call light at this time. (40 minutes after the call light was activated). 9 (a). Interview with Resident #90 on 11/05/20 at 3:30 P.M. revealed sometimes there was only one STNA working on her unit, (which can house 26 residents). She stated because of this, staff were not able to answer her call light timely. She stated because of the lack of staff, she did not always get fresh ice water each day. She stated she did not get fresh ice water on 11/05/20 as of 3:30 P.M. (b). Interview with Resident #125 on 11/05/20 at 4:00 P.M. revealed there was only one STNA working on his unit at night. He stated he sometimes must wait over two hours to be changed after an incontinent episode. (c). Interview on 11/04/20 at 12:30 P.M. with Resident #66 revealed she was concerned that staff were working too hard. They were working 12 hour shifts and were exhausted. Resident #66 claimed there was a day, but she was not able to provide an exact date, when she turned on her call light around 6:30 A.M. and told staff she needed incontinence care completed. Resident #66 claimed that staff came in and told her they would be back and turned off her call light. She then revealed she did not get changed until 2:30 P.M. that day. 10. Interview on 11/04/20 at 11:00 A.M. with LPN #527 revealed she had started her scheduled shift on 11/03/20 at 7:00 P.M. and was still currently working the floor. LPN #527 revealed she was getting ready to give report to LPN IP #201 who was going to relieve her. LPN #527 confirmed the originally scheduled nurse for the 100 unit had called off and she had to work over into day shift until someone could relieve her. LPN #527 revealed this is something that has happened more than once within the last few months. LPN #527 also revealed she does not feel there is enough staff to provide the proper care to all the residents. LPN #527 confirmed staff can ensure residents care is completed, but staff run themselves ragged trying ensure all care is provided and they are getting burnt out. LPN #527 also confirmed that due to not having enough STNAs, there are many times she has to assist the one STNA who is scheduled with resident care and this prevents her from completing required charting of assessments and care provided. Interview on 11/04/20 at 11:03 A.M. with STNA #212 revealed she was the only STNA working the 100 unit and providing care for 18 residents. STNA #212 revealed she was responsible for providing incontinence care, checking and changing resident, feeding them meals if needed, providing them with their meals, providing baths and showers and other activities of daily living (ADLs). STNA #212 revealed there was not enough help to get all the needed care provided and they needed more help and she cannot continue to work short staffed. Interview on 11/04/20 at 11:06 A.M. with STNA #511 revealed she was the only STNA working the 200 unit and providing care for 18 residents. STNA #511 revealed she had 5 scheduled showers for that day and in order for her to get them all done she would have to rush and may need to stay over into the next shift to ensure the showers were completed because if she was to leave at her scheduled time, some of the residents showers would not get done. STNA #511 confirmed the facility needs to have more staff to provide the proper care for each resident and to keep staff safe. Interview on 11/04/20 at 11:30 A.M. with LPN #513 revealed herself and one STNA were responsible for providing care for 21 residents who resided on the facility's memory care unit or the 400 unit. LPN #513 expressed concerns that there was not enough staff to properly supervise all the residents residing on the 400 unit. There were residents who required two staff assistance and there were times when the STNA needed assistance with providing care which then left all the residents remaining in the lobby area unsupervised. LPN #513 also revealed in the lobby area there were two exit doors that lead to the outside. These doors were locked and alarmed but when someone pressed on the door handle for 15 seconds, the door will open, and an alarm will sound. If both staff members were in a resident's room providing care, by the time they heard the alarm and responded the resident could already be outside the facility. LPN #513 confirmed residents have attempted to go out these doors before and were able to hold down the door handle long enough to release the lock. LPN #513 revealed the way the memory care unit had been staffed was not safe and they were not able to provide proper care or supervision. Corporate RN #200 claimed during an interview on 11/13/20 at 1:30 P.M. the facility had reached out to multiple sister facilities and staffing agencies for staffing assistance and have been told that review of the facility's daily staffing schedules made it appear like there was adequate direct care staff and they would not be able to provide assistance with staffing at this time. Corporate RN #200 added that she felt like the sister facilities and staffing agencies were just looking at the numbers and not taking into account the acuity level of the residents or the fact that most of the facility was COVID positive. Review of the facility's assessment, revised on 03/12/20 revealed under Part 3: Staffing Plan 3.1, the facility needed a total number or average or range daily, Licensed nurses providing direct care, minimum of eight hours of Registered Nurse (RN) coverage a day and 3-6 Licensed Practical nurses/ Registered Nurses each shift. Nurse aides will be staffed based on facility census. Average staffing is 1.85 per patient day (PPD). No additional information was provided. Review of the facility's 672 which indicated the acuity level of the residents revealed the following: Transfers - 114 residents required 1-2 staff assistance for transfers and 12 were dependent for transfers. Bathing - 62 residents required 1-2 staff assistance and 58 were dependent Dressing - 121 residents required 1-2 staff assistance and 5 were dependent Toilet use - 120 residents required 1-2 staff assistance and 6 were dependent Eating - 119 residents required 1-2 staff assistance and 7 were dependent. This deficiency substantiates Complaint Number OH 914, OH 553, and OH 434.

Based on staff interview, review of the medical record, facility policy and procedure for abuse, facility Self-Reported Incident (SRI), and facility investigation, the facility failed to ensure one female resident (Resident #2) assessed with [REDACTED].#115) who was known to have sexually inappropriate behavior towards female residents. This resulted in Immediate Jeopardy and the likelihood of serious harm on 11/08/20 at 8:30 P.M., when Resident #115 entered into Resident #2's room and fondled the resident's bare breast while self-stimulating with his hand. Resident #2 was completely wet in the front of her gown with yellow tinged liquid that appeared to be urine. This affected one of nine female residents residing in the Dementia Unit. The facility census was 126. On 11/09/20 at 5:25P.M., the Director of Nursing (DON) and Regional Director of Operations #501 were notified Immediate Jeopardy began on 11/08/19 at 8:30 P.M. when Resident #115, who was admitted on [DATE] and had known sexually inappropriate behaviors since 02/03/20, entered Resident #2's room, fondled her breast under her clothing while self-stimulating with his hand and completely saturated the front of her with yellow tinged fluid, presumed urine. The facility failed to ensure Resident 115's care plan that addressed his potential to participate in physical intimate interactions with females was implemented as written, updated when interventions were unsuccessful, and ensure adequate monitoring and supervision to ensure the behavior did not continue. As of 11/13/20, the Immediate Jeopardy remains ongoing. Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change MDS assessment dated [DATE] revealed Resident #2 was severely impaired for daily decision making, had adequate hearing, clear speech, could make self-understood and used corrective lenses with adequate vision. The resident was extensive assist of two for bed mobility and transfers and two-person physical assist for moving from sitting to standing and walking. She was not able to answer questions accurately. Medical record review revealed Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review for Resident #115 revealed a 02/03/20 change of condition progress note, with the initial documentation of inappropriate sexual behaviors. Review of the 02/05/20 Self-Reported Incident (SRI) # 8 to the State Agency revealed Resident #115 was in his room with his shirt off with female Resident #67 who's pants were off. In addition the note indicated hypersexual activity was displayed 02/07/20, though not descriptive of the behavior. A comprehensive plan of care was developed 02/07/20 for the potential to participate in physical intimate interactions with females. Interventions all dated 02/07/20 included medications as ordered, anticipate needs, provide opportunity for positive interaction, attention by stopping and talking with resident, intervene as necessary to protect the rights and safety of others by approaching/speaking in a calm manner, divert attention and remove from situation and take to alternate location as needed. Redirect when participating in physical intimate interactions with females. Review of the progress notes for Resident #115 revealed the following: · 04/24/20 nurses note indicated the resident was touching a female resident · 04/26/20 the resident was flirtatious and following a female resident around the unit. · 04/29/20 Resident #115 was found in a female resident's room with his clothes off. After being returned to his room and dressed, he left in less than five minutes with his shirt off heading back to the same room. · 05/04/20 he was wandering the unit pulling his pants down and his penis out. A 05/06/20 nurses note included the resident came out of his room naked. · 05/19/20, 06/14/20, and 06/19/20 wandering in and out of rooms, flirty behavior toward females was documented. · 06/20/20 the resident was following a female resident waving her on and telling her come on when she was not next to him. · 06/25/20 the resident was wandering in and out of other residents' rooms, at times he would take his pants down and urinated or defecated on chairs, beds, floors, and trashcans. · 07/13/20 he was in a room with a female resident being affectionate. · 08/01/20 he followed a female resident around the unit for several hours telling her come on and let's go. · 08/07/20 urinating on other residents' beds. Review of the 08/12/20 Quarterly Minimum Data Set 3.0 (MDS) revealed Resident #115 was severely impaired for daily decision making, felt down, depressed and tired with little energy 7-11 days of the lookback period. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 1-3 days. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 4-6 days. Wandering 4-6 days, supervision of one for bed mobility, supervision of one for transfers, supervision set up for walking in corridor and room, locomotion on and off the unit and toilet use with limited assist of one. The resident was frequently incontinent of bowel and bladder. A nurse notes dated 08/23/20 indicated the resident was attempting to hold a female resident's hand and grabbing other residents. Review of Resident #115's comprehensive plan of care for the potential to participate in physical intimate interactions with females was not updated with new interventions since the 02/07/20 initiation. Interventions included administer medications as ordered. Monitor/document for side effects and if effective, anticipate and meet needs, caregivers to provided opportunity for positive interaction and attention, stop and talk with resident when passing by, intervene as necessary to protect the rights and safety of others. Review of the TASK section of the electronic documentation for Resident #115 revealed 19 of the last 29 days 10/11/20 through 11/08/20 the resident was sexually inappropriate. Nineteen of 29 days the resident showed physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). Eighteen of the last 29 days the resident showed verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). Twenty four of the last 29 days the resident showed behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Review of Resident #115's nurses note late entry entered 11/09/20 at 1:41 A.M. for 11/08/20 at 08:30 P.M. included, when staff saw that resident was not in his room, they went to look for him and found him in Resident #2's room standing at the bed fondling the female resident's breast. The top part of Resident #2's gown was completely wet with a yellow tinged fluid. It was presumed Resident #115 urinated on Resident #2. The resident was upset. (Resident #2). Resident #115 was redirected back to his room. Review of Self-Reported Incident # 1 submitted to the State Survey Agency by the facility on 11/09/20 at 5:12 A.M. revealed an allegation of sexual abuse. The initial source of the allegation was listed as staff. Involved residents were listed as Resident #115 and Resident #2. The incident form stated both residents had dementia, and neither were able to provide any meaningful information. State tested Nurse Aide (STNA) #218 reported (Resident #115) was in bed with female (Resident #2) touching her breasts. The Summary of Incident Statement included' STNA stated she witnessed a male dementia resident on secured dementia unit in female dementia resident's room. Female resident was laying in her bed. Male resident was standing beside female's bed. STNA stated male had his hand on female's breast. STNA stated she immediately redirected male resident out of female's room to common area away from other residents. STNA then notified nurse. STNA stated she then went to female resident's room to check on female resident. STNA stated female resident was whining as is normal behavior for resident during care. Review of the summary revealed: Substantiated - abuse, neglect or misappropriation verified by evidence. Review of Resident #2's nurses notes revealed no documentation indicating Resident #115 entered her room on 11/08/20, fondled her breast and upset her. A nurses' note dated 11/09/20 at 8:06 P.M. indicated the resident's son and Physician Assistant #404 were notified of allegations of sexual abuse regarding Resident #2 and #115. Observations on 11/09/20 at 10:00 A.M. revealed Resident #2 sitting in the dining area of the dementia unit with her eyes closed. Observations on 11/09/20 at 10:05 A.M. revealed Resident #115 coming out of the bathroom inside his room, on the dementia unit. He walked over and sat on his bed. At that time, he did not respond appropriately to questions asked of him, such as how he was, or what day it was. Interview with Licensed Practical Nurse (LPN) #217 on 11/09/20 at 10:10 A.M. revealed she was the nurse assigned to work on the dementia unit (400 hall) beginning at 7:00 P.M. on 11/08/20 through 7:00 A.M. on 11/09/20. However, she stated she was also assigned to cover the 300 halls for that shift. She stated on 11/08/20 around 8:30 P.M. STNA #218 reported to her that, after being in a resident room providing care on the dementia unit, she was unable to find Resident #115 in his room. STNA #218 then looked for him and found him in female Resident #2's room. She reported that Resident #115 had his hands under Resident #2's gown near her breast area. She reported that Resident #2's gown was wet up the front. LPN #217 stated that STNA #218 presumed Resident #115 had urinated on Resident #2 as her disposable underwear was dry. LPN #217 stated Resident #2 was unable to verbally express what happened but STNA #218 said Resident #2 seemed irritated and was moaning at the time of the incident. LPN #217 stated that STNA #218 indicated Resident #115 tended to follow the female residents around and be friendly with them. LPN #217 stated she was working on 300 halls (outside of the secured doors of the dementia unit) at the time of the incident. She stated she had never worked on the dementia unit before and did not know how to handle the incident. When asked what was done as a result of the incident, LPN #217 stated they separated Resident #115 from Resident #2 and then got Resident #2 cleaned up. She stated Resident #115 then went to bed and the STNA kept an eye on him. Interview with STNA #220 on 11/09/20 at 10:25 A.M. revealed she was working on the dementia unit. She stated she does not normally work on the dementia unit and had not worked on that unit for approximately one month. She stated she had received report from night shift STNA #219 that morning. She stated she was not aware of any male resident having any type of sexually inappropriate behavior towards female residents, including Resident #115. She stated it was not reported to her that Resident #115 had touched any female, so she was unaware she was to do 15-minute checks. Interview with STNA #219 on 11/09/20 at 11:00 A.M. revealed she had been assigned to work on the dementia unit (400 unit) last night, 11/08/20 from 7:00 P.M. to 7:00 A.M. on 11/09/20. However, she was pulled to work on the 300 halls. She stated STNA #218 was working on the dementia unit (400 hall) by herself at the time the incident regarding Resident #115 happened. She stated STNA #218 came off the dementia unit and reported that Resident #115 had gone into Resident #2's room and put his hand under the resident's gown in the chest area. Resident #2 was crying and STNA #218 got him out of her room. STNA #218 went back and saw that Resident #2 was wet and Resident #115 had urinated on her. Resident #2 was still upset. Resident #2's gown was wet at the top but her depend (incontinence brief) was dry. STNA #219 stated when there was only one staff on the dementia unit, you could not keep an eye on the residents, especially when you are in a room providing care. She stated the week prior; the nurse was only able to be on the dementia unit about two hours per shift because of working on another unit also. STNA #219 stated Resident #115 had a history of [REDACTED]. She stated he would not sit down and wandered up and down the hall going in other resident rooms. She stated there was nothing they could do when they were short staffed and only had one or two staff on the unit. STNA #219 stated she felt Resident #115 knew when the staff were busy and that was when he went in female resident rooms. The STNA stated there were residents who required assistance from two staff so there are times when, if there are two staff, that they are both in a resident room providing care. Interview with the DON on 11/09/20 at 11:30 A.M. confirmed the facility had submitted a self-reported incident to the State Survey Agency that morning regarding Resident #115. She stated she had statements from staff but had not had time to look at them. A physician order [REDACTED]. Interview with the DON on 11/09/20 at 1:00 P.M. revealed she was unable to find a witness statement from STNA #218 and had no other investigation information to provide at that time, except that the residents involved were unable to provide any information related to the incident. She stated she would have to look to see if Resident #115 had any previous sexually inappropriate behaviors. Interview with the DON on 11/09/20 at 4:30 P.M. revealed 15-minute checks were started on Resident #115 last night after the incident with Resident #2. She stated evidence of this was documented on paper forms on the unit. She stated the facility did not need a physician's orders [REDACTED]. Interview with Registered Nurse (RN) #221 on 11/09/20 at 4:55 P.M. revealed she was currently the nurse on duty for the day shift for the dementia unit. She stated she was notified in report this morning regarding the incident with Resident #115. She stated she was the one who wrote the order for 15-minute checks for Resident #115 that morning (11/09/20) after report from the night shift nurse at 8:30 A.M. She revealed there was no evidence that 15-minute checks had been completed on the night shift (11/08/20 into 11/09/20) or on the day shift for 11/09/20. She further confirmed there was no evidence the physician or family had been notified of the incident that occurred with Resident #115. A physician order [REDACTED]. for staff one on one supervision of the resident. Interview with LPN #222 on 11/10/20 at 10:35 A.M. revealed one to one staff supervision had been started for Resident #115 at 7:00 A.M. that morning. Review of the one to one supervision form used by the staff to document revealed on 11/10/20 it was blank prior to 7:00 A.M. Interview with LPN #222 on 11/10/20 at 10:35 A.M. confirmed the form was blank prior to 7:00 A.M. She did not have any documentation available to show that one to one supervision had been provided for Resident #115 prior to 7:00 A.M. on 11/10/20. She further stated that Resident #115 was quick and went into other resident rooms a lot. Interview with Resident #2's son on 11/12/20 at 6:18 PM revealed he was not called on Sunday related to the sexual assault. He indicated he was called this week maybe two days ago. He checked his phone history and revealed he was notified of the incident on 11/09/20 at 8:04 P.M. Interview on 11/12/20 at 6:31 P.M. with Resident #115's wife revealed she was called Monday or Tuesday at around 8 P.M. related to her husband being in a female resident's room touching her breast. Review of Resident #2 and Resident #115's nurses note dated 11/12/20 revealed there was no evidence of Social Service intervention related to the incident on 11/08/20. Resident #2 did not have a progress note indicating there was a male perpetrator in her room. There was no evidence in the record of what transpired on 11/08/20 and her reaction as observed by STNA #218. Interview 11/12/20 at 9:04 P.M. with Corporate Registered Nurse #200 via a returned email verified there was no documentation of 15-minute checks being provided to Resident #115. Corporate Registered Nurse #200 indicated staff reported they were monitoring the resident's whereabouts on the evening of 11/08/20 after the incident. Staff reported Resident #115 did not enter any other rooms nor did he come into contact with any other residents. Resident #115 later went to sleep and settled for the evening. Corporate Registered Nurse #200 further verified the families and the physician were not notified of the incident until the following evening. On 11/12/20 at 9:28 P.M. the first nursing skin assessment for Resident #2 following the 11/08/20 incident was provided indicating it was completed 11/09/20 at 9:54 P.M. Interview on 11/15/20 at 11:45 A.M. with STNA #218 revealed she was the only staff working the Dementia Unit on 11/08/20 when Resident #2 was sexually assaulted by Resident #115. Her co-worker had been pulled to another unit at 7:00 P.M., the beginning of their 12-hour shift and the nurse normally did not arrive on the Dementia Unit until approximately 11:00 P.M. due to working three units. STNA #218 indicated on 11/08/20 at 8:30 P.M. she was in the room across from Resident #115 and his roommate. She noticed the door was open and did not see Resident #115's feet in bed. STNA #218 revealed due to his history she started to check all the rooms. Resident #2's door was closed. When she opened the door STNA #218 found Resident #115 in his pajamas standing at the side of Resident #2's bed. Resident #115 had his right hand on his crouch. His left hand was up under her night gown touching the skin of her left breast. She was whimpering telling him to stop and no. STNA #218 indicated he didn't. STNA #218 revealed Resident #2 whimpers with care when she doesn't know what is happening and is scared. STNA #218 said she startled Resident #115 when she said his name and he jumped. She asked him what he was doing. He said he was doing nothing. She indicated he repeated you didn't catch me doing nothing. STNA #218 told him to get out of the room and that they had discussed this before. After she got him out of the room, she talked to him about consent while walking him back to his room. STNA #218 included the resident said he didn't care. STNA #218 indicated she generally believed the resident knows what he is doing because of how he takes opportunities when no one is around and says they did not catch him. After walking him to his room and putting him in bed she opened the double door to the next unit to summons the nurse to come to the unit due to the incident. The nurse was unable to come to the unit due to other responsibilities. STNA #218 went back to Resident #2 and noticed she had a yellow tinged liquid over the top of her clothing. The STNA got Resident #2 out of bed and put her in a wheelchair next to the nurse station. She texted the Director of Nursing (DON) and asked her what she should do. The DON responded I don't know and included an emoji with a person shrugging. STNA #218 indicated the resident had what she thought was urine saturating her clothing, so she took her into the shower and showered her leaving no one on the unit to monitor the residents. STNA #218 included the resident was a two person assist for transfer and shower, but she was the only one on the unit, had urine all over her and she needed to bathe her. STNA #218 indicated the resident's brief was dry. She did a head to toe skin assessment when she did the shower and saw no physical evidence of injury. She was the only one to see the wet clothes on her and did not think to save them for the nurse to see for evidence. STNA #218 indicated the nurse arrived on the unit approximately 11:30 P.M. The nurse used the shower sheet for her assessment. STNA #218 thought the nurse documented what she told her. STNA #218 recalled the nurse saying it's 11:30 P.M., I am not calling the doctor and family. The STNA revealed she told the DON she was going to do 15-minute checks, but she did not fill out a form for the checks because she did not have the DON's approval. Further interview 11/15/20 at 12:22 P.M. with STNA #218 verified when she observed Resident #115 sexually assault Resident #2 by touching her bare breast while he had his other had over his own crotch. STNA #218 heard Resident #2 say no. STNA #218 had called for assistance after the sexual assault since she was the only staff on the unit. The nurse did not arrive until three hours later. She transferred and showered Resident #2, leaving no one on the unit to monitor Resident #115. STNA #218 verified the nurse did not complete an assessment of the resident after the assault. STNA #218 completed the skin assessment on a shower sheet. STNA #218 included the nurse took her word to use to document. There was no family or physician notification the evening of the incident as verbalized to her by the nurse. The STNA indicated there were 21 residents on the unit at the time of the incident. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation of Resident Property Policy revised 10/2020 revealed the facility would not tolerate Abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes sexual abuse. Sexual Abuse was defined as nonconsensual sexual contact of any type with a resident. Prevention and Identification included the deployment of staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual resident's care needs. The assessment, care planning, and monitoring of residents with needs and behavior's which might lead to conflict or neglect, such as residents with a history of aggressive behaviors and resident who have behaviors such as entering other residents' rooms. Response included staff should not have moved the resident until he/she had been assessed by a nurse supervisor for possible injuries. This deficiency substantiates Complaint Number OH 087.

Based on medical record review, observations, family interview, staff interview, review of the facility policy on visitation, and review of a Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo, the facility failed to permit family visitation for one resident (Resident #118) experiencing a significant decline in condition. This resulted in Immediate Jeopardy on [DATE] when a family member requested visitation with their mother who was experiencing a significant decline in health status and the family member was not permitted to visit. This resulted in the likelihood of serious psychosocial harm when Resident #118 expired on [DATE] without visitation from her daughter. This affected one of 126 residents (Resident #118). The facility census was 126. On [DATE] at 11:25 A.M. the Director of Nursing and Corporate Registered Nurse #200 were notified Immediate Jeopardy began on [DATE] when a family member requested visitation with their mother (Resident #118) who was experiencing a significant decline in health status and the family member was not permitted to visit. Resident #118 expired on [DATE] without visitation from her daughter. As of [DATE] the Immediate Jeopardy remains ongoing. Findings include: Review of the Department of Health and Human Services, CMS Memo (QSO ,[DATE] NH) dated [DATE] revealed facilities should use the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data site as additional information to determine how to facilitate indoor visitation: · Low (<5%) = Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond [MEDICATION NAME] care visits) · Medium (5% - 10%) = Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond [MEDICATION NAME] care visits) · High (>10%) = Visitation should only occur for [MEDICATION NAME] care situations according to the core principles of COVID-19 infection prevention and facility policies While end-of-life situations have been used as examples of [MEDICATION NAME] care situations, the term [MEDICATION NAME] care situations does not exclusively refer to end-of-life situations. Examples of other types of [MEDICATION NAME] care situations include, but are not limited to: · A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support. · A resident who is grieving after a friend or family member recently passed away. · A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration. · A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past). Allowing a visit in these situations would be consistent with the intent of, [MEDICATION NAME] care situations. However, facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with §483.10(f)(4)(v). Review of the closed medical record for Resident #118 revealed a Minimum Data Set 3.0 (MDS) assessment completed on [DATE] which indicated the resident required supervision only with eating. It further stated the resident required limited assistance from one staff for personal hygiene, toileting, bed mobility, transfers, walking, and dressing. Observations on [DATE] at 3:15 P.M. revealed Resident #118 to be walking with a wheeled walker by herself in the hallway. Review of nurse's notes dated [DATE] at 9:24 A.M. noted a rapid COVID test being positive. Review of nurse's notes dated [DATE] at 8:07 P.M. revealed the resident was noted lying on the floor next to the bed with her upper back and head leaning against the wall. The resident was complaining of severe bilateral hip pain. The physician was notified, and the resident was sent to the hospital for evaluation. The resident returned on [DATE] at 12:45 A.M. On [DATE] at 2:35 P.M. it was documented the X-rays at the hospital had no findings of acute fracture. On [DATE] at 5:10 P.M. the note stated the daughters were updated on new orders for IV fluids. On [DATE] at 6:00 P.M. the physician was updated on the resident's condition and the daughters request to change the resident to a do not resuscitate/ comfort care status (DNR-CC). On [DATE] at 1:19 P.M. it was noted the daughter was updated on the resident's status. Observations on [DATE] at 2:47 P.M. revealed Resident #118 laying on her right side in bed, resting quietly with her eyes closed. Resident #118's bilateral feet and knees were noted to have a red/purple marbled appearance. Interview on [DATE] at 2:50 P.M. with State tested Nurse Aide (STNA) #523 revealed Resident #118 use to walk up and down the halls with a wheeled walker. STNA #523 confirmed Resident #118 had a decline and was no longer ambulatory and was dependent on staff for all care. STNA #523 confirmed the red/purple marbled appearance to Resident #118's bilateral feet and knees. Review of the medical record for Resident #118 revealed a nurse's progress note on [DATE] at 12:03 P.M. stating that at 7:30 A.M. the aides called the nurse to the resident's room. The resident was found unresponsive with no respirations and no pulse. The physician was notified. An order was received to release the body to the funeral home. The resident's daughter was notified of the resident's death. Interview on [DATE] at 11:30 A.M. with Resident #118's daughter (Daughter #224) revealed she contacted a nurse (Registered Nurse (RN) #225) at the facility two days ago and asked about visiting her mother. She stated she thought she might be able to get her mother to eat if she was able to visit. She stated the nurse told her she could not permit her to visit and she would need to contact the Director of Nursing (DON) on [DATE]. Daughter #224 stated she called the DON on [DATE] but was unable to reach her. She stated she left a voicemail for the DON on [DATE] asking about visiting her mother. She stated the DON did not return her call. She stated her mother died on the morning of [DATE] without her being able to visit. Interview with RN #225 on [DATE] at 2:45 P.M. revealed Resident #118's daughter (Daughter #224) had called in to the facility on [DATE] between 5:00 P.M.-7:00 P.M. She stated she spoke with her and Daughter #224 asked to visit her mother and try to get her to eat. RN #225 stated she told Daughter #224 she would have to contact the DON or Administrator on Monday [DATE] as she was not sure if the daughter was allowed to visit as the resident was residing on a COVID unit. RN #225 stated Resident #118's condition on [DATE] and [DATE] included not getting out of bed, not eating, not taking medications, and agitated with care. She stated she felt the resident would have benefited from hospice due to her decline in mobility, eating, and taking medications in the past two weeks. RN #225 stated she did not attempt to contact any administrative staff regarding Daughter #224's request to visit. Interview on [DATE] at 3:30 P.M. with STNA #521 revealed Resident #118 was her grandmother. STNA #521 revealed her mother, which was Resident #118's Emergency Contact #1 and Power of Attorney for Healthcare (POA), had been trying to contact someone at the facility for days to see about coming in to visit Resident #118 and attempt to assist the resident with mealtime. STNA #521 stated she saw Resident #118 prior to a fall on [DATE]. She stated, at that time, Resident #118 was still walking and appeared to be at her normal baseline. STNA #521 claims that after the resident's fall on [DATE], Resident #118 had a quick decline to where she was no longer walking, required assistance with toilet use, and was no longer eating or drinking. STNA #521 stated she had worked different units than what Resident #118 was residing on and did not have a chance to visit her again until after the resident's decline (date not given). Interview on [DATE] at 3:35 P.M. with Regional Director of Operations #501 revealed the visitation policy provided by the facility did not address visits for [MEDICATION NAME] care situations except to say they could continue to occur with county COVID-19 positivity rates >10%. Interview on [DATE] at 4:45 P.M. with the DON revealed her office was on the COVID unit so she was not going to it, plus she had not had time to listen to her voice mails for the past week. She stated she was not aware of Resident #118's daughter wanting to visit. At the request of the surveyor, the DON went and listened to her voice mails. She confirmed she had received a call (she did not have dates or times) from Resident #118's daughter (Daughter #224). She stated Daughter #224 stated she felt they were going to let the resident lay there and die. She stated she could come in and help give her mother her medications. Daughter #224 stated she did not want the run around. The facility provided no evidence of a clinical or safety reason to prohibit the visitation by Resident #118's daughter. Review of the facility policy titled Outdoor/Indoor Visitation dated [DATE] and revised [DATE] and [DATE] revealed the facility would offer and assist residents with scheduled outdoor visitation in accordance with the established guidelines and safety practices starting [DATE]. The visitations are in an effort to positively impact quality of life outcomes and avoid a prolonged loss of personal connection which can have an effect on an individual's physical, mental, and psychosocial well-being. The policy stated that for a county COVID- 19 positivity rate of High (>10%) visitation should only occur for [MEDICATION NAME] care situations according to the core principles of COVID-19 infection prevention and facility policies. The policy stated the facility reserves the right to restrict visitation due to reasonable clinical or safety cause, the COVID- 19 county positivity rate, the facility's COVID-19 status, and a resident's COVID-19 status, visitor symptoms, lack of adherence to the proper infection control practices, or other relevant factor related to the COVID-19 PHE. This deficiency substantiates Complaint Number OH 115.

Based on review of the medical record, facility Self-Reported Incident (SRI), facility investigation report, facility Abuse Policy and staff and resident interviews, the facility failed to prevent resident to resident physical and verbal abuse. This affected two residents (Residents #44 and #12 ). Resident #44 was struck in the head by a glass vase while sleeping that was thrown at him by Resident #35 who had made known threats to staff and residents. This resulted in actual harm that was Immediate Jeopardy on 09/30/19 when Resident #44 sustained a laceration to the forehead and a hematoma requiring an emergent hospital transfer to obtain six sutures. Resident #44 expressed fear and suicidal ideation as a result of the incident. In addition Resident #12 expressed fear of Resident #35 who she shared a bathroom with. She stated he would pound on the door and yell foul language at her and take her walker. This affected two of three residents reviewed for abuse. The facility census was 123. On 10/03/19 at 3:07 P.M., the Administrator, the Director of Nursing (DON), and Regional Consultant Nurse #700 were notified Immediate Jeopardy began on 09/30/19 when Resident #35, who had a documented history of threatening other residents, assaulted Resident #44 while the resident was asleep. Resident #44 sustained a large hematoma and laceration that required treatment with six sutures at the emergency room , expressed fear of being assaulted again, and had [MEDICAL CONDITION] related to the incident that required an additional hospital evaluation. The Immediate Jeopardy was removed on 10/05/19 at 6:00 P.M. when the facility implemented the following corrective action: · On 09/30/19 at 11:10 P.M. Resident #44 was assessed by Licensed Practical Nurse (LPN) #504, Emergency Medical Services (EMS) was called and the resident was transported to hospital at 11:30 P.M. · On 9/30/19 at 11:10 P.M. Resident #35 was assessed by LPN #627 for physical injuries, placed on 1:1 until transferred by EMS to the hospital at 11:45 P.M. · On 09/30/19 at 11:15 P.M. local law enforcement was notified by LPN #504 and arrived at facility at 11:30 P.M. · On 10/04/19 at 4:00 P.M. Re-education by the Regional Director of Clinical Services on implementation of the Abuse and Neglect policy was completed for the Administrator and the DON. · On 10/04/19 at 4:10 P.M. the DON initiated in-servicing of all staff on the Abuse, Neglect and Misappropriation Policy with focus education on appropriate staff response to knowledge of/or witness to a resident making statements of intent to harm or kill other residents and visitors as follows: The staff will ensure resident is not left unattended to provide protection for other residents, and will have other staff or supervisor contact the Administrator for further action. In-servicing has been completed for 119 of 130 staff by the DON/designee as of 10/07/19 at 8:00 [NAME]M. The 11 staff members that had not completed the in-service will be removed from the schedule until in-servicing is completed by DON/designee. · On 10/04/19 at 4:10 P.M., the Administrator initiated a facility audit that included an interview of all interviewable residents and staff members, to determine if they had knowledge of any residents threatening to hurt or kill themselves or another resident. Audits included interview of the resident representative if the resident was unable to be interviewed. The audit was completed on 10/05/19 at 6:00 P.M. per Administrator/designee. · On 10/04/19 at 4:30 P.M., the DON initiated review of all notes for residents receiving outside psych consultations to determine if any documentation of statements from residents verbalizing desire to hurt or kill another resident. The review was completed on 10/04/19 at 5:30 P. M. by DON/ADON. No other residents were identified in the consultation notes. · On 10/04/19 at 4:45 P.M., DON initiated a facility sweep for all resident unable to be interviewed. This included skin inspections for suspicious injury, fearfulness and mood/behavior changes that were not currently identified in their care plan or behavior management plan. Completion of the sweep was by the Don/designee was 10/05/19 at 6:00 P. M. Any residents identified meeting sweep criteria will have 1:1 maintained until an investigation is completed by Administrator/designee. · On 10/04/19 at 5:30 P.M. a Performance Improvement meeting was held to determine the need for ongoing monitoring or changes to the plan of correction. · On 10/04/19 at 6:00 P.M. the DON initiated a sweep of all residents identified with behaviors to ensure behavior tracking documentation was in place with completion on 10/05/19 at 6:00 P.M. · On 10/05/19 at 7:00 [NAME]M. the Administrator /designee began to monitor for compliance of residents free from abuse via observation, record review, staff/resident interview with use of the Resident/Staff abuse interview questionnaire audit forms. This will continue 5-7 times per week for 3 months with the results reviewed at the monthly PI meeting. · On 10/05/19 at 7:00 [NAME]M. the DON/designee began to monitor for compliance of residents free from abuse via observation, record review, staff/resident interviews and review of all Clinical Note/Consultation Notes. Review of the Resident Behavior Tracking forms will be Audited 5-7 times per week for 3 months with results reviewed at monthly PI meeting to determine need for ongoing monitoring of behaviors or changes needed to resident's P[NAME]. · On 10/07/19 between 11:15 [NAME]M. and 6:12 P.M. interviews were conducted with LPN #629, LPN #511, Activities Staff #557 and #519, Activities Director #509, Housekeeping Staff #546, STNA #618, LPN #612, STNA #623, LPN #569, and STNA #605 and revealed staff were in-serviced on the facility's abuse policy and procedure and all staff were knowledgeable. · A Performance Improvement meeting is scheduled for 10/14/19 at 2:00 P.M. to review the implemented interventions and determine what, if any, changes need made. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #35 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #35 was severely cognitive impaired, experienced delusions, rejected care, and had verbal behaviors. Review of Resident #35's care plans dated 08/28/19 revealed he was noncompliant with doctor's orders. The care plan dated 08/23/19 revealed the resident had a [DIAGNOSES REDACTED]. The care plan dated 04/15/19 and updated on 10/04/19 revealed Resident #35 had episodes of confusion by yelling, throwing items, making threatening statements and exhibiting increased agitation. Review of nurse's notes by LPN #511 dated 08/25/19 at 7:25 P.M. revealed Resident #35 was threatening nurses, aides, and other residents. There were no specific details regarding what threats were being made. Review of a psychiatric evaluation completed by Psychiatric Mental Health Certified Nurse Practitioner (PMHNP) #725 dated 08/29/19 revealed Resident #35 had a history of [REDACTED]. The plan was to start Resident #35 on [MEDICATION NAME] next visit if his behaviors persisted, add [MEDICATION NAME] every six hours for increased behaviors. Review of a psychiatric evaluation dated 09/18/19 completed by PMHNP #725 revealed Resident #35 continued to be restless, agitated, and aggressive at times. He was threatening to kill staff and other residents. He was delusional, confused at times, and very difficult to redirect. Resident #35 had dementia with worsening behaviors. Resident #35 was presenting with continued agitation and aggression. Recommendations were made to have documentation of behaviors and identification of target symptoms, potential triggers, consequences of the behavior and consideration of the safety of the resident, caregivers, and others in the environment. Review of nurse's notes dated 09/21/19 (time not identified) revealed Resident #35 was throwing dishes, pounding on the door of an occupied bathroom and threatening to kill staff. Review of nurse's notes written by LPN #504 dated 09/30/19 at 11:10 P.M. revealed LPN #504 heard glass breaking down the hall and arrived at Resident #44's room. LPN #504 observed Resident #35 standing next to Resident #44's bed. LPN #504 observed broken glass and a moderate amount of blood. Resident #35 was threatening staff and residents. The local police department was called and Resident #44 was assisted to safety. Resident #35 was making threatening remarks to emergency medical staff and police officers. Resident #35 was transferred to the local emergency room and admitted to the behavioral unit at the hospital. Review of the medical record for Resident #44 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #44 had moderate cognitive deficits. Review of nurse's notes by LPN #504 dated 09/30/19 at 11:10 P.M. revealed glass was heard breaking from Resident #44's room and Resident #35 was seen standing in his room. A moderate amount of blood was noted on the floor and blood was running down Resident #44's face. Resident #44 stated to the nurse that he was asleep and Resident #35 threw a glass bowl at him. Pressure was applied to Resident #44's forehead and EMS was called to transport Resident #44 to the hospital. Review of nurse's notes by LPN #504 dated 10/01/19 at 3:30 [NAME]M. revealed Resident #44 returned from the hospital with six sutures to his forehead. Review of the facility's Resident to Resident Altercation report dated 09/30/19 (no time documented) revealed Resident #35 and Resident #44 were immediately separated and 911 was called to take both residents to the hospital. Resident #44 had a [MEDICAL CONDITION] that required six stitches. It was noted the incident occurred on 09/30/19 around 10:00 P.M. Resident #35 walked into Resident #44's room and Resident #44 stated there was a vase on the window sill and Resident #35 threw it at him striking his head. Review of SRI, tracking number 1, dated 09/30/19 and timed 11:34 P.M. revealed staff heard a sound near Resident #44's room and noted Resident #44 standing in his doorway with a laceration to his forehead. Resident #35 was found beside Resident #44's bed. Nurse immediately made sure both residents were safe. Resident #44 had pressure applied to wound site and 911 was called for both residents. Staff stayed with Resident #44 in common area until the emergency medical team arrived. Resident #44 received stitches at the emergency room and arrived back to facility. Resident #35 was admitted to the hospital for psychiatric services. Social Worker #502 met with Resident #44 the next day and Resident #44 stated he would like to see the counselor on Friday. Resident #44 stated Resident #35 had come in and went to the window side of his bed and threw a vase Resident #44 had in the window and hit him in the head. Review of witness statement dated 09/30/19 (no time documented) written by STNA #625 revealed LPN #504 requested help due to Resident #35 was in Resident #44's room throwing things and there was glass and blood everywhere. STNA #625 went to Resident #44's room and cleaned him up and got him away from Resident #35. Resident #44 stated to STNA #625 that Resident #35 busted a vase over his head while he was asleep. Review of witness statement dated 10/01/19 (no time documented) written by STNA #701 revealed she and STNA #625 were in another resident's room when the incident occurred between Resident #35 and Resident #44. LPN #504 stated Resident #35 was in Resident #44's room and there was glass and blood present. STNA #701 and STNA #625 removed Resident #44 from the situation and cleaned him up and applied pressure to his laceration until the emergency medical team and police arrived. Both residents were sent out for treatment. Review of witness statement dated 10/01/19 (no time documented) written by LPN #504 revealed he heard glass break and then saw Resident #44 standing in his doorway with blood running down his face. Resident #44 was taken to the common area and pressure was applied to his laceration. LPN #504 had gone back to Resident #44's room to try to get Resident #35 out of the room and away from the glass. Both residents were sent out for treatment. Review of witness statement dated 10/01/19 (no time) from Resident #44 taken from the Administrator revealed Resident #44 stated he was asleep when a man came in and struck him with a vase that was in his window; then the man took his call light out of the wall and started making his bed. Resident #44 was angry at the man but did not appear to know who Resident #35 was. Review of a social service note by Social Worker (SW) #502 dated 10/01/19 at 5:36 P.M. revealed Resident #44 was showing some fear and anxiety associated with the incident. Resident #44 had been seeing a counselor and the counselor was notified by the unit manager of the incident. Resident #44 stated when the counselor comes to the facility, he would like to talk to her and indicated that the upcoming Friday would be okay when she comes in. Resident #44 was concerned about Resident #35 being in the facility. SW #502 assured Resident #44 that Resident #35 was not in the facility. Review of witness statement dated 10/04/19 (no time) by STNA #566 revealed she had seen Resident #35 come out of his room once or twice a shift. STNA #566 stated previously she also had seen Resident #35 go into Resident #12's room through the adjoining bathroom and threaten her and her roommate before seeing Resident #35 come out of his room and sit in the lobby. Review of witness statement dated 10/04/19 (no time) from STNA #607 revealed Resident #35 would go into Resident #12's room at times and had not seen him go into any other resident rooms. Observation and interview were conducted on 10/04/19 at 10:42 [NAME]M. with Resident #44. Resident #44 had a u shaped incision to his forehead with sutures. The resident's right eye was black and red with periorbital swelling noted. He stated he got hit by a man at the facility while he was a sleep and he did not feel safe. Interview was conducted on 10/04/19 at 10:49 [NAME]M. with STNA #607 and she stated Resident #35 was combative with staff and she had not seen him be combative with residents. She stated Resident #35 would wander into other resident rooms and was not always easily redirected and sometimes they just had to stay with him until he left the room. She stated she knew he would go into Resident #12's room. Interview was conducted on 10/04/19 at 10:52 [NAME]M. with Resident #12 and she stated she shared the bathroom with Resident #35, and he would pound his fist on the bathroom door and come into her room and take her walker. She stated Resident #35 would use very foul language and he scared her and that she would put her call light on, and staff would come and take him out of her room. Resident #12 stated Resident #35 scared her to death, but he was not here anymore, and that staff did put a lock on her bathroom door. Interview was conducted on 10/04/19 at 11:37 [NAME]M. with the DON and she stated there was no behavioral tracking done for Resident #35 for (MONTH) and (MONTH) 2019 due to Resident #35 was not on any [MEDICAL CONDITION] medications. She verified Resident #35 had frequent behaviors of combativeness with staff, being noncompliant, and threatening staff. She denied any behaviors with Resident #35 towards other residents. She verified she did not read the psychiatrist notes from 08/29/19 and 09/18/19 and did not know the statement was made that Resident #35 threatened to kill staff and residents. The DON stated she was not aware that Resident #35 had gone into Resident #12's room and scared her. Interview was conducted on 10/04/19 at 12:09 P.M. with the DON and she stated she had forgotten that they did place a lock on Resident #12's bathroom door but did not know the date that had happened. She stated Resident #35 would not be coming back to facility that it was not an appropriate place for him. She verified that Resident #44 had fear and anxiety over the incident. The DON stated it was sad and that they assured him Resident #35 would not be returning. Interview was conducted on 10/04/19 at 1:00 P.M. with the Administrator who stated she was not aware of Resident #35 threatening any other residents before 09/30/19. The Administrator stated that when Resident #35 returned to the facility, they would ensure he was in a private room. The Administrator verified Resident #35 was in a private room before he was sent out to the hospital and she stated when he returned, he would be in a more private room without an adjoining bathroom. Review of nurse's notes by LPN #589 dated 10/04/19 at 3:39 P.M. revealed Resident #44 had been resting in bed all day. He received Tylenol for pain expressed from wounds to his head. His sutures were in place and bruising and swelling was evident at his right eye and forehead. Review of Counselor #730's risk assessment dated [DATE] revealed Resident #44 was sleeping on 09/30/19 when another resident assaulted him causing injuries to his face and Resident #44 stated that was the last straw. Resident #44 was expressing [MEDICAL CONDITION] during the session and described a plan. Resident #44 stated he no longer felt safe at the facility. Review of a note by SW #502 dated 10/04/19 at 6:59 P.M. revealed Resident #44 had made statements to the counselor that he did not feel safe at the facility. He was thinking of harming himself and he was going to the hospital for further evaluation. He stated he wanted to go to another facility when he leaves the hospital. Review of nurse's notes by LPN #518 dated 10/05/19 at 1:25 [NAME]M. revealed Resident #44 returned to the facility. Call light cords were removed and a call bell was given to the resident and every fifteen-minute checks were started. Observation and interview on 10/07/19 at 8:45 [NAME]M. with Resident #44 revealed he was sitting in his room on his bed. He stated yes when asked if he was still fearful and stated yes that he wanted to harm himself. When asked if he felt safe and did not give any more details. When asked if he wanted to live at another facility, he stated yes. Interview was conducted on 10/07/19 at 8:52 [NAME]M. with Licensed Counselor #730 and she stated she was very familiar with Resident #44 as she had seen him at another facility too. She stated he never had [MEDICAL CONDITION], and this was new for him. She stated the facility did call her on 10/01/19 and inform her of the incident that occurred on 09/30/19 and that she would see him on next visit. She stated the facility called her again on 10/04/19 and she came in to see Resident #44. She stated Resident #44 expressed to her that he did not feel safe at the facility because he was asleep when Resident #35 threw a vase at him. He stated he wanted to harm himself and was pretty [MEDICATION NAME] about it. She stated she then immediately notified the nurse to send him out for evaluation. She stated she was at the facility today to see him for follow up. Interview was conducted on 10/07/19 at 9:54 [NAME]M. with SW #502 and she stated she saw Resident #44 on the morning of 10/01/19 and he had sutures to his head. She had asked what happened and then learned about the altercation between Resident #35 and Resident #44. She stated she had never seen Resident #35 go into Resident #44's room before. She stated Resident #44 was seen by his counselor on 10/04/19 and will be seen again today, 10/07/19. She stated he never made any [MEDICAL CONDITION] to her. She stated Resident #44 would come out of his room and walk around and smoke prior to the incident on 09/30/19. Review of nurse's notes by the DON dated 10/07/19 at 10:25 [NAME]M. revealed the facility counselor was in to see Resident #44. The counselor stated that Resident #44 denied any [MEDICAL CONDITION] and was demonstrating less distress. The counselor recommended lifting suicidal precautions and Physician #726 was made aware. Review of social worker notes by SW #502 dated 10/07/19 at 12:53 P.M. revealed Resident #44 now did not want to leave this facility to go to another facility. He nodded his head yes when asked if he felt safe and shook head no when asked if he was afraid. Resident #44 shook his head no when asked if he wanted to harm self. Review of nurse's notes by the DON dated 10/07/19 at 1:15 P.M. revealed Physician Assistant #727 was in facility and the nurse updated him on the counselor notes. Physician Assistant #727 stated to continue every fifteen-minute checks and no call cords and he would reevaluate him on Friday (10/11/19). Observation and interview on 10/07/19 at 2:40 P.M. with Resident #44 revealed he was sitting on his bed watching television. He stated he was staying at the facility now and when asked if he felt safe, he held up his fist and shook it and stated, if that man comes back, I will kill him. He stated no when asked if he felt like he wanted to harm himself. Review of the facility's Abuse and Neglect Prevention Policy and Procedure, dated (MONTH) (YEAR), revealed the purpose was to establish guidelines that prevents, identifies, and reports resident abuse and neglect. All residents have the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, staff of other agencies serving the resident, family members, friends, or other individuals. Resident to resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched, or kicked and results in physical harm, pain, or mental anguish is considered resident to resident abuse.

Based on closed medical record review, interviews with staff and physician, review of the Emergency Medical Service (EMS) run report, review of the facility cardiopulmonary resuscitation (CPR) policy and procedure and review of the facility Code Blue policy, (if the resident is Full Code, CPR is started and emergency 911 services are activated), the facility failed to initiate CPR for one resident (Resident #111) who was found unresponsive, without a pulse, respirations or blood pressure, and who was identified as a Full Code status. Life threatening harm and death occurred when Resident #111 did not receive ventilation along with chest compressions from staff who initiated an emergency Code Blue. This resulted in Immediate Jeopardy for Resident #111 who expired. This affected one of three residents reviewed for an emergent change in condition and death. The facility identified 54 current residents who were designated as having a Full Code status. On [DATE] at 5:08 P.M., Regional Nurse Consultant (RNC) #326, the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 2:40 A.M. when Resident #111 was assessed and found to have no respirations or pulse, was a full code, and CPR was not initiated by Registered Nurse (RN) #264 who indicated Certified Nurse Practitioner (CNP) #330 told her do not start CPR. The medical record contained no documentation of signs of irreversible death. Immediate Jeopardy was removed on [DATE] at 7:45 P.M. when the facility implemented the following corrective actions: · On [DATE] at 11:57 A.M. the DON, assistant director of nursing (ADON), Licensed Practical Nurse (LPN) #242 and LPN #275 initiated in-services on when and how to initiate CPR. All nurses were in-serviced by [DATE] at 11:30 A.M. · On [DATE] an in-house audit was started at 11:30 A.M. and completed at 2:30 P.M. to ensure all residents' advanced directives matched the physician's orders [REDACTED]. · On [DATE] the DON reviewed the medical records of residents that expired in the facility between [DATE] and [DATE]. The review was completed on [DATE] at 4:15 P.M. revealing no issues with Full Code status and initiation of CPR. · On [DATE] at 8:00 A.M. a plan of correction was reviewed with CNP #330 which included a house audit of all residents' code status verifying they were correct and that the codes were easy to identify. The plan of correction included audits to assure staff were aware of the location of the code status book and that staff were aware of when and how to initiate CPR. A mock Code Blue was also included in the plan. CNP#330 reviewed the plan with Medical Director (MD) #325. · On [DATE] random audits were completed by the ADON, LPN #242 and LPN #275 to verify nurses were able to locate the code status book and knew when to initiate CPR. The audits were to continue one to two times weekly for three months. · On [DATE] at 2:30 P.M. a mock Code Blue was conducted by the DON on both shifts. All of the nurses responded appropriately. The mock Code Blue procedure will continue ,[DATE] times monthly for three months and will be reviewed in the Quality Assurance (QA) meetings. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance. Findings include: Closed record review revealed Resident #111 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #111 Minimum Data Set (MDS) 3.0 completed on [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of physician orders [REDACTED]. Review of nurse's progress notes dated [DATE] at 6:00 P.M. indicated RN #212 went to Resident #111's room per family request and found the resident lethargic, non-responsive and not responding to a sternal rub. Vital signs were reported within normal limits and a finger stick revealed Resident #111's blood glucose was 31 (,[DATE] normal value). CNP #330 was notified and an order was obtained to administer [MEDICATION NAME] 1 milligram (mg). Resident #111 was sent to the hospital for evaluation on [DATE] at 6:20 P.M. and returned to the facility on [DATE] at 9:30 P.M. Review of Resident #111's nursing progress notes revealed a blood sugar was obtained on [DATE] at 9:30 P.M. upon returning to the facility. The blood sugar was 99.0 and all other vital signs were stable. Resident #111's skin was described as warm and dry. Cardiovascular examination revealed normal rate, rhythm and heart sound and respirations were assessed as normal with no effort. Review of a nursing progress note completed by RN #264 on [DATE] at 2:40 A.M. reveled she was called to Resident #111's room by State tested Nurse Aide (STNA) #322 who reported Resident #111 was without respirations or pulse. The progress note indicated a Code Blue was called as Resident #111 was a full code. The nursing progress note indicate CNP# 330 was contacted regarding Resident #111's status. The Emergency Medical Service (EMS) was alerted and in route. There was no documentation in the progress note indicating Resident #111 was in obvious clinical signs of irreversible death including rigor mortis, dependent lividity or decompensation. A second progress note completed by RN #264 on [DATE] at 2:40 A.M. revealed STNA#322 called RN# 264 to Resident #111 room where the resident was found without respirations or pulse. A Code Blue was called. The progress note indicated nursing staff arrived with a crash cart at 2:42 A.M. Emergency services 911 was called and EMS was in route. The progress note revealed RN #264 was on the telephone with CNP #330 regarding Resident #111's current status. RN #264 documented CNP#330 advised her not to start compression/respirations for Resident #111. The progress note did not indicate Resident #111 presented obvious clinical signs of irreversible death such as rigor mortis, dependent lividity or decomposition. On [DATE] at 2:50 A.M. a progress note completed by LPN #234 documented RN #264 had received an order from CNP #330 to not proceed with CPR compressions because Resident #111 was without vital signs and without respirations/apical/pulses. On [DATE] at 3:00 A.M. a progress note documented by RN #264 indicated EMS was on scene at the facility. An electrocardiogram confirmed that Resident #111 was absent of heart rhythm. Resident #111's family was contacted, as was Regional Manager, RN #326, the administrator and the DON. The record indicated the family arrived at the facility on [DATE] at 3:55 A.M. Review of the paramedic (EMS) incident report dated [DATE] revealed the unit was dispatched at 2:53 A.M. for CPR in progress. The unit was advised of a possible Death on Arrival (DOA). Upon arrival, Resident #111 was found in bed, pulseless, apneic and warm to touch. Resident #111 was placed on an electrocardiogram, showing no pulse in three leads. EMS was told that Resident #111 had refused to have vitals done on [DATE] at 1:30 A.M. and this was the last time the patient was seen. Patient was found at approximately 2:40 A.M. on [DATE] pulseless and apneic. The report indicated staff advised not to start CPR by nurse practitioner. EMS did not start CPR due to the time patient was down. The report indicated Patient did not have Do Not Resuscitate (DNR). Scene cleared at 3:13 A.M. Review of CNP #330 progress note dated [DATE] indicated a call was received from a nurse at Logan Care and Rehabilitation regarding a resident who was found deceased . The note indicate the RN was hysterical on the phone stating he is a full code and I don't know what to do. He is not breathing and has no heart beat. CNP# 330's progress note indicated she instructed the facility to follow full code protocol and call EMS. The RN stated again the resident was not breathing and had no heart beat and may have been gone for a while. CNP# 330 documented informing the facility they needed to follow protocol for a resident with a full code status. On [DATE] at 12:25 P.M. during an interview with the DON revealed she noticed a missed call Sunday morning on her cell phone and called the facility to inquire what it was regarding. LPN #215 reported Resident #111 had passed earlier that day. The DON reported she was informed a Code Blue had been called for Resident #111 when absence of respirations and pulse was identified. LPN# 215 informed the DON that as they were placing the back board underneath the resident, RN #264 contacted CNP #330 and was instructed not to initiate CPR. The DON reported she questioned why CNP #330 was contacted. The DON reported CPR should have been initiated and CNP #330 should not have been contacted until later. The DON reported CNP #330 stated to the DON that RN #264 called her regarding Resident #111. CNP #330 indicated to the DON she told RN #264 she should follow the facility policy regarding code status. The DON indicated RN #264 was disciplined after the incident on [DATE] and received a final written notice on [DATE] for failing to lead and follow facility protocol in regards to CPR. Corrective action was to include performance training regarding CPR and Nurse Practice Act within the next 30 days. A failure to complete the corrective action would result in termination for RN #264 . An interview was conducted on [DATE] at 10:44 A.M. with Resident #111's Physician and the facility's Medical Director (MD) # 325. MD #325 indicated he was returning a phone call because CNP #330 was currently on leave and not available. MD #325 was inquiring if he could answer any questions. MD #325 indicated he was aware of the situation with Resident #111; that the facility had talked with him regarding Resident #111 being a full code and not receiving CPR. MD #325 reported he had completed an investigation regarding the CPR not being performed. MD #325 reported there was no reason for staff to contact a physician before starting chest compressions when a resident's status is full code. MD #325 reported he was familiar with Resident #111 and he had his autonomy and chose his own code status, wanting everything done. An interview was conducted on [DATE] at 11:27 A.M. with RN #264. RN #264 reported she remembered working the night Resident #111 passed away. RN #264 reported STNA #322 informed her Resident #111 was found without respirations. RN #264 reported she confirmed Resident #111 was a full code, called a Code Blue and LPN #236 called 911. RN #264 reported while returning to Resident #111's room, she attempted to call the physician and CNP #330 answered the call because MD #325 was out of town. RN #264 was unable to give a reason for contacting CNP #330 during the interview. RN #264 indicated CNP #330 questioned if EMS had been alerted and was informed they were in route. RN #264 reported CNP #330 then stated if Resident #111 showed no obvious signs of respirations or pulse, then compressions would not be recommended. RN#264 stated as she entered Resident #111's room, staff were placing him on a back board and beginning to apply an ambu bag for respirations when she told staff not to start cardiopulmonary resuscitation per CNP #330's telephone order. A phone interview was conducted on [DATE] at 12:07 P.M. with LPN #298. LPN #298 reported she recalled the incident regarding Resident #111 and was working on ,[DATE] Hall when the Code Blue was called. LPN #298 stated another nurse grabbed the crash cart and they proceeded to the 700 Hall where Resident #111 resided. LPN #298 reported the crash cart was taken into the room; Resident #111 was assessed and found to be without pulse or respirations. The crash cart was opened and oxygen was hooked up to the ambu bag. LPN #298 reported she assisted the STNA (unable to recall her name) to roll Resident #111 over and place a back board underneath him. LPN #298 reported she was getting ready to administer oxygen via the ambu bag when RN #264 entered the room and reported CNP #330 gave a verbal order to stop the code. LPN #298 reported no compressions had been initiated and oxygen had not been applied. LPN# 298 indicated Resident #111 did not have appear to have any mottling or rigor mortis. On [DATE] at 2:52 P.M. interview with LPN #236 revealed she was working the night Resident #111 expired. LPN #236 stated she was working the front hall when RN #264 reported she was unable to find paperwork regarding Resident #111 code status. LPN #236 stated RN #246 said that if no paperwork was located then a full code would be initiated. LPN #236 reported she checked the electronic record and confirmed Resident #111 was a full code and notified LPN #298 who was in the room at the time of the Code Blue. LPN #236 indicated RN #264 was calling CNP #330 during this. LPN #236 indicated she was in Resident #111's room, when RN #264 entered the room and indicated CNP #330 stated do not do CPR on Resident #111. LPN #236 indicated that it would not be expected to call the physician during a code situation but that the physician would be notified after the EMS squad arrived. LPN #236 indicated Resident #111's color was poor and mouth was open, however she was not aware if body temperature was cool. LPN #236 d did not observe any mottling on the skin. LPN #236 indicated if a resident was a full code and found in a similar situation as Resident #111, she would have called a Code Blue and started CPR. Review of the Code Blue policy, dated [DATE], indicated if a resident was found to be without heartbeat or respiration, the nurse on duty identifies the code status and if the resident is Full Code, CPR is started and emergency 911 services are activated, revealed the staff did not follow the policy for Resident #111. This deficiency substantiates Complaint Number OH 218.

Based on observation, medical record review, hospital record review, staff and resident interviews, and review of the facility's smoking policy, the facility failed to supervise residents identified as supervised smokers to prevent them from keeping and utilizing smoking materials in their rooms. This resulted in Immediate Jeopardy when Resident #5 utilized cigarettes and a lighter in his room while receiving continuous oxygen via nasal cannula resulting in serious life threatening injuries when the resident caught his shirt and oxygen tubing on fire and sustained second [MEDICAL CONDITION] the right side of his neck. This affected one (Resident #5) of three residents reviewed for accident hazards. The facility identified 13 residents (Residents #3, #5, #8, #10, #11, #22, #36, #54, #58, #70, #102, #112 and #114) who smoked. The facility census was 117. On 01/23/18 at 4:30 P.M., the Administrator, Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) #114 were notified Immediate Jeopardy began on 01/14/18 at 3:55 P.M. when Resident #5, who was assessed as requiring supervision while smoking, refused to turn over his smoking materials to staff, was permitted to return to his room where he utilized the cigarettes and lighter while receiving continuous oxygen via nasal cannula. The flame ignited his oxygen tubing and shirt causing a fire which burned his shirt and the oxygen tubing in half. The resident was sent to the emergency room (ER) for evaluation and treatment and was diagnosed with [REDACTED]. The Immediate Jeopardy was removed on 01/22/18 when the facility implemented the following corrective actions: · On 01/14/18 at 8:30 P.M., Registered Nurse (RN) #99 completed a head to toe assessment of Resident #5. Resident #5 was removed from his room and placed on 1:1 supervision while waiting transport to the emergency room for evaluation. · On 01/14/18 at 8:30 P.M., RN #99 notified the DON of the incident. The room of Resident #5 was searched by RN #99 and State tested Nursing Assistant (STNA) #82 and a lighter and cigarettes were confiscated during this search. · On 01/14/18 at 9:00 P.M., RN #99 provided in servicing to all staff present in the facility for ensuring the return of all lighters and cigarettes to the nurse upon each smoking resident's arrival back into the building after smoking. This education concluded at 9:30 P.M. · On 01/14/18 at 9:45 P.M., RN #99, Licensed Practical Nurse (LPN) #40, LPN #1, LPN #68, STNA #69 and STNA #82 initiated room sweeps of all rooms of residents who smoked (Residents #3, #5, #8, #10, #11, #22, #36, #54, #58, #70, #102, #112 and #114). No cigarettes or lighters were found during these sweeps. · On 01/15/18 at 2:10 A.M., Resident #5 returned to the facility from the ER and was reeducated to supervised smoking times and the requirement to return all smoking items to the nurse for securement. The education was completed by LPN #68. · On 01/15/18 at 8:00 A.M., a search of Resident #5's room was completed by the Assistant Director of Nursing (ADON) #85 with no cigarettes or lighters found. · On 01/15/18 at 8:10 A.M., ADON #85 provided verbal education to Resident #5 regarding his smoking privileges, oxygen therapy and the smoking policy. · On 01/15/18 at 8:30 A.M., ADON #85 posted a Please See Nurse Before Entering sign on Resident #5's door to enable the nurses to educate family members and friends of the need for all smoking materials be turned over to nursing staff and not given to any of the residents. · On 01/19/18 at 9:00 A.M., the Administrator and RDCS #114, revised the facility smoking policy. Revisions included that no residents, whether supervised or unsupervised smokers, were permitted to maintain smoking materials on their person, in their rooms, or other portions of the smoking grounds, and family members, guests, and visitors were not permitted to give smoking materials and products directly to residents. · On 01/15/18 at 9:00 A.M., the DON, ADON #33 and ADON #85 began all staff in servicing on the newly revised smoking policy which included that all visitors or family members are to turn in all smoking materials to the nurse. Education also included that staff are to provide 1:1 (one on one) supervision for any resident who refuses to turn over smoking materials until either the DON or the Administrator intervenes. This in service lasted throughout the day. All staff were educated on 01/15/18 by 6:01 P.M. · On 01/15/18 at 10:10 A.M., the DON educated the family of Resident #5 on turning in all smoking supplies to the nurse and not the resident, if smoking materials are brought into the facility. · On 01/15/18 at 10:30 A.M., the DON posted information regarding smoking times and indicating smoking materials must be turned into the nurse for identified smoking residents (Residents #3, #5, #8, #10, #11, #22, #36, #54, #58, #70, #102, #112 and #114) inside their rooms and in designated smoking areas. Additionally, ADON #85 also posted signs at each unit in the building as well the entrance and exits of all buildings for staff and visitors to see. · On 01/15/18 at 3:20 P.M., Licensed Social Services Director (SSD) #16 completed a BIMS assessment for Resident #5, who scored a 12 on this assessment indicating minimal cognitive deficits. At 4:30 P.M., a smoking assessment was also completed for Resident #5 by ADON #85. This assessment indicated that Resident #5 required supervision at all times while smoking. · On 01/15/18 at 4:00 P.M., ADONs #85 and #33, and the DON verbally educated all identified smoking residents (Residents #3, #5, #8, #10, #11, #22, #36, #54, #58, #70, #102, #112 and #114) on the smoking policy. All 13 residents verbalized understanding of the policy, and the facility obtained resident signatures for receipt of the new policy. · On 01/15/18 at 4:30 P.M., ADONs #33 and #85 completed smoking assessments for all residents in the facility who smoke including Residents #3, #5, #8, #10, #11, #22, #36, #54, #58, #70, #102, #112 and #114. · On 01/15/18 at 4:49 P.M., the DON completed a room sweep of Resident #5's room and no smoking materials were discovered. · On 01/15/18 at 4:55 P.M., the DON educated Resident #5 on the new smoking policy revision with the addition of all smoking materials brought in by family members or friends were to be provided to the nursing staff. Smoking times, which were posted in the resident's room, were reviewed as well. Resident#5 verbalized understanding of the policy, and provided a signature for receipt of the new policy. · On 01/16/18 at 8:00 A.M., the Administrator mailed letters to all smoking residents' family members (Residents #3, #5, #8, #10, #11, #22, #36, #54, #58, #70, #102, #112 and #114) regarding the new update of the smoking policy. This letter indicated that all smoking supplies brought in must be given to nursing staff. · On 01/19/18 at 10:30 A.M., an Interdisciplinary Team (IDT) meeting was held by the Administrator, DON, ADON #33, ADON #85, RDCS #114 and Medical Director (MD) #115. The IDT team reviewed the facility smoking policy revisions, review of the initial audits, Resident #5's smoking incident, and potential causative factors. · On 01/22/18 at 4:00 P.M. the Administrator and DON placed the newly revised smoking policy into the Admission packet for any resident admitted to the facility to review. The facility also added in servicing to their orientation procedures for newly hired staff in regards to the smoking policy. · On 01/23/18 at 6:30 A.M., interview with LPN #1 revealed that he was educated on the revision to the smoking policy on 01/15/18 and stated that all smoking materials were to be stored at the nursing stations. LPN #1 stated that if a resident would refuse to hand in their smoking materials, they are to be provided with 1:1 observation and they are to notify Administration. · On 01/23/18 at 8:15 A.M., interview with LPN #107 and on 01/23/18 at 8:25 A.M. interview with STNA #38 revealed they were educated on the new smoking policy on 01/15/18 and that all smoking materials are to be turned into nursing staff for storage after smoking times. Residents are to be provided with 1:1 observation by staff if they refuse to turn in their smoking materials. LPN #107 and STNA #38 both stated that if a resident would refuse to hand in their smoking materials, they are to be provided with 1:1 observation and they are to notify Administration. Although the Immediate Jeopardy was removed, 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, including their new policy, and were monitoring to ensure continued compliance. Findings include: Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #5's physician's orders [REDACTED]. Review of Resident #5's smoking evaluation dated 12/05/17 indicated Resident #5 was to be supervised when smoking and the facility needed to store the resident's lighter and cigarettes. Review of Resident #5's care plan dated 12/05/17 revealed Resident #5 was at risk for injury related to smoking tobacco/cigarette products. Interventions included to complete a smoking assessment and report non-compliance with the smoking policy immediately to the supervisor. Review of Resident #5's progress note dated 01/12/18 revealed the resident refused to take any evening medications unless he was permitted to go outside to smoke. Review of Resident #5's progress note dated 01/14/18 revealed the resident refused to wear his continuous oxygen unless he was permitted to go outside to smoke Review of Resident #5's progress notes dated 01/14/18 at 3:55 P.M. revealed the resident had called a friend on his own personal cell phone, and shortly afterwards was observed unsteadily ambulating alone outside to the smoking area. The resident had left his wheelchair and his oxygen tank in the building. The progress note documented STNA #38 then went out and supervised Resident #5 while he smoked. Upon the resident's return to the building, Resident #5 refused to give up his smoking materials and stated that he did not have a lighter. The resident stated that someone would have to pry it from his dead fingertips. There was no documented evidence management or other staff were notified of the resident's refusal to return his smoking materials and no indication Resident #5's room had been searched for such materials. Review of Resident #5's progress notes dated 01/14/18 at 8:30 P.M. revealed that LPN #68 was called to this resident's room by STNA #82 who was holding pieces of burned oxygen tubing, with the resident lying in bed. The resident was noted with burn marks to the right side of his neck and a scorched neckline of his shirt. The resident's bed was wet as the resident had used his bedside water pitcher to extinguish the flames on his shirt. Upon inspection of the room, two used cigarettes were found inside a styrofoam cup which had previously been extinguished. A pack of cigarettes and a lighter was also found on the bedside table. A head to toe assessment was completed with burn areas noted to the neck. Resident #5 was assisted to a wheelchair and brought to the lobby with staff to await transportation by EMS for further evaluation and treatment at the hospital. One staff member was present at all times while waiting for transport. The Physician, DON, Unit manager, and resident's brother aware. Review of Resident #5's hospital record dated 01/14/18 revealed the resident was sent to the hospital on [DATE] at 9:03 P.M. The resident was noted to have burned himself smoking a cigarette while on oxygen and was diagnosed with [REDACTED]. An additional order was also received to clean and dress the wound with [MEDICATION NAME] ointment. Resident #5's discharge orders also indicated the resident was prohibited from smoking until the issue was addressed by the attending physician since it posed a significant danger to the resident and the facility. Resident #5 was discharged from the hospital on [DATE] at 1:17 A.M. to return to the facility. Interview with LPN #107 on 01/22/18 at 2:10 P.M. revealed Resident #5 recently picked up smoking again in the last two weeks. The nurse stated that on the day of the incident, the resident informed this nurse that a friend had brought him in a pack of cigarettes and a lighter. The nurse stated that she attempted to obtain these items from him and the resident stated that you will have to pry them from my cold dead hands. The nurse stated that the resident told her that he no longer had a lighter. LPN #107 stated she decided not pursue the conversation any further and would try at a later time but never did. The nurse verified that she did not report this to anyone and also verified she did not do a room sweep of Resident #5's room and didn't know if one had been completed prior to the incident. Interview with STNA #82 on 01/23/18 at 9:00 A.M., revealed Resident #5 had a friend bring him a pack of cigarettes and a lighter on 01/14/18. The STNA stated that during the evening she discovered the resident had been smoking in his room as she found two burned cigarette butts, burned oxygen tubing, and a smell of smoke and other burning material coming from his room. She stated that the resident denied smoking in his room at the time of the incident. The STNA stated that the resident was also soaking wet, as he had used his water pitcher to extinguish the flames from his tubing and where his shirt had caught fire. The STNA stated that some residents had been able to keep their cigarettes and lighter on their person prior to this incident, and that no one was permitted to do so any longer. STNA #82 state she was not aware if a room sweep was completed after the resident refused to give up his smoking materials earlier that day prior to the incident. Interview with STNA #38 on 01/23/18 at 9:15 A.M. revealed on 01/14/18 at 3:30 P.M., she witnessed Resident #5 ambulating alone through the exit doors and proceeding to smoke outside. She was sent outside with the resident by one of the nurses to supervise him. The STNA stated that he left his wheelchair and oxygen inside the doors and did not take them outside with him. STNA #38 stated the resident then had two cigarettes and when she told him to turn them in at the nurse's station, she was told by the resident that they would have to kill him first, before he would give them up. The STNA stated that she does not think he ever turned them in. STNA #38 verified the resident had both a lighter and a pack of cigarettes when he returned inside the building and verified she did not take them from him. STNA #38 stated she was unsure if a room sweep of Resident 5's room was completed by staff prior to the incident that occurred later that night. Interview with Resident #5 on 01/23/18 at 9:18 A.M. revealed that he does not remember the incident or smoking in his room. Interview on 01/23/18 at 10:30 A.M. with the DON revealed Resident #5's lighter and cigarettes were at the nurse's station on 01/14/18. The DON indicated Resident #5 called an unknown friend on the afternoon of 01/14/18 and had him bring in a new pack of cigarettes and a lighter. The DON stated that the resident was observed by a nurse going outside to smoke, for which the nurse sent out an aide to supervise him. The DON verified when Resident #5 returned to the building from outside, he refused to give up his cigarettes, and he denied that he had a lighter. The DON stated that later that evening, an STNA was walking through the hallway and smelled smoke and a burnsmell. She stated the origin of the smell was coming from the room of Resident #5 and upon entering the room, the resident had a burn to his right neck area, and his shirt was burned as well, with the resident visibly wet from the contents of his water pitcher that he used to extinguish himself. The DON stated that the resident was then transported to the emergency room for evaluation and treatment and was diagnosed with [REDACTED].#5 refused to give up his smoking materials on 01/14/18 prior to the incident in his room. Interview on 01/24/18 at 10:55 A.M. with RDCS #114 verified after Resident #5 returned to the building on 01/14/18 and refused to hand over his smoking materials, a search of his room for the smoking materials was not completed by staff. Review of the facility's smoking policy (revised on 12/19/16) revealed that any resident without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. Additionally, smoking shall not be permitted in bed ever. This policy also indicated any resident with restricted smoking privileges requiring monitoring shall have direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. This deficiency substantiates Complaint Number #OH 700

Based on record review, observation, and staff interview the facility failed to prevent the development of a suspected deep tissue injury and promote healing of the area on Resident #5's left foot. Harm occurred when Resident #5 developed a suspected deep tissue injury to his left foot that subsequently became three suspected deep tissue injuries. These areas became an unstageable pressure ulcer infected with [MEDICAL CONDITION] Resistant Staph Aureus (MRSA). This affected one resident (Resident #5) of three residents reviewed for pressure ulcers. Finding include: Review of medical record revealed Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment, clear speech, could be understood and could understand others. Review of the care plan revealed Resident #5 had actual and/or potential for impaired skin integrity with interventions that included Prevalon boots to help minimize pressure, friction and shearing to his feet. Review of physician orders [REDACTED].#5 was in bed or in the chair. Review of the initial wound assessment dated [DATE] revealed a suspected deep tissue injury (SDTI) was discovered on the bottom of Resident #5's left foot. The area measured 1.0 centimeter (cm) long and 1.5 cm wide. No new interventions were noted. On 03/06/17 the weekly wound assessment revealed the area to Resident #5's left foot had become three areas. One area measured 0.5 cm long and 0.9 cm wide, the second area was 0.5 cm long and 0.3 cm wide, and the third area was 0.6 cm long and 0.8 cm wide. On 03/20/17 review of the weekly wound assessment revealed there was only one area to the bottom of Resident #5's left foot. The area measured 0.8 cm long and 0.8 cm wide and was an unstageable pressure ulcer. There was eschar (dead tissue) throughout the wound, without drainage and a brown crust covered the wound bed with no redness on the outer wound. On 03/31/17 at 6:02 P.M. a nurse note revealed the physician was notified that the wound to Resident #5's left foot (pad area of the foot) had deteriorated and had serosanguinous (serous/clear and bloody) drainage without odor. An order was received for a culture and sensitivity to the wound on the bottom of Resident #5's left foot. On 04/03/17 at 4:15 P.M. a nurse note revealed the culture and sensitivity results for the wound on Resident #5's left foot revealed there was an infection [MEDICAL CONDITION] in the wound. On 04/05/17 a new order was received for [MEDICATION NAME] (antibiotic) 300 milligram four times a time for five days. On 04/09/17 at 9:31 A.M., Resident #5 was observed lying in bed with his bare right foot against the footboard of the bed. On 04/09/17 at 2:52 P.M., the dressing change was observed for Resident #5 and was completed by Licensed Practical Nurse (LPN) #5. There was a dime size area to the pad area of Resident #5's left foot below his third and fourth toes. LPN #5 stated the pressure ulcer was caused by Resident #5's feet being against the footboard. LPN #5 stated Resident #5 should have his Prevalon boots on his feet and she verified the resident did not have the Prevalon boots on. LPN #5 stated there was nothing to keep Resident #5's feet away from the footboard and to relieve pressure. On 04/09/17 at 3:46 P.M., an interview with State tested Nursing Assistant (STNA) #6 revealed she could not locate the Prevalon boots in Resident #5's room but found some in a storage closet. On 04/09/17 at 4:11 P.M. an interview with Unit Manager, LPN #7 revealed Resident #5 developed a deep tissue injury to his left foot on 01/21/17. LPN #7 stated Resident #5 was to have Prevalon boots on in bed. LPN #7 stated the pressure area to Resident #5's left foot had started out as one area, became three areas, and was now one area again. LPN #7 stated Resident #5 was being seen at a wound clinic but not for the area to his left foot. LPN #7 verified the wound had started as a SDTI and the current wound was now classified as an unstageable. LPN #7 verified Resident #5 had [MEDICAL CONDITION] in the wound to his left foot. On 04/09/17 at 4:52 P.M. LPN #7 verified no new interventions were put in place after Resident #5 developed a pressure ulcer to the pad of his left foot. This deficiency substantiates Complaint Number OH 361.

Based on record review, policy review and staff interview, the facility failed to ensure a resident's post surgical pain was adequately managed by not obtaining a prescribed narcotic pain medication ordered on an as needed basis from their pharmacy in a timely manner and by not informing the physician of the resident's complaints of severe pain when the prescribed pain medication was not available. This affected one (Resident #120) of three residents reviewed for pain. This resulted in harm for Resident #120 who complained of severe post surgical knee pain she rated at a severity level of 10 out of 10 while having to wait two and a half hours for the facility to obtain the authorization it needed to pull the prescribed medication from the emergency supply box before she could be properly medicated. Findings include: Review of Resident #120's closed medical record revealed she was admitted to the facility on [DATE] status [REDACTED]. A review of the nurses' progress notes revealed she was admitted at 10:30 A.M. A nurse's progress note dated 04/06/14 at 10:30 A.M. revealed a new order was received to discharge the resident to another nursing facility per the family's request. She was transferred from the facility on 04/06/14 at 1:45 P.M. A nurse's progress note for a late entry on 04/05/14 at 7:45 P.M. written on 04/06/14 at 11:10 P.M. revealed a call had been received from Resident #120's family inquiring as to why the resident had not received her pain medication. The nurse informed the family that they were waiting on an authorization to get the medication from the pharmacy. A late entry for a nurse's progress note for 04/05/14 at 7:47 P.M. revealed the nurse informed the resident that they would get her pain medication as soon as possible. The resident told them she knew they were trying but it was frustrating. A nurse's note for 04/05/14 at 7:50 P.M. a call was placed to the pharmacy informing them that the resident was complaining of pain that was rated a 10 on a one to 10 scale with 10 being the worst pain ever. The nurse told the pharmacy a prior authorization was needed in order to pull the medication from the facility's emergency supply box. The nurse also indicated that the medication was needed immediately due to the resident's level of pain. The pharmacy told the nurse that the prescription did not have a DEA (Drug Enforcement Agency) number. The facility nurse looked at the prescription and noted the DEA number was located at the top right hand corner of the prescription. The pharmacy acknowledged it was there and would move the request up on their priority list. A late entry for a nurse's progress note dated 04/05/14 at 8:30 P.M. revealed no prior authorization was received yet. The nurse called the pharmacy again explained to them that the resident needed her prescribed pain medication that was ordered on an as needed (prn) basis. The pharmacy informed the facility that the prior authorization sheet had not been faxed to them. The facility's nurse checked the fax sheets and located the prior authorization form and confirmed it had been sent five times. The pharmacy then checked their computer while the facility's nurse sent the fax again and the pharmacy confirmed they had in fact received it. The nurse again stressed the urgency in getting the authorization to pull as the resident remained in pain. The pharmacy informed the facility they would put it at the top of their priority list. A late entry for a nurse's progress note dated 04/05/14 at 8:45 P.M. revealed the family had contacted the facility nurse again requesting that the resident's paperwork to be faxed elsewhere. The nurse went to the resident's room and explained the situation to her and expressed empathy. A late entry for a nurse's progress note dated 04/05/14 at 9:15 P.M. indicated the nurse called someone from the the facility's nursing management team to receive additional guidance in the situation and to brainstorm for any other ideas to achieve pain control for Resident #120. Relaxation/ distraction techniques and position changes were suggested and it was recommended that they call the pharmacy again. A late entry for a nurse's progress note dated 04/05/14 at 9:45 P.M. revealed the relaxation and distraction techniques were attempted and failed to relieve the resident's pain. A late entry for a nurse's progress note for 04/05/14 at 10:00 P.M. revealed the pharmacy was called and the urgency of the situation was impressed upon them by the nurse. The pharmacy again assured the nurse that it would be moved to the top of their priority. A late entry for a nurse's progress note for 04/05/14 at 10:20 P.M. indicated that they finally received a prior authorization to pull the medication from the narcotic medication emergency supply box. The resident was medicated for her severe pain at that time which was two and a half hours after her her pain was reported as being a 10 out of 10. The nurse's progress notes did not show any evidence that the physician had been contacted to inform him of the resident's severe pain or the difficulty they were having getting the authorization to pull the prescribed pain medication from their emergency supply box. There was also no evidence that the physician had been consulted to see if there were any other interventions that could have been ordered to help manage the resident's pain that did not require an authorization from the pharmacy. On 06/12/14 at 9:50 A.M., an interview with LPN #9 revealed he worked the day shift on 04/05/14 when Resident #120 was admitted . He denied the resident was having any discomfort at the time of her admission as she had been previously medicated with pain medication at the hospital before she came. The resident was still drowsy from the medication when she arrived. He confirmed he had done her admission process which included faxing the prescription for the [MEDICATION NAME] she had ordered on a prn basis to the pharmacy. He reported he received a call from the pharmacy sometime between 11:30 A.M. and 12:00 P.M. as there was an issue with the prescription written by the physician at the hospital. He thought the physician failed to write the number of pills to be dispensed when the pharmacy filled the order. He contacted the hospital to have a new prescription written for the [MEDICATION NAME] to include how many pills to dispense and sent to the pharmacy. He denied that the resident was having any pain when his shift ended at 3:00 P.M. but stated the resident did say she felt something coming on and would eventually need something for pain. LPN #9 stated the afternoon shift was working on getting the authorization completed for the use of [MEDICATION NAME]. The facility was using Omnicare as their pharmacy at that time, which was new to them, and there had been problems with them getting authorization to access the controlled medications when needed. He knew there were DEA regulations that had to be followed but they had not had that much of a problem with the prior pharmacy they used. He reported the facility had since switched back to their old pharmacy due to the problems they experienced. He Indicated the nurse that relieved him on 04/05/14 at 3:00 P.M. was LPN #8. On 06/12/14 at 11:00 A.M., an interview with the Director of Nursing (DON) revealed he had been aware there were issues with Resident #120's pain control and getting the prescribed pain medication from the pharmacy. He did agree that two and a half hours was a long time for the resident to wait for an authorization to pull medication for her to be able to get the prescribed pain medication she needed. He acknowledged there was no documented evidence that the resident's physician had been notified of the resident being in severe pain in her right knee or that they were having problems getting the authorization they needed to be able to use the prescribed pain medication as ordered. he confirmed there had been problems with the pharmacy they were using at that time which was the reason they switched back to their prior pharmacy. On 06/12/14 at 2:35 P.M., an interview with RN #7 revealed she worked as the night shift supervisor on 04/05/14. She reported for duty at 7:00 P.M. and worked until 7:00 A.M. the following morning. She was assigned to work the 600 hall opposite from Resident #120's hall but was involved with getting her pain medication from the pharmacy and also with talking with the family. She spoke with the pharmacy on three different occasions that night trying to get authorization to pull [MEDICATION NAME] from the emergency medication supply box too give to the resident for her pain. The family had called in twice that night with concerns about the resident's pain control. She confirmed the resident complained of pain in her right knee that she rated a 10 out of 10 at 7:50 P.M. She stated the first time she spoke with the pharmacy there was a problem with the DEA number on the prescription. She reported the normal procedure for getting an authorization to pull a controlled narcotic medication from the emergency box was for the facility nurse to complete the top portion of the authorization form and fax it to the pharmacy. The pharmacy would complete the bottom half and then fax it back to them giving them an authorization to pull the medication from their emergency supply box. The second time she spoke with the pharmacy they claimed they did not receive an authorization form from the facility requesting authorization. She faxed the completed authorization form to them again. She stated she proceeded with her medication pass on her hall while they waited to get it back. After she finished her medication pass she realized they still had not received the authorization they needed to pull the medication. She called the pharmacy for the third time and was told it should have been sent. She reported the facility has had problems in the past with that pharmacy getting authorizations they needed for pulling controlled medication from the emergency supply box. She confirmed the pharmacy they were using then was still somewhat new to them. She denied that they had similar issues with their prior pharmacy they used before the facility switched. She denied that she had contacted Resident #120's physician to inform him the resident was experiencing severe pain and her prescribed pain medication was not available for use. On 06/12/14 at 3:06 P.M., an interview with LPN #8 revealed she cared for Resident #120 on the evening shift on 04/05/14. She worked from 3:00 P.M. until 11:00 P.M. She recalled the resident had issues getting her ordered pain medication from the pharmacy that night. She had to call the pharmacy due to not getting the authorization they needed to pull the medication from their emergency box. She reported RN #7 was working on it as well. She reported they had to fax paperwork through to the pharmacy several times. She remembered assessing the resident when she reported for duty at 3:00 P.M. and stated she documented it on a progress note. She was not sure why the nurse's progress note she documented her assessment on was not part of Resident #120's medical record. She stated her assessment was written on a new progress note and she remembered RN #7 had it when talking to the resident's family and the pharmacy. She denied the resident was in any pain when she assessed her at that time. LPN #8 reported she contacted the pharmacy the first time around 6:30 P.M. when the pharmacy had not delivered the resident's pain medication as they were supposed to. She stated she was told the medication would be there by that time. She indicated the resident was also beginning to complain of pain at that time and reported her pain was starting to get bad. When she called the pharmacy she found out there had been a problem with the DEA number on the prescription not being completely visible so they did not send it. She stated they faxed things to the pharmacy five different times and RN #7 took it over from there. She confirmed the resident complained of severe pain in her right knee that she said was a 10 out of 10 while they were still trying to get the authorization they needed to pull the ordered pain medication from there emergency supply box. She indicated by 10:00 P.M. they had everything worked out and was given the authorization they needed to pull it from the emergency box. She confirmed it was 2 and a half hours after the resident first reported her pain to be severe before she got her ordered prn pain medication. She denied that she had contacted the resident's physician to inform him of her complaints of pain or of the difficulty they were having with getting the prescribed pain medication. She thought maybe RN #7 had called the physician but was not sure if she did. A review of the facility's policy on new orders for scheduled II controlled substances revised 1/1/13 revealed new orders for scheduled II controlled substances required a complete written prescription prior to dispensing unless there was an emergency situation. An emergency situation was defined as one in which the prescribing practitioner determined that immediate administration of the scheduled II medication was necessary for proper treatment of [REDACTED]. If a controlled medication was needed before the pharmacy can make arrangements for a timely delivery, the facility must fax a request to remove a controlled medication from the emergency drug supply to the pharmacy. This citation substantiates the complaint OH 958.

Based on record review and staff interview the facility failed to adequately monitor, assess and provide interventions for Resident #7 related to constipation. a resident for bowel movements. Harm occurred to Resident #7 when the resident went five days without a bowel movement, without intervention or physician notification, developed coffee ground projectile vomiting, a fever and was subsequently admitted to the hospital with [REDACTED]. Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive assistance of one staff member with toileting and was dependent of two staff members for transfers. The resident was assessed to be incontinent of bowel and bladder. Review of the residents physician orders [REDACTED]. Review of the November 2013 bowel movement records revealed the resident had a usual bowel movement pattern which included a bowel movement every one to three days until 11/26/13. Record review revealed the resident did not have a bowel movement documented from 11/26/13 through 12/01/13. The MAR (medication administration record) and the nurse's progress notes lacked documentation of administration of Milk of Magnesia for constipation during this time period. The medical record also lacked documentation of an abdominal assessment (pain, distention, the presence of bowel sounds) during that time frame. The medical record lacked documentation of physician notification for the lack of a bowel movement in the six day time frame. Review of the December 2013 bowel movement records revealed the resident did not have a bowel movement from 12/05/13 through 12/09/13. A bowel movement (BM) was documented on first shift on 12/04/13. On 12/04/13 at 11:00 P.M. the nurse documented Milk of Magnesia was given for constipation. No follow up documentation was noted until 12/08/13 at 1:10 P.M. when Resident #7 was again given Milk of Magnesia for constipation. The documentation reflected the resident had a soft abdomen with bowel sounds in all four quadrants. The nurse's progress notes revealed on 12/08/13 at 5:00 P.M. the resident had a moderate amount of emesis of undigested food and the resident complained of an upset stomach. Record review revealed no evidence the physician was notified. On 12/08/13 at 8:15 P.M. an order was obtained for the anti-nausea medication, [MEDICATION NAME]. On 12/09/13 the resident had a temperature of 102.0 degrees Fahrenheit. Tylenol was given at that time. At 3:00 A.M., the resident ' s temperature was 97.6 degrees. On 12/10/13 at 2:30 A.M. the resident had a coffee ground in color projectile emesis. The resident's abdomen was hard and distended and the resident complained of slight pain above the navel (belly button). The resident was sent to the emergency room and was admitted to the hospital for a bowel obstruction. Interview with licensed practical nurse (LPN) #76 on 12/11/13 at 11:00 A.M. verified Resident #7 did not have a bowel movement from 12/05/13 through 12/09/13. The LPN contacted the hospital at that time to obtain Resident #7's admission [DIAGNOSES REDACTED]. Interview with the director of nursing (DON) on 12/11/13 at 5:10 P.M. confirmed the medical record lacked documentation of an assessment of bowel sounds with the emesis and also that the Milk of Magnesia medication had been administered two times from 12/04/13 through 12/09/13 without documented follow up. The DON indicated the resident generally had a BM every one to three days per the BM record. Interview with LPN #31 on 12/12/13 at 9:40 A.M. confirmed staff should assess bowel sounds before administering an as needed (prn) medication for constipation. The LPN stated if the medication for constipation was ineffective after 24 hours, the physician should be contacted to try a different medication. The LPN stated if a resident began to vomit, the nurse should assess to see if anything would cause them to be sick. The LPN also stated they would notify the physician if a resident had not had a BM and began vomiting. The LPN revealed Resident #7 did not have a history of bowel problems or issues with constipation. Interview with the DON on 12/12/13 at 10:10 A.M. also verified Resident #7 did not have a bowel movement from 11/26/13 through 12/01/13. The DON verified the lack of documentation to determine the resident had been assessed (including an abdominal assessment), the physician was notified and/or that interventions were attempted during this time period. The DON stated the facility does not notify the physician unless a resident has less than one BM in a week. The DON also stated Milk of Magnesia needed a few days to work. The DON confirmed the medical record lacked documentation of physician notification of the resident's condition except on 12/08/13 when a telephone order was written for [MEDICATION NAME]. However, the nurse's progress notes lacked documentation of the physician update. Interview with LPN #131 on 12/12/13 at 11:27 A.M. revealed if a resident did not have a BM within the next shift after giving a medication for constipation, the physician should be notified. The LPN stated some of the doctors want to wait but the nurse should call the physician to update. The LPN stated if the resident had not had a BM in three days, an abdominal assessment should be completed to see how the resident is feeling. The LPN also stated the nurse's progress should contain documentation of physician notification when an order is received.

Based on observation, record review, employee personnel file review, and physician and staff interview the facility failed to provide the necessary care and assistance to residents required for personal care to prevent the resident from falling and failed to implement fall prevention interventions for another resident as per their plan of care. This affected two residents (Resident #67 and #84) of four residents who were reviewed for falls and resulted in harm for Resident #67 who had an avoidable fall from bed during personal care that resulted in the resident sustaining a fracture to her right hip and a questionable fracture of the right lower leg. Findings include: 1. Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing evaluation form completed as part of an annual review dated 08/19/13 indicated the resident had an altered mental status (cognitive loss) related to her [DIAGNOSES REDACTED]. The bed safety section of the evaluation described the resident as being non-ambulatory, she required assistance to get out of bed as she had poor bed mobility, she had an altered safety awareness due to her cognitive decline and had a known history of falls. The Morse fall risk scale (an assessment tool used by the facility to identify the resident's fall risk) that was completed as part of the annual evaluation assessed the resident as being a medium risk for falls. The activity of daily living section of the nursing evaluation described the resident as being dependent with transfers with the use of a mechanical lift. She was marked as having functional impairment of her range of motion on both sides of her upper and lower extremities. An annual Minimum Data Set (MDS) 3.0 assessment, completed on 09/01/13 revealed the resident had unclear speech and was not able to make herself understood and was not able to understand others. Her vision was highly impaired. She had both short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was identified as being dependent on two for bed mobility, transfers and toilet use. The monthly physician's orders [REDACTED]. The date the order was originated for the resident to receive the assist of two for changing, turning and repositioning was 05/20/11. A care plan for the resident's impaired physical mobility revealed the impaired mobility was related to a history of a prior right hip fracture with repair, decreased mobility, and her being non-ambulatory. The interventions included the need for the resident to have the assist of two persons for turning and repositioning and also identified her as being dependent on two for bed mobility. A nurse's progress note dated 09/05/13 indicated the nurse was called to the resident's room by facility staff as the resident had fallen. The nurse found the resident on the floor by the bed when she entered the room. The nurse's note stated staff were turning the resident when the resident slid out of the side of the bed. The nurse's note reported the resident was assisted to the floor by staff. An initial assessment of the resident completed at the time of the fall found her to have two raised hematomas to her posterior head and a skin tear to the top of her right foot. The resident was assisted back to bed with no signs of any pain or other discomforts. A post fall evaluation dated 09/05/13 also indicated the resident slid out of bed while staff was turning her during care. The post fall evaluation also indicated the resident was assisted to the floor by staff. The nurse's progress note and the post fall evaluation was not specific as to how many staff were present at the time the fall occurred. A nurse's note dated 09/07/13 at 10:00 A.M. revealed the resident was noted to have bruising to the medial (inside) and lateral (outside) aspect of her right knee with swelling present. The physician was contacted and updated on the findings of the resident's right knee. An x-ray was ordered to the resident's right hip, femur (upper leg bone that extends from the hip down to the knee) and knee due to her fall with noted swelling and bruising. The x-ray was obtained on 09/07/13 and showed a Garden classification II acute femoral neck fracture (a fracture of the hip that was complete but nondisplaced) and a questionable nondisplaced supracondylar fracture (a fracture of the lower part of the femur just above the knee). Findings were confirmed with LPN #42. On 12/11/13 at 10:10 A.M., an interview with LPN #42 revealed the nurse who worked the night of 09/05/13 when Resident #67 fell was RN #36. She confirmed the nurse was still employed at the facility but was not working that day. She identified STNA #156 as being the aide who worked that night and was with the resident when she fell . She denied that STNA #156 still worked at the facility. On 12/11/13 at 10:35 A.M., an interview with the director of nursing (DON) revealed he was able to determine through the fall investigation that STNA #156 was providing incontinent care and turning the resident by himself at the time Resident #67 fell . He confirmed the resident required the assist of two for turning, repositioning and incontinent care and the STNA should not have been doing it by himself. He stated he was able to determine STNA #156 was the only staff member in the room providing care to Resident #67 at the time of the fall by his interview with RN #36. The DON stated the resident was turned in the direction of the STNA who was providing her care when she started to slide out of bed. STNA #156 assisted the resident to the floor. The DON reported he felt the fractures noted with the x-ray that was obtained on 09/07/13 were the result of the resident falling out of bed and onto the floor. He indicated STNA #156 had the bed placed at a working height at the time the fall occurred. Review of STNA #156's employee personnel file revealed the STNA was given counseling regarding his failure to follow Resident #67's plan of care when he provided personal care to the resident unassisted. His actions were thought to be the causative factor of the resident's fall. The counseling was said to be the STNA's final written warning. On 12/11/13 at 12:20 P.M., a phone interview with Physician #157 revealed he felt the fracture of Resident #67's right hip and the questionable fracture of her right lower femur was the result of her fall that occurred on 09/05/13. He denied that those fractures could have been the result of the resident being turned in bed even with her osteoporosis. He stated, with the location of the fractures, they would have been caused by trauma such as from a fall. He was not surprised the resident did not show any bruising or swelling until two days after the fall occurred due to the locations of where the fractures were. He also was not surprised the resident did not have any complaints of pain as she was bed bound and pain would not have been experienced unless weight bearing was taking place. He stated if the resident was able to bear weight then the resident would have shown signs of pain immediately after the fall occurred. 2. Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was readmitted to the facility on [DATE] after she underwent a revision due to persistent pain and an inability to ambulate independently. Post fall evaluations reviewed for the past 12 months revealed the resident had fallen several times. A post fall evaluation dated 12/02/13 revealed the resident had slid forward out of her wheelchair while in the activity room that resulted in her sitting on the floor. Due to the resident sliding out of her chair, dycem (a non-slip material on a roll that has a tacky surface and can be cut to size to prevent sliding out of a chair) was added as a fall prevention intervention and was to be placed on the resident's wheelchair seat. The most recent post fall evaluation dated 11/12/13 revealed the resident was getting into her wheelchair when she slid onto the floor. Two standard bed pillows were noted to be in the seat of the wheelchair when the fall occurred. The immediate intervention added to prevent additional falls from occurring was to remove the pillows from the wheelchair and add a cushion to the wheelchair. The interdisciplinary team met with both falls and agreed with the interventions added. The care plan for the resident's risk for falls included the need to evaluate the resident for appropriate seating devices as indicated and for the use of dycem to the wheelchair seat as fall prevention interventions. A patient nursing evaluation completed on 11/13/13 indicated the resident had a history of [REDACTED]. She required extensive assistance for transfers and ambulation and had a functional limitation in range of motion with one side of her lower extremities. The most recent quarterly Minimum Data Set (MDS) 3.0 assessment with the assessment reference date of 11/12/13 revealed the resident had fallen without injury since her last assessment. The monthly physician's orders [REDACTED]. On 12/12/13 at 11:55 A.M., an observation of Resident #84 noted her to be wheeling herself back to her room in her wheelchair from the dining room. She was outside her room. When asked if she was seated on a pressure reduction cushion and dycem. She locked her wheelchair and stood using the hand rails in the hall to assist her in standing from a seated position. She reported she was able to stand unassisted as she was also able to transfer herself when she wanted. There was no evidence of a pressure reduction cushion or dycem in place under the resident. She was sitting on a standard bed pillow with a pillow case on it. A bed blanket and a knitted afghan was also noted under the resident with the blanket being under the pillow and the knitted afghan noted on top of the pillow. The resident was not sure what happened with the cushion or the dycem and was not sure how long it had been since she used them. Findings were confirmed with LPN #42 on 12/12/13 at 12:00 P.M. who also had the resident stand to reveal the pressure reduction cushion and the dycem were not in place. On 12/12/13 at 12:00 P.M., an interview with LPN #42 revealed the pressure reduction cushion and the dycem should have been under the resident as per her physician's orders [REDACTED]. She acknowledged that both interventions had been added following falls to prevent additional falls from occurring. She also acknowledged the use of the standard bed pillow was thought to be a causative factor with one of the resident's prior falls and should not have been used for the resident to sit on. She was not sure what happened with either the pressure reduction cushion or the dycem and indicated she would get some from the therapy department.