Every finding on record at Embassy of Winchester

Based on record review, resident and staff interviews, review of the Emergency Medical Services (EMS) run report, review of the death certificate, policy review, and review of the National Institutes of Health guidance, the facility failed to ensure Resident #96 was monitored for acute respiratory failure when oxygen saturations went to 65 percent and failed to appropriately assess a resident's change in condition. This resulted in Immediate Jeopardy and the serious life-threatening harm and death on [DATE] when Resident #96 exhibited a change in condition. Resident #96 was assessed with a low oxygen level (O2) of 65 percent and exhibited shortness of breath (SOB). At 1:34 A.M., Resident #96's 02 saturation was 91 percent with oxygen at four liters per minute (LPM). Registered Nurse (RN) #225 did not provide ongoing monitoring after the first vital signs with an O2 saturation of 91 percent to ensure Resident #96 was stable. From 1:35 A.M. to 3:09 A.M., there was no monitoring of Resident #96. At 3:14 A.M., EMS found Resident #96 with rigor mortis (post-mortem stiffness of skeletal muscles) and dependent lividity (reddish-purple discoloration that appears when blood settles in the lowest parts of a body after death). Resident #96 was pronounced dead and his cause of death was acute hypoxic respiratory failure (a sudden, life-threatening condition where the lungs cannot adequately transfer O2 into the bloodstream). Additionally, the facility failed to ensure to follow up with an outside provider related to Resident #9's skin laceration. This affected one (Resident #96) of one resident reviewed for death and one (#9) of one resident reviewed for skin concern not related to a pressure ulcer.On [DATE] at 1:08 P.M., the Administrator, Regional Director of Clinical Services (RDCS) #300, Director of Nursing (DON), and Director of Social Work #250 were notified Immediate Jeopardy began on [DATE] at approximately 1:35 A.M. when the facility failed to ensure Resident #96 was monitored for acute respiratory failure after Resident #96 began exhibiting a change in condition at 12:42 A.M. On [DATE] at 12:42 A.M., Resident #96 reported he could not breathe. His O2 saturation was 65 percent on room air. RN #225 called the on-call physician and reported Resident #96 was wheezing in upper lobes and Certified Nurse Practitioner (CNP) #230 ordered O2 at two LPM to increase to six LPM if needed to maintain O2 level above 89 percent and ordered a two-view chest x-ray. At 1:34 A.M., Resident #96's 02 was 91 percent with four LPM of O2. There was no evidence Resident #96 was monitored, physically assessed, vital signs obtained, or evaluation of Resident #96's condition from 1:34 A.M. through 3:09 A.M. RN #225 notified EMS that Resident #96 was having trouble breathing, but did not complete an assessment, observe for signs of obvious death, or obtain vital signs at this time and left Resident #96's paperwork for the EMS. At 3:15 A.M., EMS entered the facility and went into Resident #96's room. The EMS run report stated Resident #96 was obviously dead and rigor mortis and dependent lividity were observed on Resident #96 (indicating Resident #96 was dead for some time). Skin was cold, lividity, mottled, and pale. Rigor in the jaw and neck, mottled skin, and dependent lividity in the back and buttocks. The death certificate stated cause of death was Acute Hypoxic Respiratory Failure.The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: -On [DATE], the DON reviewed the medical records for all 91 residents for the need for O2 therapy and ensured the residents were being routinely monitored for O2 saturation levels. The DON ensured their medical records had accurate documentation of O2 use and monitoring. -On [DATE], the DON completed education on O2 therapy and change in condition to include assessment, documentation, and monitoring was completed with all 20 licensed nurses. -On [DATE], the DON provided coaching to RN #225 for failure to document appropriately on a resident and unsatisfactory work performance. RN #225 needs to improve on documentation and obtain vital signs on all changes in conditions, remain with any distressed residents or have a staff member assist until documentation of stability and follow all physician orders.-On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the facility's abatement plan with no additional recommendations. Those in attendance included the Administrator, DON, Medical Director #245 (by telephone), Social Services Director (SSD) #250, Director of Rehabilitation #654, Maintenance Director #30, Unit Manager #99, Human Resource Director #112, and Medical Records Director #89.-On [DATE], Licensed Practical Nurses (LPN) #698, #105, #672, and #99 completed an assessment on all 91 residents for the need of O2 therapy and identify any changes in conditions. There were no new concerns identified. -On [DATE], the DON reviewed all 91 resident's medical records for ongoing documentation by the nurses, and documentation of monitoring and assessment with residents who received O2 therapy. -On [DATE], the Administrator, RDCS #300, Regional Director of Operations (RDO) #310, and DON conducted a root cause analysis and identified the root cause was the failure to monitor Resident #96's acute respiratory failure and to appropriately assess the resident with a change in condition. The DON and Administrator re-interviewed all staff who worked the night of [DATE] via telephone and educated staff to sign the statements on next scheduled shift to work. -On [DATE], RDCS #300 educated the DON on completing thorough investigations, including obtaining interviews from all staff who worked around the time of the event and collecting signed staff statements to ensure the accuracy of their accounts. -On [DATE], the DON completed education for all 20 licensed nurses regarding the following: O2 administration and monitoring of residents with respiratory change in condition; The licensed nurse will remain with the resident until vital signs are within normal limits for five minutes and recheck frequency of vital signs every 15 minutes for an hour thereafter; Medical Emergency Response included assessing for obvious signs of death; and change in condition including assessment, and documentation of physician notification. -On [DATE], the DON completed a Code Blue Drill for a Medical Emergency Response with facility staff. There were no identified concerns from the drill conducted.-Beginning [DATE], the DON or Designee will complete an Emergency Medical Response Drill weekly times four weeks or as determined by the QAPI. The results will be reported to the QAPI committee and modifications of interventions adjusted as needed. The sample size would include three to five residents per week with a compliance threshold of 95 percent to be reported to the QAPI monthly for three months. -Beginning [DATE], the DON or Designee will monitor nursing documentation when a resident has a change in condition. This will include investigation and daily monitoring of the 24/72 Hour Report with the Clinical Interdisciplinary Team to ensure the resident's changes in conditions were documented appropriately. The sample size will include five residents weekly for four weeks.Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring to ensure on-going complianceFindings include: 1. Review of the medical record for Resident #96 revealed an admission date of [DATE]. Diagnoses included type two diabetes mellitus, severe protein-calorie malnutrition, metabolic encephalopathy, hypertension (HTN), peripheral vascular disease, chronic kidney disease stage three A, personal history of pulmonary embolism, personal history of transient ischemic attack and cerebral infarction, and solitary pulmonary nodule. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had intact cognition. Resident #96 required staff assistance for all his care and was frequently incontinent with bladder and bowel. Resident #96 was not on O2 therapy. Review of the care plan dated [DATE] revealed Resident #96 had alteration/potential for alteration in cardiac output related to cancer, HTN, hyperlipidemia, stroke occlusion and stenosis of bilateral carotid arteries, personal history of transient ischemic attack, cerebral infarction without residual deficits, and atherosclerosis of native arteries of extremities with intermittent claudication unspecified extremity. Interventions included to administer O2 as ordered by the physician, check pulse oximetry as ordered by the physician, auscultate lung sounds and report abnormalities to physician/nurse practitioner, be alert to changes with heart rate and rhythm, inspect for signs of reduced cardiac output with bradycardia: weak pulse, dizziness, syncope, shortness of breath (SOB), chest pain, and observe for signs of reduced cardiac output that may accompany tachycardia: rapid pulse, reduced blood pressure, SOB, chest pain, fatigue, and restlessness (noting that not all patients are symptomatic with each episode). The care plan dated [DATE] revealed Resident #96 has altered respiratory status/difficulty breathing related to solitary pulmonary nodule. Interventions included to observe for signs/symptoms of respiratory distress and report to the physician as needed: increased respirations; decreased pulse oximetry; increased heart rate (tachycardia); restlessness; diaphoresis; headaches; lethargy; confusion; hemoptysis; cough; pleuritic pain; accessory muscle usage; skin color changes to blue/grey, and observe/document/report abnormal breathing patterns to physician, increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed lip breathing, nasal flaring, position resident with proper body alignment for optimal breathing pattern, and provide O2 as ordered. Review of the progress notes dated [DATE] to [DATE] revealed Resident #96 had no breathing issues and was not on O2 until [DATE] at 12:59 A.M. Review of the on-call physician report dated [DATE] at 12:42 A.M. revealed RN #225 called the on-call provider (CNP #230) and reported Resident #96 could not breathe, O2 saturation of 65 percent on RA (a level 65 percent indicates severe hypoxemia and threatens organ function; below 67 percent often leads to cyanosis (bluish discoloration); should prompt urgent medical attention) and wheezing in upper lobes. CNP #230 ordered O2 administration at two LPM to increase to six LPM if needed to maintain O2 level above 89 percent and chest x-ray two views. Review of the vital signs dated [DATE] at 12:50 A.M. revealed Resident #96's resting pulse was 100 (irregular), respirations 24 breaths per minute (RR) (normal is 14-20), and O2 saturation of 68 percent on room air. The progress note dated [DATE] at 12:54 A.M. written by RN #225 revealed Resident #96 had complaints of breathing trouble, and O2 saturation of 65 percent. The physician was notified and ordered O2 STAT; start out at two LPM up to six LPM as needed (PRN) due to SOB; check O2 saturations; if O2 saturation was still below 90 percent, call the physician, and send the resident to the emergency room (ER). CNP #230 also ordered chest x-ray two views. Review of the physician order for Resident #96 dated [DATE] at 12:59 A.M. revealed an order to obtain O2 saturation, if below 90 percent, call doctor. Start O2 as needed for two LPM increase up to six LPM. There was no physician order written to obtain a chest x-ray two views as prescribed by CNP #230 to RN #255. The progress note dated [DATE] at 1:05 A.M. written by RN #225 revealed Resident #96 placed on three LPM of O2 via nasal cannula per physician orders. Resident #96 tolerated O2 well with minimal restlessness. Resident #96 was alert and oriented and denied any pain or discomfort. The vital signs dated [DATE] at 1:05 A.M. revealed respirations were 24 RR and O2 saturation of 70 percent on three LPM of O2. The progress note dated [DATE] at 1:16 A.M. written by RN #225 revealed Resident #96 was alert and oriented and able to respond to questions appropriately. Resident #96 denied any pain or discomfort; Resident #96 verbalized the O2 administration brought him minimal comfort at this time. The vital signs dated [DATE] at 1:18 A.M. revealed resting pulse was 92 (irregular), respirations were 22 RR, and O2 saturation of 82 percent on four LPM of O2. The vital signs dated [DATE] at 1:24 A.M. revealed resting pulse was 92 (irregular), respirations were 22 RR, and O2 saturation of 86 percent on four LPM of O2. The vital signs dated [DATE] at 1:34 A.M. revealed resting pulse was 98 (irregular), respirations 22 RR, and O2 saturation at 91 percent on four LPM of O2. There were no further vital signs recorded for Resident #96. The progress note dated [DATE] at 1:34 A.M. written by RN #225 revealed Resident #96 was resting comfortably in bed, with eyes closed. Resident #96 has responded to questions appropriately and denied any pain, discomfort or chest tightness at this time. Resident #96 stated his SOB has decreased significantly. Resident #96 continued with O2 administration at four LPM. The nurse stated she would continue to monitor Resident #96 and update the physician as needed. Review of the Emergency Medical Squad (EMS) run report dated [DATE] at 3:09 A.M. revealed a call was received from the facility reporting [Resident #96] was having difficulty breathing. At 3:15 A.M., EMS arrived on scene and at Resident #96's room. The primary impression and complaint were obvious death with signs and symptoms of rigor mortis (primary) and dependent lividity. The EMS run report narrative revealed the nursing home stated they did not know when they last assessed Resident #96 prior to calling 911. The staff at the front desk stated they did not know what was going on. The EMS crew walked to Resident #96's room. The facility staff (RN #225) walked out of Resident #96's room and stated, he is already gone. The EMS crew walked into the room to assess Resident #96. Resident #96 was lying supine in bed. Resident #96 presented with no pulse, rigor in the jaw and neck, mottled skin, cool skin, dependent lividity in the back and buttocks and fixed non-reactive pupils. At 3:27 A.M., the EMS call was closed. Review of the on-call physician report dated [DATE] at 3:14 A.M. revealed Resident #96 had a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) order (before an arrest the patient receives full life-saving medical care. This includes medications, surgeries, blood pressure support, and other medically indicated treatments). EMS has been notified, and RN #225 notified CNP #232. CNP #232 ordered RN #255 to notify next of kin, and approval to release the body to the funeral home. The progress notes dated [DATE] for Resident #96 revealed there was no monitoring, physical assessment, vital signs obtained, or evaluation of Resident #96's condition from 1:34 A.M. until 3:38 A.M. The progress note dated [DATE] at 3:38 A.M. written by RN #225 revealed during rounds, the nurse checked on Resident #96's condition while was receiving O2. Resident#96 continued to complain of difficulty breathing, and EMS were called. Emergency Medical Technicians (EMTs) arrived and pronounced Resident #96 deceased . The DON, physician, and family were notified that Resident #96 was deceased . The family was to contact the funeral home of their choice. Review of the Death Certificate for Resident #96 revealed the death was on [DATE] at 3:38 A.M. with cause of death stated as Acute Hypoxic Respiratory Failure. The death certificate for Resident #96 was signed by Medical Director #245 and manner of death was natural causes with no autopsy performed. Review of the facility's investigative documents for Resident #96's change in condition revealed the documents included the resident's face sheet, vital signs, three staff interviews/statements, O2 administration policy, in-service and training documents for staff, emergency QAPI meeting to review O2 therapy safety and compliance and auditing. There was no summary of the incident, no root cause analysis, and there was no documentation of a corrective action plan and monitoring of their plan. Review of the typed telephone interview for RN #225 revealed it was undated and signed by the DON and not RN #225. RN #225 stated she had stayed with Resident #96 until his O2 saturations reached 91 percent. Then RN #225 checked on him every 15 to 30 minutes. Upon EMS arriving, Resident #96 appeared to go unresponsive but still breathing. RN #225 stated she remained in the room until EMS arrived, took over, and ultimately pronounced Resident #96 deceased . Then RN #225 notified the physician, DON, and family. Review of the typed interview with RN #160 dated [DATE] revealed it was signed by the DON and not RN #160. RN #160 stated RN #225 put O2 on Resident #96 immediately after a pulse oximetry reading of 68 percent and then received an order for three LPM of O2. Additionally, RN #160 called the family after Resident #96 expired. Review of the undated typed interview with Certified Nursing Assistant (CNA) #71 revealed it was signed by the DON and not CNA #71. CNA #71 stated he had alerted RN #225 that Resident #96 was having trouble breathing. CNA #71 stated he had stayed with Resident #96 until RN #225 had returned with O2 concentrator. Additionally, CNA #71 stated he had checked on Resident #96 a few times and RN #225 was present in the room with Resident #96 each time he checked on Resident #96. During an interview on [DATE] at 4:26 P.M., the DON stated RN #225 thought Resident #96 stabilized at 1:34 A.M. and she went back in to check on him two hours later. The DON confirmed RN #255 did not follow through with standards of practice and did nothing during the two hours. The DON stated she disciplined RN #225 and RN #225 resigned. During an interview on [DATE] at 9:44 A.M., Lead Paramedic #236 and Deputy Chief #237 revealed Lead Paramedic #236 stated he does remember the EMS run on [DATE] to the facility. Lead Paramedic #236 stated dispatch told them the resident was having difficulty breathing when they were receiving the emergency call. Lead Paramedic #236 stated they walked into the facility, no staff members seemed to know what was going on and the staff did not know of anyone calling EMS. Lead Paramedic #236 stated as he walked down the hall, a nurse (RN #225) was walking out of the room, and she said Resident #96 was already deceased . Lead Paramedic #236 stated they quickly had someone get tools as Lead Paramedic #236 was checking Resident #96, but Resident #96 was deceased . Lead Paramedic #236 stated Resident #96 had been dead for quite a while. Lead Paramedic #236 stated rigor and lividity had already set in based on his assessment. Lead Paramedic #236 stated he asked the facility when they last assessed or seen Resident #96 and he said they could not tell him. Lead Paramedic #236 stated he could not say how long Resident #96 had been deceased . Deputy Chief #237 stated rigor and lividity take time to set in and so Resident #96 had been dead for some time. During an interview on [DATE] at 9:58 A.M., CNP #240 stated she does not know how long it would take for rigor and lividity but would think it would take at least an hour. During an interview on [DATE] at 1:09 P.M., the DON confirmed the facility has no further information to support monitoring of Resident #96 was done between 1:34 A.M. and 3:38 A.M. The DON also could not provide an explanation when RN #255 assessed Resident #96 with having difficulty breathing at 3:14 A.M. and called EMS and reported Resident #96 was having difficulty breathing. (This contraindicates the EMS run report which stated Resident #96 was obviously dead a minute later upon arrival and rigor and lividity had set in.) The DON stated the facility was still investigating if the stat x-ray was ordered and radiology was notified when CNP #230 ordered the chest x-ray on [DATE] at 12:42 A.M. During an interview on [DATE] at 1:28 P.M., CNP #232 revealed she was vaguely familiar with Resident #96. CNP #232 did receive a telephone call on [DATE] but couldn't remember the exact time of the telephone call. The telephone call was very short and stated Resident #96 was deceased . CNP #232 stated she was told Resident #96 was having SOB problems and assumed it was earlier in the evening/night because he had expired by the time she heard about Resident #96. In general, CNP #232 stated continually monitoring the resident would be expected of nursing when there was a health concern; CNP #232 would give specific orders on how to monitor (for example, continuous pulse oximeter machine, and check resident every 15 to 30 minutes). During an interview on [DATE] 1:42 P.M., CNP #230 revealed on [DATE], she was notified Resident #96 was having O2 level trouble. CNP #230 stated she told RN #255 to put him two LPM of O2 and to titrate up to six LPM to keep the O2 above 90 percent and if not above 90 percent, then to send the resident to the ER. CNP #230 stated they try to keep the residents at the facility if they can treat them there, so CNP #230 ordered a chest x-ray. CNP #230 stated she was told Resident #96 was still responsive at this telephone call (at 12:42 A.M.) and she told RN #255 to text her with updates or to follow up with CNP #230 directly so that she would not get a different provider. CNP #230 stated no one from the facility called or texted her for follow up after the 12:42 A.M. telephone call. CNP #230 stated she usually gives a resident at least one hour for a resident's O2 saturations to stabilize while gently titrating them up to six LPM of O2. CNP #230 stated she would like for the pulse oximeter to be continually monitoring the resident's O2 saturations, but she knows that different facilities have different capabilities. CNP #230 stated her expectation was the resident would reach his baseline of 90 percent or above, then leave the pulse oximeter on the resident and monitor the resident every 30 minutes or more routinely. CNP #230 stated the appropriate monitoring for a resident would be checked every 30 minutes to ensure they were maintaining their goal and stability. During an interview on [DATE] at 2:15 P.M., the DON stated her expectation for a change in condition would be for the nurse to stay with the resident, check vital signs every 15 minutes or more if needed, follow the physician order, and notify the DON. The DON stated she had educated the staff about this change in condition expectation during all staff meetings or in-person education. The DON stated when Resident #96 reached 90 percent or more, the expectation was to stay with Resident #96 and to keep assessing him. The DON stated as a nurse, she would have stayed with Resident #96 for 30-45 more minutes to make sure he was stable because the O2 saturation can go up, then dip back down within one minute. During an interview on [DATE] at 3:09 P.M., Resident #83 (Resident #96's roommate on [DATE]) stated on the night Resident #96 died, Resident #96 was gagging like he was choking. Resident #96 could not remember anything else from that night. During an interview on [DATE] on 8:00 A.M., RN #160 stated she worked on [DATE] when Resident #96 died, but Resident #96 was not on her assignment. RN #160 revealed RN #225 told her Resident #96's O2 was low and so RN #225 turned the O2 up. A couple hours later, RN #225 told RN #160 that Resident #96 was deceased . RN #160 said What do you mean, he's gone? RN #160 stated she went to Resident #96's room and he was just lying in their flat on the bed and had O2 nasal cannula in his nose. RN #160 stated she told RN #225 to call EMS, the on-call physician, and Resident #96's family. During an interview on [DATE] at 2:07 P.M., RN #225 stated CNA #71 told her Resident #96 was having breathing distress on [DATE]. RN #225 stated she raised the head of the bed (HOB) up for Resident #96. RN #225 stated Resident #96 did not have an order for O2, so she called the physician before starting the O2 for Resident #96. RN #225 reported she could not recall the last time any staff member checked on Resident #96 before she entered the room at 3:09 A.M. RN #225 stated she was worried about another resident who was diabetic down the hallway whose blood sugar was high. RN #225 stated she should have sent Resident #96 to the hospital the first time (at 12:42 A.M.) when she called CNP #230. RN #225 stated the last time she checked on Resident #96 at 3:09 A.M., Resident #96 said he was fine but complained of SOB, so RN #225 turned the O2 up from two LPM to three LPM, (this contraindicates her progress note) then went to call EMS and get Resident #96's paperwork ready. When she went back into the resident's room, Resident #96 was dead. During an interview on [DATE] at 10:07 A.M., the DON confirmed the facility did not have any further documented staff interviews than the three provided to the state survey team. The DON stated she interviewed four other aides and one nurse who worked the night of the incident and they saw/heard nothing, so she didn't document them. The DON also confirmed that the facility did not obtain signatures or confirmation from the three staff members they interviewed to verify that their statements were accurate. During an interview on [DATE] at 10:18 A.M., LPN #122 stated if a resident had an O2 saturation of 68 percent, she would immediately call EMS to send them out. If a resident had an abnormal O2 saturation, she would monitor the resident until it reached baseline and they would still monitor the resident's O2 saturation every 30 to 60 minutes, until she gets further monitoring instructions from the physician. LPN #122 would capture all the vital signs and communications in the resident's medical record. An attempt to interview Medical Director #245 during the survey was This interview with LPN #122 was when [NAME] and I went back onsite to talk with Administration related to their ongoing IJ. This interview shows that the nurses were not aware of the facility's abatement plan to check on every 15 minutes. I thought it helped support the ongoing IJ with removal date of 6/15. unsuccessful. Review of the policy titled Oxygen Administration, undated, revealed O2 is administered under orders of a physician, except in the case of an emergency. In such case, O2 is administered and orders for O2 are obtained as soon as practicable when the situation is under control. Staff shall document the initial and ongoing assessment of the resident's condition warranting O2 and the response to the O2 therapy. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, O2 saturations, or evidence of complications associated with the use of O2. Review of the policy titled Notification of Changes, dated [DATE] revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Significant changes in the resident's physical, mental or psychosocial condition such as deterioration in health, mental, or psychosocial status. This may include life-threatening conditions, or clinical complications. Review of the policy titled Medical Emergency Response, revised [DATE], revealed the employee who first witnesses or is the first on the site of a medical emergency, who is trained, will initiate immediate action. A nurse will assess the situation and determine the severity of the emergency. Stay with the resident. The RN Supervisor or Charge Nurse will ensure accurate documentation of the event and delegate any other duties or tasks needed. Review of the National Institutes of Health guidance titled Oxygen Saturation dated [DATE] and found at https://www.ncbi.nlm.nih.gov/books/NBK525974/ revealed O2 saturation is an essential element in the management and understanding of patient care. O2 is tightly regulated within the body because hypoxemia can lead to many acute adverse effects on individual organ systems. These include the brain, heart, and kidneys. Due to the critical nature of tissue O2 consumption in the body, it is essential to monitor current O2 saturation. A pulse oximeter can measure O2 saturation. The use of pulse oximetry has become a standard of care in medicine. Pulse oximetry can provide a rapid tool to assess O2 saturation accurately. It is particularly useful in emergencies for this reason. Cyanosis may not develop until O2 saturation reaches about 67 percent. As such, pulse oximetry is extremely useful because the signs and symptoms of hypoxemia may not be visible on physical examination. The human eye's ability to detect hypoxemia is poor. The presence of central cyanosis, blue coloration of the tongue and mucous membranes, is the most reliable predictor; it occurs at an oxyhemoglobin saturation of about 75 percent. Review of the National Institutes of Health guidance titled Methods of Determination dated [DATE] and found at https://www.ncbi.nlm.nih.gov/books/NBK549867/ revealed rigor mortis is the post-mortem stiffening of muscles caused by the depletion of adenosine triphosphate (ATP) from the muscles, which is necessary for the breakdown of actin-myosin filaments in the muscle fibers. Rigor mortis starts immediately after death and is usually seen in a sequence known as the march of rigor and Nysten's Law (a forensic principle describing the sequential progression of rigor mortis (muscle stiffening) in a body after death.) While rigor mortis develops simultaneously in all muscle tissue in the body, voluntary and involuntary, the size of the muscle determines the perceptibility of changes by the examiner. Smaller muscles over the face-around the eyes, around the mouth, etc. are the muscles where rigor mortis first appear, followed by rigor mortis of the muscles in the hands and upper limbs, and finally appears in the large muscles of the lower limbs. Rigor mortis appears approximately two hours after death in the muscles of the face, progresses to the limbs over the next few hours, completing between six to eight hours after death. The final change in the classical triad is livor mortis (lividity), which is the purplish-blue discoloration of the skin in the dependent parts of the body due to the collection of blood in skin vessels caused by gravitational pull. Hypostasis develops as spots of discoloration within half an hour to two hours. 2. Review of the medical record for Resident #9 revealed an admission date of [DATE]. Diagnoses included cerebral infarction, respiratory failure, metabolic encephalopathy, tracheostomy status and malignant neoplasm of the larynx. Review of the care plan dated [DATE] revealed Resident #9 had an actual area of skin impairment related to a skin tag or laceration on the left side of the neck. Interventions included to initiate wound treatment and continue treatment as ordered, observe the dressing daily to ensure it remained intact, and observe and document the wound weekly. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #9 was severely cognitively impaired, did not reject care, and was dependent on staff for activities of daily living. Review of the wound care note dated [DATE] revealed Resident #9 was being seen for a chronic and reoccurring laceration on the left sid

Based on observations, review of physician orders, staff interview, and policy review, the facility failed to properly store and date food items in the freezer. This had the potential to affect all 90 residents who receive food from the kitchen. Residents #28 and #56 receive no food by mouth. The facility census was 92. Findings include:Observations on 06/08/26 from 1:55 P.M. to 2:05 P.M. revealed the following items were opened and undated in the facility walk in freezer: three bags of country fried steak in plastic bag, a plastic bag of cauliflower, a plastic bag of cheese omelets, a plastic bag of chicken tenders, a plastic bag of unbreaded chicken breasts, and a plastic bag of french fries. The were also, a plastic zipper bag of hot dogs that had a faint date of 05/28/26, but the hot dogs were freezer burned. Interview with Dietary Manager (DM) #146 on 06/08/26 at 2:05 P.M. confirmed there were three bags of country fried steak in plastic bag, a plastic bag of cauliflower, a plastic bag of cheese omelets, a plastic bag of chicken tenders, a plastic bag of unbreaded chicken breasts, and a plastic bag of french fries were opened and undated. DM #146 confirmed the hot dogs were freezer burned. Review of Resident #28 and #56's medical records revealed they had physician orders to receive no food by mouth. Review of the facility's undated policy dated Dating for Food Storage revealed all foods that require time and temperature control should be labeled with the following: common name of the food, date the food was made, date the container was opened, and use by date. Items that were being stored in the freezer must be labeled, dated, sealed in the same manor, and may be stored for the period of time per HACCP (Hazard Analysis and Critical Control Points) guidelines.

Based on medical record review and staff interview, the facility failed to administer medications in accordance with the parameters ordered by the physician. This affected one (Resident #34) of five residents reviewed for unnecessary medications. The facility census was 92. Findings include: Medical record review for Resident #34 revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had a severe cognitive impairment. Review of Resident #34's physician orders dated 10/29/25 revealed an order for blood glucose monitoring one time a day every Monday and Wednesday, and to notify the physician if the blood sugar levels were less than 60 or above 200. There was an order for Prazosin two milligrams (mg) two capsules for nightmare disorder and to hold if systolic blood pressure (SBP) was less than 110. Additionally, there was an order for Metoprolol Succinate 50 mg for hypertensive retinopathy and to hold is SBP was less than 110 or if heart rate was less than 60. Review of Resident #34's medication administration records (MAR), dated December 2025 to May 2026, revealed the following: on 12/08/25, his blood sugar was 239 and there was no documentation to support the physician was notified; on 12/13/25, his heart rate was 50, yet his metoprolol succinate was still administered; on 01/02/26, his heart rate was 51, but his metoprolol succinate was still administered; on 02/07/26, his heart rate was 59, but his metoprolol succinate was still administered; on 03/14/26, his heart rate was 55, but his metoprolol succinate was still administered; on 03/27/26, his blood pressure was 106/70 yet his Prazosin was still administered; and on 05/25/26, his blood sugar was 250 and there was no documentation to support the physician was notified. Interview with Director of Nursing (DON) on 06/10/26 at 3:26 P.M. confirmed Resident #34 was administered prazosin on 03/27/26 and metoprolol succinate on 12/13/25, 01/02/26, 02/07/25 and 03/14/26 when the resident's heart rate or SBP was outside the physician ordered parameters. The DON confirmed there was no documentation the physician was notified when Resident #34's blood sugar levels were outside the physician ordered parameters on 12/08/25 and 05/25/26.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure a resident with a suprapubic catheter was provided preventative care to prevent potential complications of infection and possible dislodgement. This affected one (Resident #14) of one resident reviewed for urinary catheters. The facility census was 92 residents. Findings include:Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, quadriplegia, and neuromuscular dysfunction of the bladder.Review of the physician orders dated 04/23/26 revealed an order for a suprapubic catheter 18 French (F) with 10 bulb to straight drain.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact, dependent on staff for toileting hygiene, and had an indwelling urinary catheter.Review of the care plan dated 04/22/26 revealed Resident #14 had the potential for complications related to use of a suprapubic catheter. Resident #14's suprapubic catheter care plan did not include an intervention to keep the collection bag off the floor. An intervention for suprapubic catheter care was added 05/28/26.Review of Resident #14's physician orders revealed on 05/26/26, an order for suprapubic catheter care: cleanse with normal saline, pat dry, apply split gauze around the suprapubic catheter site, and secure with tape to be performed every shift and as needed. There was no order for suprapubic catheter care from 04/22/26 to 05/25/26.Review of Resident #14's medication administration record (MAR) and treatment administration record (TAR) from 04/22/26 to 05/25/26 revealed no documentation suprapubic catheter care was performed. The progress notes from 04/22/26 to 05/25/26 revealed suprapubic catheter care was documented as completed in a skilled progress note on 04/26/26, 05/01/26, 05/19/26, and 05/20/26. There were no other progress notes did not reveal documentation suprapubic catheter care was completed from 04/22/26 to 04/25/26, from 04/27/26 to 04/30/26, from 05/02/26 to 05/18/26, and from 05/21/26 to 05/25/26.Observations on 06/08/26 at 10:21 A.M. and 2:52 P.M. revealed the catheter bag was laying on the floor below Resident #14's bed.Interview on 06/08/26 at 2:52 P.M. with Certified Nursing Assistant (CNA) #68 confirmed the catheter bag was on the floor below Resident #14's bed but should hanging on the lower bed frame.Observation on 06/09/26 at 2:39 P.M. revealed CNA #201 provided suprapubic catheter care for Resident #14. CNA #201 secured the catheter tubing several inches away from the insertion site. Using a clean washcloth, soap, and water, CNA #201 cleaned down the catheter tubing. As CNA #201 cleaned the tubing, Resident #14 complained of pulling while the tube was being cleaned.Interview on 06/09/26 at 3:09 P.M. with CNA #201 confirmed the catheter was not secured adequately during the procedure, causing a pulling sensation.Interview on 06/10/26 at 1:55 P.M. with the Director of Nursing (DON) confirmed suprapubic catheter care was not consistently documented in the medical record for Resident #14 from 04/22/26 to 05/25/26. At 4:58 P.M., the DON confirmed suprapubic catheter care should be documented in the medical record every shift and a physician order should be in place to provide suprapubic catheter care.Review of the policy titled 'Catheter Care' revised 06/01/24 revealed catheter care will be performed every shift and as needed by nursing personnel. When providing catheter care, hold the catheter in place so as to not pull on the catheter. Catheter care should be documented.

Based on observations, interview, medical record review, and review of facility policy, the facility failed to ensure the call light was in reach at all times for one resident. This affected one (Resident #21) of two residents reviewed for environment. The facility census was 92 residents.Findings include:Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cardiomyopathy, anoxic brain damage, anxiety, and depression.Review of the care plan revealed Resident #21 required assistance with activities of daily living related to immobility with an intervention to keep the call light in reach while in bed, initiated on 08/27/25.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was rarely or never understood and dependent on staff for all activities of daily living.Observations on 06/08/26 at 12:38 P.M. and 2:50 P.M. revealed Resident #21 was resting in bed. Resident #21's bed was positioned so that the right side was against the wall. A fall mat was on the floor to the left of Resident #21's bed. Resident #21's nightstand was positioned to the left of the fall mat. Resident #21's call light was out of reach hanging over the nightstand. Resident #21 stated they were wer unable to locate the call light.Interview on 06/08/26 at 2:56 P.M. with Certified Nurse Aide (CNA) #168 confirmed Resident #21's call light was out of reach.Review of the policy titled 'Call Lights: Accessibility and Timely Response' reviewed/revised 04/01/22 revealed with each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of the resident and secured, as needed.

Based on observation and staff interviews, the facility failed to ensure the resident's room had outlet covers to ensure the electrical wiring was covered. This affected one (#11) of 24 residents reviewed for physical environment. The facility census was 92.Findings include:Observation on 06/08/26 at 11:18 A.M. revealed Resident #11's room had a missing outlet cover with exposed electrical housing located above the resident's footboard directly above the resident's legs. The uncovered outlet was being used for a packaged terminal air conditioner located adjacent to the window.Observations on 06/09/26 at 11:34 A.M. and 4:15 P.M. revealed the outlet cover remained missing with exposed electrical still present in Resident #11's room.Observation on 06/10/26 at 10:20 A.M. revealed the outlet cover was still missing and the exposed electrical remained in Resident #11's room.Interview and observation on 06/10/26 at 3:40 P.M. with Certified Nursing Assistant (CNA) #448 confirmed Resident #11's outlet above the bed did not have a cover and exposed electrical was visible. CNA #448 stated she would place a work order for repair.Interview on 06/11/26 at 3:13 P.M. with Maintenance Director #130 revealed he had been made aware of the missing outlet cover and exposed electrical on 06/10/26 and had not received earlier notification of the issue.

Based on medical record review, financial record review, staff interview, and policy review, the facility failed to ensure resident funds were handled appropriately and failed to prevent the mixing of resident's funds with facility funds. This affected two (Residents #25 and #89) of five resident financial records reviewed. The census was 92. Findings include: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment, dated 05/19/26, revealed Resident #25 had a severe cognitive impairment. Review of Resident #25's transaction report, dated 07/31/25 to 06/11/26, revealed the report included Resident #25's Resident Fund Management System (RFMS) and resident qualified income trust (QIT)) accounts. There were several additional instances in a month where money was removed from these two accounts and it was marked for cost of living. These additional withdrawals were transferred out of these two accounts into the facility's 'cost of care' account. During this review period, the facility had removed a total of $2,741.78 and directed those payments to the facility cost of care account. There was no evidence Resident #25 should be charged an additional $2,741.78. Interview with Business Office Manager (BOM) #114 on 06/11/26 at 12:45 P.M. confirmed Resident #25 had two accounts with the facility, and this was the RFMS and QIT accounts. BOM #14 confirmed there were several instances in a month where the money was transferred out of these two accounts into the facility's cost of care account in the past year. BOM #114 explained she did this because these two accounts would exceed $2,000 and thought she needed to do this so Resident #25 would not lose their qualification to receive Medicaid benefits. BOM #114 stated when she removed the money from Resident #25's RFMS and QIT accounts, she spoke to the family and they agreed to it. BOM #114 confirmed Resident #25 did not owe the facility additional money. At 2:30 P.M., BOM #114 stated the facility withdrew a lump sum of $2,741.78 from the cost of care account and was placed back into Resident #25's RFMS account on 06/11/26. BOM #114 confirmed no one told her this was not done correctly until 06/11/26. Review of the facility's Wire Transfer document dated 06/11/26, revealed a lump sum of $2,741.78 was placed back into Resident #25's RFMS account.2. Medical record review revealed Resident #89 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment, dated 05/25/26, revealed Resident #89 had severe cognitive impairment. Review of Resident #89's transaction report, dated 07/31/25 to 06/11/26, revealed the report included Resident #89's Resident Fund Management System (RFMS) and resident qualified income trust (QIT)) accounts. There were several additional instances in a month where money was removed from these two accounts, and it was marked for cost of living. These additional withdrawals were transferred out of these two accounts into the facility's 'cost of care' account. During this review period, the facility had removed a total of $18,850.63 and directed those payments to the facility cost of care account. There was no evidence Resident #89 should be charged an additional $18,850.63 Interview with Business Office Manager (BOM) #114 on 06/11/26 at 12:45 P.M. confirmed Resident #89 had two accounts with the facility, and this was the RFMS and QIT accounts. BOM #14 confirmed there were several instances in a month where the money was transferred out of these two accounts into the facility's cost of care account in the past year. BOM #114 explained she did this because these two accounts would exceed $2,000 and thought she needed to do this so Resident #89 would not lose their qualification to receive Medicaid benefits. BOM #114 stated when she removed the money from Resident #89's RFMS and QIT accounts, she spoke to the family and they agreed to it. BOM #114 confirmed Resident #89 did not owe the facility additional money. At 2:30 P.M., BOM #114 stated the facility withdrew a lump sum of $22,350.63 from the cost of care account and was placed back into Resident #89's RFMS account on 06/11/26. BOM #114 confirmed no one told her this was not done correctly until 06/11/26. Review of the facility's Wire Transfer document dated 06/11/26, revealed a lump sum of $22,350.63 was placed back into Resident #89's RFMS account. Review of the facility's Resident Trust Fund policy, undated, revealed a nursing facility shall establish and maintain a system that ensures full, complete, and separate accounting of each resident's resident trust account. The facility has a responsibility to safeguard the resident's financial affairs and to manage the resident's personal funds appropriately and according to the facility's state regulations. The corporate office of the facility will conduct a quarterly audit of all resident accounts. Misappropriation of resident funds will be reported to the corporate compliance officer. All suspicious or allegations of misappropriation of resident funds are to be fully investigated and reported according to the facility's abuse prevention policy. Facility will determine the total amount of misappropriated funds and make appropriate restitution to the resident(s) involved.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to change the oxygen tubing per physician order for one resident. This affected one (Resident #3) of two resident reviewed for respiratory care. The facility census was 92 residents. Findings include:Review of Resident #3's medical record revealed the resident was readmitted to the facility on [DATE]. Diagnoses that included chronic obstructive pulmonary disease (COPD) and chronic systolic (congestive) heart failure.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired and utilized oxygen therapy.Review of the care plan dated 01/27/26 revealed Resident #3 had altered respiratory status/difficulty breathing due to COPD. Interventions included to change the tubing and humidifier weekly initiated on 06/04/26.Review of Resident #3's physician orders dated 06/04/26 revealed an order for oxygen: tubing and humidifier change every night shift every Thursday initiated.Review of Resident #3's Medication Administration Record (MAR) for June 2026 revealed documentation that the oxygen tubing was changed on 06/04/26.Observation on 06/09/26 at 7:51 A.M. revealed Resident #3 was resting in bed. Nasal cannula was in place. Oxygen tubing was dated 05/28/26.Interview on 06/09/2026 at 1:40 P.M. with Licensed Practical Nurse (LPN) #105 confirmed the oxygen tubing was dated 05/28/26 and should have been changed on 06/04/26. LPN #105 confirmed Resident #3's oxygen tubing should be changed every Thursday on nightshift.Review of the policy titled 'Oxygen Administration' undated revealed staff shall change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on observation, interview, and facility policy review, the facility failed to ensure the safety of Resident #71 during a Hoyer lift transfer. This had the potential to affect 14 residents who the facility identified as requiring the assistance of a Hoyer lift for transfers. The facility census was 87. Findings include:Findings include:Review of Resident #'71s medical record revealed an admission date of 12/27/23.Diagnoses include essential hypertension, type II diabetes mellitus without complications, osteoarthritis, contracture to right and left knee, need for assistance with personal care, unspecified dementia and other symptoms and signs involving cognitive functions and awareness.Review of Resident #71's Minimum Data Set (MDS) 3.0 dated 01/03/26 revealed a Brief Interview for Mental Status (BIMS) score of 10. Review of Resident #71's functional abilities revealed Resident #71 is dependent for chair/bed-to-chair transfer.Review of Resident #71's care plan revised on 01/22/26 revealed Resident #71 needed assistance with Activities of Daily Living (ADL's), with a goal that Resident #71 will be groomed and free of odors at all times and will participate as able in ADL self-care. Interventions include transfers by three helpers and mechanical lift. Observation on 03/04/26 at 11:30 A.M. with certified Nursing Assistant (CNA) #123, and CNA #97, of Hoyer lift transfer for Resident #71 revealed CNA # #123 controlling the Hoyer lift and CNA #97, securing Resident #71 in Hoyer sling while Resident #71 was in wheelchair. Further observation revealed CNA #123 controlling Hoyer lift with remote with Resident #71 suspended in the air, at the same time CNA #97 removed Resident #71's wheelchair from below Resident #71 and moving it out of the area. Further observation revealed CNA #97, moving from Resident #71's side to opposite side of the bed closest to the wall leaving Resident #71 suspended in the air without someone guiding Resident #71 in the Hoyer sling to the bed.Interview on 03/04/26 at 11:56 A.M. with CNA #123, CNA #97 and Licensed Practical Nurse (LPN) #127 confirmed staff did not provide Resident #71 support as she was suspended in Hoyer lift while CNA #97 went to opposite site of bed.Interview on 03/04/26 at 11:56 A.M. with CNA #123 and CNA #97 revealed CNA #123 and CNA #97 when asked the process before initiating the use of a Hoyer lift CNA #123 and CNA #97 could not verbalize how to inspect Hoyer lift or assessment of sling for safety check prior to use. Further interview with CNA #123 and CNA #97 confirmed observation of this process was not completed and they were unable to verbalize this process unless prompted.Review of the Medline Battery Operated Patient Lift MDS450EL manual confirmed persons should inspect the slings prior to each use. Do not use a sling that has worn thread or frayed straps.Review of the facility's policy titled, Hoyer Lift Transfer not dated confirmed check the sling to be sure no signs of wearing or tears. Further review of the policy reveals one person utilizes and stabilizes the lift while second person guides and stabilizes resident and guide the sling with the resident slowly and steadily, until over the surface they're being transferred to.This deficiency represents non-compliance investigated under Complaint Number 2732241.

Based on observation and interview the facility failed to perform hand hygiene during incontinence care for Resident #71. This had the potential to affect 20 residents who the facility identified as requiring assistance with incontinence care. The facility census was 87. Findings include: Review of Resident #'71s medical record revealed an admission date of 12/27/23.Diagnoses include essential hypertension, type II diabetes mellitus without complications, osteoarthritis, contracture to right and left knee, need for assistance with personal care, and unspecified dementia and other symptoms and signs involving cognitive functions and awareness. Review of Resident #71's Minimum Data Set (MDS) 3.0 dated 01/03/26 a Brief Interview for Mental Status (BIMS) score of 10. Review of Resident #71's functional abilities revealed Resident #71 is dependent on staff for assistance with toileting hygiene. Observation on 03/04/26 at 11:50 A.M. of incontinence care on Resident #71 completed by Certified Nursing Assistant (CNA) #97 revealed after the incontinence care was completed CNA #97 handed Resident #71 her call light with the gloves she wore during incontinence care. Interview on 03/04/26 at 11:56 A.M. with CNA #97, confirmed she did not perform hand hygiene after completing incontinence care and handed Resident #71 her call light with her soiled gloves on.

Based on observation, interview, and facility policy review the facility failed to prepare and handle food in a sanitary manner. This affected 85 residents in the facility who receive food from the kitchen. The facility identified two residents who were nothing-by mouth (NPO). The facility census was 87.Finding include:Observation on 01/27/26 at 12:30 P.M. for lunch tray service revealed [NAME] #299 was not wearing a hair net while placing places into insulated plate base for lunch meal trays.Interview on 01/27/26 at 1:05 P.M. [NAME] #299 confirmed he did not wear hairnet during lunch service and was observed getting a hair net.Review of the facility's policy titled, Hair Restraints, not dated confirmed hair shall be restrained to prevent physical contamination of food. Hair restraints shall be worn by all employees while in the kitchen to cover all hair.Observation on 01/27/26 at 12:31 P.M revealed dietary manager #215 touching own face with hands on 01/27/26 at 12:35 P.M. and did not perform hang hygiene while serving trays during lunch tray service.Interview on 01/27/26 at 1:05 P.M with dietary manager #215 confirmed she did not perform hand hygiene during lunch tray service.Review of the facility's policy titled, Hand Hygiene. dated 10/01/22, it is confirmed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.This applies to all staff working in all locations within the facility. Observation on 01/27/26 at 12:35 P.M., and 12:43 P.M., revealed [NAME] #141 not filling the 3/4 cup scoop of beef stroganoff fully leaving about a 1/4 of an inch of space for residents who required regular serving of food. Interview on 01/27/26 at 1:05 P.M with dietary manager #215 confirmed it is difficult to level some items when serving. No policy was received regarding meal portion sizes. This deficiency represents non compliance investigated under Master Complaint Number 2718652.

Based on medical record review, self-reported incident (SRI) investigation review, staff interview, and review of the facility's abuse policy and procedure, this facility failed to ensure an allegation of resident-to-resident sexual abuse was submitted to the appropriate state agency as required. This affected two (Resident #410 and #510) of the three residents reviewed for sexual abuse. The facility census was 87. Findings include:1.Review of the medical record for Resident #510 revealed an initial admission date of 07/31/2025 with a re-entry date of 08/20/2025 and a discharge date of 11/202/2025. Diagnoses included cognitive communication deficit, anxiety disorder, mood disorder, and need for assistance with personal care. Review of Resident #510's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a BIMS score of 10 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Review of the nursing progress note dated 11/14/25 at 2:44 P.M. created by the Director of Nursing (DON) revealed Resident #510 came to the Social Worker and Nurse Manager and expressed that another resident (Resident #410) touched her breast twice last night. Resident #510 stated at 9:30 P.M. last night another resident (Resident #510) entered my room, talking about buying her a pop. Asked her if she had a boyfriend and told her she had a supply of food in his room. She went down to his room, there were gallons of tea on the floor, he ended up grabbing her breast. She quickly left the room, and he came in blaring porn on his phone, and he touched her breast again. Immediately other residents were interviewed and placed on one on one. Resident #510 denies any allegations and states he is a good Christian man. Resident #410 is offered to go to the hospital and declines, head to toe assessment completed, no new skin issues noted or discolorations, resident denies pain, resident also declines to move rooms at this time, and resident has a normal mood and affect at this time. Resident #410 is not tearful and even states he is not a rapist; he is just a little boy. Resident #410 states her psychosocial needs are being met currently. Medical Director notified, Certified Nurse Practitioner (CNP) notified, power of attorney aware, administrator, regional staff, and DON aware. Fairfield sheriffs notified and will be sending out officer to take a report.Review of the Medical Record for Resident #410 revealed an admission date of 10/13/2025 and a discharge date of 12/19/2025. Diagnosis included acute respiratory failure with hypoxia, alcohol dependence and need for assistance for personal care. 2.Review of Resident #410's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Noted with no impairments to bilateral upper or lower extremities and required a wheelchair for mobility. Was noted to be occasionally incontinent of bladder and always continent of bowel. Received antidepressants and anticoagulant daily. Review of the plan of care dated 11/17/25 and revised on 12/29/25 revealed Resident #410 has been observed displaying sexually inappropriate behavior: Perceiving relationship with female or male peers is closer/more sexually oriented than it actually is, touching Interventions include allowing opportunities for resident to express need for companionship, explain to resident relationships are important to their identity and self-esteem when done in a appropriate manner, limit any at risk situations, maintain resident's dignity, provide alternative activities as needed, provide cues as needed that behaviors is unacceptable and what expectations are, redirect from entering females or males rooms without permission. Provide one on one care which was initiated on 12/14/25.Interview on 01/27/2026 at 12:28 P.M. with the Director of Nursing (DON) when asked if she had an SRI for a sexual abuse that occurred on 11/14/25 between Resident #410 and Resident #510, she said she did. When asked why it was not submitted to the proper state agency, she said she would have the Administrator explain that. Interview on 01/27/26 at 12:40 P.M. with the Administrator and the DON revealed that a complete investigation had been completed but not submitted. The administrator claimed he was in the process of filling out the information for the report to be submitted and got distracted with a facility issue and failed to hit the submit button. Upon returning to work that following Monday he realized that it was never submitted and spoke with his cooperate team who said to just continue with the complete investigation. If the incident was submitted now, it will be considered late reporting. Resident #510 had medication changes, 1:1 supervision care which turned into every 15-minute checks, psych services were provided and a room change was completed. Shortly after this incident occurred, Resident #510 was discharged to the local hospital per own request and Resident #410 had discharged to a local assisted living as per previously planned. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 01/01/2024 revealed Sexual Abuse is non-consensual sexual contact of any type with a resident. Also noted under section VII. Reporting/Response. The facility will have written procedure that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified time frames. This deficiency represents non compliance investigated under Master Complaint Number 2718652.

Based on observation, interview, medical record review, and facility policy review the facility failed to perform hand hygiene during incontinence care. This affected one (Resident #374) of one resident observed during incontinence care . The census was 87.Findings include:Review of Resident #374's medical record revealed an admission date of 11/27/23. Medical diagnoses include unspecified dementia, moderate with psychotic disturbance, moderate-protein calorie disturbance, essential (primary) hypertension, hyperlipidemia, anxiety, depression, atrial fibrillation, personal history of transient ischemic attack and cerebral infarction without residual deficits, dysarthria and anarthria, low back pain, and irritable bowel syndrome with constipation.Review of Resident #374's quarterly Minimum Data Set (MDS) 3.0 dated 01/09/26 revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15. Resident #374's functional abilities revealed Resident #374 was dependent on staff for toileting hygiene.Review of Resident #374's care plan dated 10/14/25 revealed Resident #374 always experiences bowel and frequently experiences bladder incontinence. Goal stating Resident #374's toileting needs will be met by staff, with interventions aimed at the prevention of infection and/ or skin impairment. Interventions include be aware of change sin urinary elimination, inspect for skin breakdown and intervene when needed, observe skin each time you are providing incontinence care and notify nurse of any new area of breakdown, observe urine color, odor, clarity, frequency and amount as needed, provide incontinence care with care rounds and as needed, apply moisture barrier and review labs as ordered. Resident #374 has a focus with assistance needed for activities of daily living (ADL's) related to cognitive impairment, personal history of transient ischemic attack and cerebral infarction without deficits. Resident #374's goal stating she will be groomed and free of odors at all times and will participate as able in ADL self-care. Interventions include apply house moisture barrier after each incontinence episode, keep call light in reach while in bed, resident it totally dependent and does not participate in any aspects of the task including toileting hygiene requiring assist one helper, and staff is to have witness with all care.Observation on 01/27/26 at 1:54 P.M revealed Certified Nursing Assistant (CNA) #313 performing perineal care for Resident #374 with the assistance of Registered Nurse (RN) #255. CNA #313 provided Resident #374 by pulling curtain and performed hang hygiene and applied personal protective equipment (PPE). CNA #313 then warmed water and prepared wash basins for care and set up for perineal care. CNA #313 then performed hand hygiene and placed clean gloves on. CNA #313 then removed Resident #374's brief and performed perineal care, washing and drying appropriately before asking RN #255 to assist with turning Resident #374 to clean her buttock. CNA #313 then washed, dried and applied barrier cream to Resident #374 buttock and applied a new brief. RN #255 assisted CNA #313 with placing new brief on Resident #374. CNA #313 then gave Resident #374's baby dolls to her using same gloves used during incontinence care.Interview on 01/27/26 at 2:15 P.M. with CNA #313 confirmed they did not perform hand hygiene and change gloves during incontinence care.Review of the facility's policy titled, Hand Hygiene. dated 10/01/22, it is confirmed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene should be performed using with soap and water or alcohol based hand rub when, during resident care, moving from a contaminated body site to a clean body site and after handling items potentially contaminated with blood, body fluids, secretions, and excretions.Review of the facility's policy titled, Perineal care dated 01/08/25, confirms after performing perineal care to remove gloves and perform hand hygiene and ensure call light is in reach.

Based on observation, staff interview, and facility policy review, the facility failed to maintain a clean, safe, and comfortable living environment for residents. This had the potential to affect all residents in the facility. The facility census was 94. Findings include: An observation on 08/04/25 from 8:57 A.M. to 9:12 A.M. was conducted throughout multiple hallways and common areas. Upon entrance to the building, a large stain was noted on the ceiling tile above the second door on the right. In Hallway G, light fixtures two, six and seven contained debris and light shades on fixtures six and seven were cracked. Peeling ceiling drywall was observed after light fixture three. Outside Resident #74's room, the ceiling showed damaged paint and unfinished ceiling texture. Outside Resident #72's room, peeling ceiling was identified around the fire sprinkler and a ceiling stain was visible above the beauty shop door.Continued observation revealed in Hallway H, damaged drywall shaped like a removed hand sanitizer dispenser was observed before the emergency doors. Light fixture one had a cracked shade. Light fixtures two, three, four and five contained bugs and debris. Ceiling cracks and staining were identified outside the clean linen room. In Hallway F, ceiling vents near light fixtures one, two, four, six and seven had visible dust accumulation clinging to the ceiling surface. Light fixtures three and eight had cracked shades. Outside Resident #42's room, damaged drywall shaped like a removed hand sanitizer dispenser was observed. Light fixtures six, seven and eight had light shades containing significant amounts of debris. In Hallway E, located in the resident lounge, the ceiling was unfinished and had a ceiling curtain track along the side of the wall. In Hallway E, light fixtures one, two, three, four, six and eight contained debris. Light fixture seven was missing its light shade. Ceiling vents located outside rooms two, three and eight had heavy dust accumulation.Observation conducted on 08/04/25 from 2:42 P.M. to 2:55 P.M. revealed all concerns identified remained unaddressed.Interview conducted on 08/04/25 at 2:24 P.M. with the Administrator confirmed environmental and maintenance concerns are present. The Administrator reported the Director of Maintenance was out on leave, and a new assistant was just hired and currently in orientation. The Administrator stated the new maintenance assistant had minimal resources to provide or follow up on maintenance concerns or complaints at the current time. Interview and observation on 08/05/25 at 10:55 A.M. of all previously observed locations was conducted with the Director of Housekeeping (DOH) #257 and the Assistant Director of Housekeeping (ADOH) #600. During this walkthrough, both DOH #257 and ADOH #600 confirmed the presence of all identified issues. They acknowledged debris inside light fixtures G two, G six, G seven, H two, H three, H four, H five, F six, F seven, F eight and E one, E two, E three, E four, E six and E eight, cracked shades on G six, G seven, H one, F three and F eight and the missing shade on E seven. They confirmed the presence of peeling and stained ceilings at G three, above the beauty shop door, outside room [ROOM NUMBER] and outside the clean linen room, damaged drywall in hallway G outside Resident #74 room, before the emergency doors and in F hallway outside Resident #42 room and visible dust buildup on ceiling vents at F one, F two, F four, F six, F seven and E outside rooms two, three and eight. DOH #257 and ADOH #600 stated cleaning of light fixtures and vents falls under housekeeping's responsibilities while issues involving drywall and ceiling damage are referred to maintenance for resolution. Review of the policy Safe and Homelike Environment dated 06/01/24 revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on interview and record review, the facility failed to ensure discharge Minimum Data Set (MDS) 3.0 assessments were completed accurately and a correction was submitted timely to reflect Resident #90's disposition. This affected one resident (#90) out of four residents reviewed for MDS assessments. The facility census was 94.Findings include:Review of the medical record for Resident #90 revealed an admission date of 06/17/19, with diagnoses including hypertension, cognitive communication deficit, depression, polyneuropathy, chronic pain, dementia, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia, acquired absence of the right leg above the knee, and schizoaffective disorder.Review of a progress note dated 03/02/25 revealed Resident #90 was enroute to a local hospital by critical transport, and the power of attorney was notified of the intended location.Review of the Discharge Minimum Data Set (MDS) 3.0 assessment, completed on 03/02/25, revealed the discharge status was coded as discharge - return anticipated and marked as an unplanned discharge.Review of an appointment form dated 03/03/25 revealed the resident was discharged to the hospital with the intention of going home on hospice services.Interview conducted on 08/05/25 at 11:36 A.M. with Registered Nurse (RN) MDS Coordinator #260 revealed a correction to the MDS assessment was not completed to reflect the discharge disposition of discharge - return not anticipated. RN MDS Coordinator #260 revealed a correction assessment would be submitted to ensure MDS data reflected an accurate record.

Based on observation, interview and record review the facility failed to ensure pressure reducing devices were free from soil. This affected one (Resident #33) out of three residents reviewed for pressure reducing measures. The facility census was 94. Findings include:Review of the medical record for Resident #33 revealed an admission date of 05/06/25 with diagnoses of acute respiratory failure with hypoxia, type two diabetes mellitus, severe protein-calorie malnutrition, severe sepsis with septic shock, metabolic encephalopathy and a stage 2 pressure ulcer on the left heel.Review of the care plan dated 05/07/25 revealed Resident #33 has an actual area of skin impairment with interventions including use of an air mattress, encouragement to wear boots on both feet, evaluation for pain, completion of wound treatments, nursing observation of the wound dressing to ensure it remains intact, monitoring for clinical changes in the wound and completion of skin observations on shower days and as ordered.Review of physician orders dated 05/08/25 revealed the resident is to wear boots on both feet while in bed as tolerated for prevention.Review of the admission Minimum Data Set (MDS) 3.0 assessment completed 05/13/25 revealed Resident #33 is moderately cognitively impaired, dependent on staff assistance for bathing and hygiene and has one stage three pressure ulcer present upon admission.Review of the skin grid pressure assessment completed 07/30/25 revealed Resident #33 has a skin impairment on the left heel, present upon admission. The wound is classified as unstable measuring 5.5 centimeters (cm) by 2.3 cm with 30% granulation and 70% slough, moderate serosanguinous and yellow/green drainage with slight odor. The wound showed noted improvement.Observation on 08/04/25 at 3:30 P.M. during wound care with the Assistant Director of Nursing (ADON) #276, Licensed Practical Nurse (LPN) #274 and Certified Nursing Assistant #273 revealed Resident #33 had a pressure ulcer located on the left heel. Prior to beginning wound care, both boots were noted to have staining on the exterior bottom portion of the heel-elevating boots. The staining appeared scattered with ring-like formations indicative of dried fluid and light pink discoloration. Additionally, the interior portion of the right boot, specifically in the toe area, showed shadowing or discoloration, slightly darkened but without definitive staining or wetness. LPN #274 began the dressing change by removing the resident's left boot, noting the dressing was saturated with pale yellow drainage. LPN #274 confirmed a large amount of drainage but denied dressing seepage through to the boot. The boot was placed at the bedside. No concerns were noted during wound care and once completed, the boot was replaced with the staining present.Observations on 08/05/25 at 6:34 A.M. and 11:03 A.M. of Resident #33's boots revealed both remained soiled with the same staining present.Interview on 08/05/25 at 11:30 A.M. with LPN #238 confirmed the staining on the exterior bottom portion of Resident #33's heel-elevating boots. LPN #238 denied performing Resident #33's wound dressing change but stated new heel boots are needed and the old boots will be laundered.Interview on 08/05/25 at 12:40 P.M. with the Director of Nursing (DON) confirmed Resident #33's pressure-reducing boots were soiled on the exterior portion.

Based on observations, interviews, and policy review, the facility failed to ensure name badges were worn at all times by facility staff. This affected all 93 residents at the facility. Facility census was 93. Findings include: Observation on 06/30/25 at 9:48 A.M. of Certified Nurse Assistant #1111 revealed no name badge present. Concurrent interview verified no name badge was present and has not had a permanent one since being hired. The temporary badges that are being used fall off a lot as they are just a sticker. Observation on 06/30/25 at 10:29 A.M. of Activities Aide #1000 revealed no name badge present. Concurrent interview verified that no name badge was present and had not had a permanent one since she lost it. Will obtain a temporary sticker one now. Interview on 06/30/25 at 10:31 A.M. with Resident #301 revealed the staff at the facility rarely have name badges on. Interview on 06/30/25 at 10:42 A.M. with Resident #302 revealed the staff at the facility rarely have name badges on and she can't keep them straight because of that. Interview on 06/30/25 at 10:47 A.M. with Resident #200 revealed the staff continue to not wear name badges so she is not sure who cares for her. Interview on 06/30/25 at 11:31 A.M. with Administrator #2222 verified it is the Administrators duty to make sure all staff are wearing their name badges as part of the facility uniform policy. Interview on 06/30/25 at 11:38 A.M. with the Human Resource Manager #4444 verified she has not been printing off permanent name badges for several months or longer as she should have been. Review of facility policy titled Uniform Policy, no date, revealed name badges are to be worn at all times as part of the uniform. This deficiency represents non-compliance investigated under Master Complaint Number OH00167052.

Based on interviews, observation and policy review, the facility failed to ensure scheduled activities were completed as well as ensuring evening activities were scheduled. This affected 92 residents (except for Resident #233) who attend/participate in activities. The facility census was 93. Findings include: Interview on 06/30/25 at 10:31 A.M. with Resident #301 in the activities room revealed the facility rarely does the activities that are posted on the board and stated They just sit out stuff on the table for us to do on our own. No activities in the evening so he gets bored a lot. Interview on 06/30/25 at 10:42 A.M. with Resident #302 revealed there are really never any activities occurring. There are items on the tables, but when it comes to the scheduled events, they rarely happen. There are no evening activities to do as well. She goes into the activities room a lot and can never find anyone with activities in there. Observation on 06/30/25 at 11:30 A.M. of the activities room revealed no move and groove activity being conducted as per schedule with a total of 9 residents throughout the area sitting at tables. No activity workers in the room. Observation on 06/30/25 at 11:47 A.M. of the activities room revealed no move and groove activity being conducted as per schedule with a total of 12 residents throughout the area sitting at tables. No activity workers in the room. Interview on 06/30/25 at 11:48 A.M. with Resident #333 revealed her to be waiting for the move and groove activity in the activity room and had been waiting for at least 10 minutes. Interview on 06/30/25 at 11:52 A.M. with the Activities Recreation Director revealed she was not sure why the move and groove activity was not occurring as scheduled and went to check with her Activity Aide. Interview on 06/30/25 at 12:47 P.M. with the Activities Recreation Director revealed that for evening activities, they always leave activities out on the tables, but no scheduled evening activities as the activities department goes home and no other staff conduct activities when the activities department are not there. Verified for July 2025 no scheduled activities after 2:00 P.M. every Saturday and Sunday and no weekday scheduled events after 4:00 P.M. Interview on 06/30/25 at 2:19 P.M. with the Activities Recreation Director said her assistant only asked two residents when they came in from smoking if they wanted to do the 11:30 A.M. activity which was the move and groove and they denied. She did not ask any other residents throughout the time period of the activity as residents came and gone for activities. Verified the move and groove activity was not completed as scheduled and the Activities Aide should have been in the room asking residents if they wanted to participate throughout the time frame of the activity. Review of the Activities Calendar for June 2025 revealed no activities scheduled after 2:00 P.M. every Saturday and Sunday and no activities scheduled after 4:00 P.M. every weekday. Review of facility policy titled Activities, revised 06/01/24, revealed activities will encourage both independence and interaction within the community. Residents are encouraged to participate in scheduled activities. This deficiency represents non-compliance investigated under Complaint Number OH00167006.

Based on observations , and staff interviews the facility failed to ensure the steam warmer and two compartment sink was maintained in a safe and operating condition . This had the potential to affect 85 residents. The census was 88. Findings include: Observation on 12/04/24 at 10:24 A.M. of the kitchen's two compartment sink omitted a strong odor of sewage. The sink was empty. Verified by dietary Aide #105. Observation on 12/4/24 at 10:28 A.M. behind the serving line the steam oven was dripping water from the bottom left side of the door. The water dripped approximately 2 feet down to a 11 x 11 serving metal bin. [NAME] # 217 revealed when she uses the steamer the water drips out . The staff must empty the water filled bin every one to two hours. Dietician #168 verified the water and confirmed she reported the issue to corporate in November 2024. Interview on 12/04/24 03:16 P.M. with the Administrator regarding the steam oven, he confirmed it had been replaced once in the past. The maintenance man must change the seals to prevent the water from dripping. Interview on 12/05/24 01:08 P.M. to 1:30 P.M. with Maintenance Director #177 confirmed the steamer was not new when they got it from a sister facility. He was aware of the drip ; the seals have not been replaced. He is aware of the odor in the kitchen. He explained, Three weeks ago, he tried to snake the drains under the two compartment sink , but the odor still exists. After surveyor intervention he has called a Plumber to service the drains on 12/05/24. Review of the e-mail from the administrator on 12/05/24 at 3:40 P.M. confirmed after surveyor intervention corporate approved the facility to purchase a new steamer. They received a quote, and it has been approved and purchased. Arrival date is to be determined. Review of the work receipt by the plumber dated 12/05/24 revealed he cleaned the kitchen sink drain to remove clog. Determined the odor was coming from floor drains from grease interceptor not being properly cleaned. The drains all need to be cleaned and the pumps need to be pumped.

Based on personnel record review and staff interview, the facility failed to complete staff performance evaluations as required. This had the potential to affect 88 of 88 residents. Findings Include: Review of Certified Nursing Assistant (CNA) #165 and CNA #179 personnel records found they did not have a completed 90 day performance evaluation completed. Interview with Visiting Administrator #600 on 12/04/24 at 10:30 A.M. confirmed they have no evidence to support the above staff had performance evaluations completed as required.

Based on observation, medical record review, facility policy and procedure review and interview, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #79. Actual harm occurred on 08/10/23 when Resident #79, who was moderately cognitively impaired, at risk for pressure ulcer development and required extensive assistance from staff for bed mobility, developed an unstageable (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) pressure ulcer to the right heel. There was no evidence of adequate and necessary interventions in place prior to the development of the ulcer. This affected one resident (#79) of three residents reviewed for pressure ulcers. The census was 88. Findings Include: Review of the medical record for Resident #79 revealed an initial admitted [DATE] with diagnoses including psoriatic arthritis, diabetes mellitus, anemia, cachexia, candidal esophagitis, gastro-esophageal reflux disease, legal blindness, depression, insomnia, seborrheic dermatitis, bilateral corneal pannus, bilateral age-related nuclear cataract, vitamin D deficiency and history of other mental and behavioral disorders. Review of the resident's admission assessment with baseline care plan dated 12/06/22 revealed the resident was admitted with no pressure ulcer/injuries. Review of the plan of care dated 12/06/22 revealed the resident had potential for alteration in skin integrity related to incontinence. Interventions included educated resident/family on skin breakdown, risk factors and preventative measures, encourage to float heels while in bed, encourage to turn and reposition every two hours and as needed, keep nail edges smooth and trimmed as tolerated, pressure reducing cushion to chair/bed, provide assistance with hygiene including peri-care as needed, record meal intake percentages per facility policy, trim nails each shower day as tolerated and use barrier cream with showers and incontinent episodes. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident required extensive assistance of one staff member with bed mobility, toilet use, dressing and personal hygiene. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had no skin issues. Review of the weekly skin observation dated 08/07/23 revealed the resident had no skin issues. Review of the progress note dated 08/10/23 at 2:09 P.M. revealed a State tested Nursing Assistant (STNA) found a pressure wound to the right heel during care. The wound nurse, Director of Nursing (DON) and physician were notified of the wound. Review of the weekly skin observation dated 08/10/23 revealed the resident was noted to have a Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcer to the right heel. Review of the weekly skin grid pressure dated 08/10/23 revealed the resident was observed to have an unstageable pressure ulcer to the right heel measuring 7.5 centimeters (cm) in length by 11.5 cm width and described as having moderate serous drainage, necrotic tissue present, 10% dermis and 80% subcutaneous tissue. Review of the progress note dated 08/11/23 revealed the Nurse Practitioner (NP) was notified of the wound, treatment orders were put in place as well as heelzup (device used to elevate the heels of the bed) while in bed as tolerated. Review of the weekly skin grid pressure dated 08/15/23 revealed the unstageable pressure ulcer to the right heel measured 3.5 cm by 8.5 cm by 0.1 cm and described as having moderate amount of serous drainage, 30% thick adherent devitalized necrotic tissue, 10% dermis/subcutaneous tissue and 60% slough. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 08/22/23 revealed the unstageable pressure ulcer was now classified as a Stage III pressure ulcer measuring 2.2 cm by 6.8 cm by 0.1 cm and described as having a moderate amount of serous drainage, 10% thick adherent devitalized necrotic tissue, 20% slough, 30% granulation and 40% dermis/subcutaneous tissue. The wound bed was pink/black and yellow in color. Surgical excision debridement was performed. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 08/29/23 revealed the Stage III pressure ulcer measured 2.2 cm by 6.3 cm by 0.1 cm and described as having a moderate amount of serous drainage, 10% thick adherent devitalized necrotic tissue, 20% slough, 30% granulation and 10% dermis/subcutaneous tissue and 30% skin. The wound bed was pink/black and yellow in color. Surgical excision debridement was performed. The facility determined the wound had improved with this assessment. Review of the plan of care dated 09/01/23 (following the wound development) revealed the resident was noncompliant with care/treatment as ordered by physician, does not follow physician ordered diet and would refuse meals, refuse medications, refuse to be turned and repositioned, refuse treatments, refuse to be weighed, had the tendency to refuse accuchecks and refused breathing treatments. Interventions included if appropriate, stop care when resident is upset and try again later, educate resident as to the negative consequences of not following physician orders, notify the physician/NP of refusals of medications and treatments and praise all attempts to cooperate with care giving efforts and any improvement in behavior. Review of the weekly skin grid pressure dated 09/05/23 revealed the Stage III pressure ulcer measured 4.2 cm by 6.5 cm by 0.1 cm and described as having a moderate amount of serous drainage, 10% thick adherent devitalized necrotic tissue, 20% slough and 70% dermis/subcutaneous tissue. The wound bed was pink/black and yellow in color. Surgical excision debridement was performed. The facility determined the wound had declined with this assessment. Review of the weekly skin grid pressure dated 09/12/23 revealed the wound had declined to a 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) pressure ulcer measuring 5.5 cm by 7.4 cm by 1.0 cm with 100% thick adherent devitalized necrotic tissue. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was black and dark brown. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 09/19/23 revealed the Stage IV pressure ulcer measured 5.0 cm by 6.5 cm by 1.0 cm with 100% thick adherent devitalized necrotic tissue. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was black and dark brown. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 09/26/23 revealed the Stage IV pressure ulcer measured 4.5 cm by 6.0 cm by 1.0 cm with 80% thick adherent devitalized necrotic tissue. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was black and dark brown. Review of the weekly skin grid pressure dated 10/03/23 revealed the Stage IV pressure ulcer measured 4.0 cm by 5.8 cm by 1.0 cm with 70% thick adherent devitalized necrotic tissue and 30% dermis/subcutaneous/tendon. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was dark brown and pink. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 10/10/23 revealed the Stage IV pressure ulcer measured 4.5 cm by 5.5 cm by 1.0 cm with 40% thick adherent devitalized necrotic tissue and 30% granulation tissue and 30% dermis/subcutaneous/tendon. Surgical excision debridement performed by physician. The wound had a moderate amount of serous drainage, and the wound bed was gray/brown and pink. The facility determined the wound had improved with this assessment. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had one Stage IV pressure ulcer no present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition, or hydration intervention to manage skin problems, pressure injury care and applications of ointments/medications other than to feet. Review of the weekly skin grid pressure dated 10/17/23 revealed the Stage IV pressure ulcer measured 4.0 cm by 5.7 cm by 1.0 cm with 30% thick adherent devitalized necrotic tissue and 70% granular, tissue with the edges indurated and rolled in. The wound had a moderate amount of serous drainage. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 10/24/23 revealed the Stage IV pressure ulcer measured 4.5 cm by 5.5 cm by 1.0 cm with 20% thick adherent devitalized necrotic tissue and 80% granular. The wound had a moderate amount of serous drainage. The facility determined the wound had improved with this assessment. Review of the weekly skin grid pressure dated 10/31/23 revealed the Stage IV pressure ulcer measured 4.3 cm by 4.1 cm by 1.0 cm with 20% thick adherent devitalized necrotic tissue and 80% granular. The wound had a moderate amount of serous drainage, and the wound bed was gray/brown and pink. The facility determined the wound had improved. Review of the weekly skin grid pressure dated 11/07/23 revealed the Stage IV pressure ulcer measured 4.2 cm by 4.0 cm by 0.5 cm with 10% thick adherent devitalized necrotic tissue and 90% granular. The wound had a moderate amount of serous drainage, and the wound bed was brown and red. The facility determined the wound had improved. Review of the monthly physician orders for November 2023 identified orders dated 05/03/23 diabetic protein based food snack at bedtime, 09/07/23 encourage resident to keep nail edges smooth and trimmed, 09/12/23 prevalon boots to bilateral lower extremities while in bed as tolerated, 09/17/23 remove foot board from bed, 10/23/23 turn left to right side as tolerated, and 11/07/23 cleanse right heel with normal saline (NS) and apply Mesalt, cover with island dressing daily until resolved. Observation on 11/16/23 at 10:49 A.M. of Registered Nurse (RN) #150 and Licensed Practical Nurse (LPN) #132 provide the physician ordered treatment for Resident #79 revealed the nurses washed their hands. LPN #150 removed the soiled dressing and washed her hands, donned gloves. RN #150 set-up the required supplies on a barrier on the resident's bedside table. RN #150 washed her hands then cleansed the heel wound with normal saline and 4X4 while LPN #132 held the resident's foot up. RN #150 pat the wound dry with a 4X4, applied Mesalt and covered the wound with an island dressing. The wound was beefy round in color. On 11/16/23 at 9:50 A.M., an interview with Registered Nurse (RN) #107 verified the facility had inadequate preventative measures in place leading to the development of a pressure ulcer for Resident #79. Review of the facility policy titled, Skin Care, last revised 11/2018 revealed the facility will provide the care necessary to ensure the resident does not develop pressure injuries, unless clinically unavoidable. Skill will be observed upon admission and routinely throughout the resident's stay. Preventative care plans will be developed and implemented for each resident. Residents identified will be encouraged/assisted to turn and reposition.

Based on observation, record review and interview the facility failed to provide restorative nursing services, including orthotic/splinting devices for Resident #66 as ordered by the physician. This resulted in Actual Harm for Resident #66, who was severely cognitively impaired, quadriplegic and dependent on staff for activities of daily living when the resident was assessed to develop and sustain worsening contractures to her bilateral ankles, knees, and hips without evidence of proper interventions being in place to prevent the deterioration. This affected one resident (#66) of three residents reviewed for braces and splints. The facility census was 86. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE] with diagnoses including quadriplegia, acute respiratory failure with hypoxia, depression, injury at unspecified level of cervical spinal cord, anxiety, gastrostomy, dysphagia, dependence on supplemental oxygen, urinary tract infection, dysphagia, depression, insomnia, and alcohol abuse. Review of a physical therapy evaluation dated 01/24/22 revealed Resident #66 had admitted to the facility for continued care and rehabilitation. The resident was noted to have minimal lower extremity mobility, poor postural control, bilateral lower extremity (BLE) contractures, and increased risk for skin breakdown. The goal was to decrease contracture advancement. Review of the discharge summary dated 02/08/22 revealed the insurance cut Resident #66 from therapy despite therapy recommendations. The resident had not met her goals. Discharge recommendations included active range of motion and passive range of motions of bilateral lower extremities (BLE) and to resume therapy as condition improved. Review of a physical therapy evaluation dated 05/05/22 revealed Resident #66 was referred to therapy due to decreased overall activity participation, concerns for drop foot or plantar flexion (the movement of the foot in a downward motion away from the body) contracture with need for splinting. Range of motion was decreased overall through BLE; however, left lower extremity increasing plantar flexion contracture was noted. There was a goal to tolerate a splint to the left foot and ankle for four hours a day. Review of the discharge summary dated 05/31/22 revealed Resident #66 was being discharged due to highest practical level achieved. The resident had been tolerating range of motion to bilateral hips, knees, and ankles. She was additionally tolerating the left foot and ankle splint for up to eight hours. Caregivers were educated on the splinting schedule. The resident had a good prognosis with consistent staff follow through. The discharge recommendation was to wear the splints up to eight hours at a time. Review of a plan of care dated 06/03/22 revealed Resident #66 was dependent for bilateral foot and ankle splints for neutral foot alignment. Interventions included checking for proper fit, cleaning splints, monitoring site for redness, and notifying therapy if the resident was not tolerating the splints. For the right and left lower extremities there was impaired passive range of motion of the ankle, knee extension, and hip abduction. Review of the physician's orders revealed an order, dated from 06/02/22 to 01/31/23 for bilateral ankle/foot splints to be worn for up to eight hours as tolerated for contracture management. The kickstands on the splints were to be in place for neutral foot alignment. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 06/02/22 to 08/05/22 revealed no documentation to indicate the knee, ankle, and foot splints were in place daily. Review of a physical therapy evaluation dated 08/05/22 revealed Resident #66 was referred to therapy due to decreased use of splints, caregiver education needed, and new onset of decreased range of motion strength, neuromotor control, postural alignment, and skin integrity. The evaluation noted a need to resume BLE splints for prevention of worsening plantar flexion and help correct abnormal hip rotation. Caregivers needed educated in proper use of splints, wear times, skin checks, and positioning as staff members working with the resident had changed since previous therapy sessions. Resident goals included tolerating the splint to bilateral foot and ankles and to prevent worsening contractures and skin breakdown. Review of the discharge summary dated 09/16/22 revealed the highest practical level had been achieved. The resident had a good prognosis with consistent staff follow through. The recommendation was for bilateral ankle and foot splints to be applied for up to eight hours at a time with the kickstand applied for neutral lower extremity as possible. Review of the MAR and TAR from 09/16/22 to 11/21/22 revealed no documentation to indicate the knee, ankle, and foot splints were in place daily. Review of a physical therapy evaluation dated 11/21/22 revealed a referral was made due to decreased range of motion, increased need for assistance, splint schedule and nursing staff training. Therapy was started following a hospital stay for urinary tract infection and needed for resuming of bilateral ankle and foot splints for prevention of worsening plantar flexion contractures and help correct abnormal hip rotation. Additionally, further staff education was needed as staff members had changed. Review of the discharge summary dated 12/08/22 revealed the resident was discharged due to highest practical level achieved. She had a good prognosis with staff follow through with a recommendation to continue the splints. Review of the MAR and TAR from 12/08/22 to 12/22/22 revealed no documentation to indicate the knee, ankle, and foot splints were in place daily. Review of a physical therapy evaluation dated 12/22/22 revealed Resident #66 had been referred due to the possible need of new splints. She had worsening bilateral knee flexion contractures. The goals included tolerating bilateral knee extension splints for up to four hours and tolerate a passive range of motion program for the BLE which staff was to be educated in once the program was established. At baseline her right lower extremity was 52 degrees from extension, and her left lower extremity was 42 degrees from full extension. By 01/11/23 her right lower leg was 50 degrees from extension and her left lower extremity was 35 degrees from extensions. Review of the discharge summary revealed the resident's highest practical level was achieved. She was tolerating knee extension at discharge her right lower extremity was 42 degrees from full extension and left lower leg was 30 degrees from full extension. The recommendation was to continue with bilateral knee extension and ankle and foot splints for up to eight hours as tolerated and to perform passive range of motion program at least three times a week. Review of the physician's orders revealed an order, dated 01/31/23, 20 days after Resident #66 was discharged from therapy, for bilateral knee extension splints as well as bilateral ankle and foot splints to be worn for up to eight hours as tolerated for contracture management. Kickstand on ankle and foot splints to be in place for neutral foot alignment. Review of the MAR and TAR from 01/11/23 to 07/11/23 revealed no documentation to indicate the knee, ankle, and foot splints were in place daily. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had severely impaired cognition. The assessment revealed the resident required extensive assistance of two persons for bed mobility and toileting, and was totally dependent on two persons for transfer, locomotion, personal hygiene, bathing, and dressing. The MDS revealed the resident received no restorative nursing programming. Review of a physical therapy evaluation dated 07/11/23 revealed Resident #66 was referred due to worsening bilateral knee flexion contractures and to re-educate new and prior staff on the use of the resident's bilateral knee and ankle splints. The resident's range of motion was assessed and her passive knee extension for her right leg was 74 degrees from full extension and her left leg was 98 degrees from full extension. Bilateral planter flexion contractures were present as well as bilateral hip contractures with the bilateral lower extremities swayed to the right. Goals included positioning in bed to be performed and staff education to improve the residents hip alignment bed and decrease the risk of worsening contractures, tolerating the bilateral knee extension splints and the ankle and foot splints for up to eight hours to prevent contractures, and to educate staff on the proper use of the splints and the schedule to wear them. Under the goals it was indicated that the bilateral ankle and foot splints had been put on for one hour, but they were unable to put on the knee extension splints due to hip contracture, adjustments needed made to the splints to allow them to fit properly. The goal of therapy was to improve the resident's bilateral lower extremity range of motion and prevent worsening issues. Therapy was still ongoing as of 08/02/23. Review of the Certified Nurse Practitioner and Physician progress notes dated 11/28/22, 12/02/22, 12/12/22, 12/21/22, 12/26/22, 01/13/23, 01/18/23, 02/03/23, 02/10/23, 03/04/23, 03/15/23, 04/02/23, 05/01/23, and 07/04/23 revealed Resident #66 had bilateral upper extremity spasticity and was on multiple medications to manage it. On 08/01/23 at 3:34 P.M. interview with Resident #66's family member revealed her family was concerned because they never saw the resident with her braces on when they visited. On 08/02/23 at 8:55 A.M. Resident #66 was observed sitting in her bed. The resident's legs were observed to be contracted; she was sitting with pressure on her right hip. Her legs were pulled up towards her torso, her knees were to the right and her feet to the left. On 08/02/23 at 8:45 A.M. and 2:07 P.M. interview with PT #113 revealed Resident #66 did not originally require splinting when she was first seen in January 2022. However, in June 2022 therapy staff were notified the resident's contractures had worsened and he believed with her spinal cord injury she was having involuntary movements where she was drawing her limbs in. It was determined to do bilateral ankle splints rather than (splinting) just her left side when they came in to fit her for her splints. PT #113 verified therapy notes indicated multiple times that the ankle and foot splints need to be resumed and staff education was required indicating they may not have always been in use. He reported the kickstand attachment to her ankle splints were to help her hip rotation and prevent contractures; however, her knees were now too contracted for this intervention. PT #113 reported the resident's hip contracture was different than expected; one side was internal, and one side was external while normally, they see both sides externally contracted. PT #113 explained that when measuring passive knee extension zero degrees meant the leg was fully extended, so any higher than that meant what position the knee was stuck in. He verified there was a decline in the resident's knee extension between when she discharged from therapy in January 2023 and when she was picked back up in July 2023. He additionally verified the knee device was not fitting the resident when she was picked up by therapy based on her current contractures, and he was unsure when they were last in place prior to therapy. He indicated therapy had to adjust the splint for them to fit her again. PT #113 confirmed he had recommended passive range of motion at discharge in January 2023; however, the facility did not have a restorative program, so it was mostly a reminder for staff to do passive range of motion if they had time. He indicated ideally; passive range of motion would have been done prior to putting the splints on. PT #113 reported the nurse's aides were the staff therapy educated to put the assistive devices on the residents. Interview on 08/02/23 at 9:07 A.M. with State tested Nursing Aide (STNA) #129 revealed she always worked Resident #66's hallway. She reported the resident's knee and ankle braces were a new intervention by therapy and before therapy started in July 2023, she had not been wearing them. Interview on 08/02/23 at 3:23 P.M., 3:36 P.M., and 4:37 P.M., with the Director of Nursing (DON) verified the way the order for the knee, ankle, and foot splints was written they could not prove the device had been applied daily. She stated she believed the splints were being used because she stated she would check; however, when discussing the knee splint versus the ankle splint she admitted she could not say for sure if they were both on every time she looked at the resident. The DON was unsure the last time Resident #66's knee brace was on. She additionally verified the facility did not have any type of restorative nursing programs in place for any residents, including Resident #66. This deficiency represents non-compliance investigated under Complaint Number OH00144808.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), review of facility policy and procedures, review of the facility floor plan, observations, staff interviews and record reviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy when the facility failed to implement adequate infection control measures increasing the resident outbreak status of five residents (#22, #47, #61, #128 and #383) testing positive for COVID-19 on [DATE] to seven residents (#44, #52, #59, #64, #115, #384 and #482) testing positive for COVID-19 on [DATE]. Furthermore, Resident #128 who was COVID-19 positive expired on [DATE] in the facility. On [DATE] observations made onsite revealed the COVID-19 unit and quarantine units lacked personal protection equipment (PPE) carts and biohazard waste receptacles for each room, resulting in staff walking down the hallways in soiled PPE, staff wearing N95 masks without a covering while entering and exiting quarantine rooms, staff not wearing goggles or face shield and not cleansing the goggles and/or face shield if worn when exiting COVID-19 positive rooms and/or quarantine rooms. Biohazard receptacles were overflowing with soiled PPE, staff were observed not washing hands after removing PPE and transporting soiled linens, and staff placed soiled N95 mask on the clean PPE storage cart while donning clean PPE then picking the soiled N95 mask up with clean PPE. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 134 residents at risk for the likelihood of harm, complications and/or death. The facility census was 134 residents. On [DATE] at 3:37 P.M. the Administrator was notified that Immediate Jeopardy began on [DATE] when infection control practices were not maintained resulting in the risk of continued transmission of COVID-19 amongst staff and residents. Continued breaches in infection control practices on the COVID-19 and quarantine unit after five residents tested positive on [DATE] and seven more on [DATE] put all 134 residents at risk of potential harm. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 2:30 P.M. immediate education was provided to 14 State tested Nursing Assistants (STNA), four Licensed Practical Nurses (LPN) and two Registered Nurses (RN) on duty by RN #540 regarding PPE for quarantine and isolation rooms, and PPE should be readily available near rooms. N95 masks should be changed out within each room or a surgical mask placed over and then the surgical masks changed out after each room. Goggles should be cleaned in between each room. Biohazard boxes should be emptied when full and joint equipment must be cleaned before exiting hall of quarantine or isolation hallways. · On [DATE] at 3:05 P.M. education was provided to all facility staff by RN #406 via text application. The RN sent all staff education including PPE must be placed near each door for easy reach and use. Trash can bins must be placed inside the doorway of each room on quarantine or isolation units. N95 masks must be changed after each room or place a surgical mask over N95 in each room and discard after each room. Goggles are to be cleaned in between use. Biohazard boxes must be emptied and not allowed to spill over. PPE must be changed between units and equipment cannot be taken off quarantine or isolation units with cleaning. · On [DATE] at 3:05 P.M. review of all residents potentially affected per RN #406 revealed all residents from G unit (quarantine unit for COVID-19 exposure) were already in quarantine due to potential exposure. Review of all residents on the F unit (COVID-19 positive unit) revealed all residents were already in quarantine. · On [DATE] at 3:30 P.M. all staff working completed competency on correct process and procedure including changing the N95 mask between each room or place a surgical mask over the N95 mask and change the surgical mask in between each room. When entering a COVID-19 or quarantine room all PPE (gown, gloves, N95 (surgical mask over) and eyewear must be worn. When leaving an isolation room all PPE must be removed inside the doorway and eye coverage must be cleansed between each room per the Administrator. · On [DATE] at 4:30 P.M. the Administrator and RN #406 verified all rooms on quarantine units (located on unit B and G) have a designated biohazard trash can in each room. · On [DATE] at 4:45 P.M. signs were placed on hallways/doorways explaining PPE procedure by the Administrator. · On [DATE] at 5:00 P.M. an emergency Quality Assurance Performance Improvement (QAPI) with the Administrator, Social Services #481, MDS Coordinator #453, Registered Dietician (RD) #488, Housekeeping/Laundry Supervisor #447, Admissions/Marketing #336, Human Resources #420, Director of Nursing (DON) #374, Activities #460, Therapy #548, Maintenance Director #346, Licensed Practical Nurse (LPN) #304 and Registered Nurse (RN) #406. · On [DATE] at 9:00 P.M. a root cause analysis was competed by RN #406 and out of an abundance of caution the facility implemented the following QAPI measures: 1. On [DATE] staff member and/or manager was assigned to oversee each designated unit to initiate and continue ongoing auditing of practices. Ongoing QAPI includes: Infection Control Nurse/Infection Preventionist and governing body will review ongoing audits weekly and as needed. 2. On [DATE] audits initiated per designated staff members of Interdisciplinary Team (IDT) to be assigned to each unit to complete audits of donning/doffing PPE, use of PPE, and hand hygiene every one to two hours for 12 hours on each hall, then reduce to three times daily on each hallway for two weeks or until outbreak is complete. Once outbreak completed, audits are to continue on each hall daily four times a week for two weeks. 3. Weekly QAPI for four weeks per the Administrator. · On [DATE] at 10:05 A.M. individual education was provided to STNA #423 by RN #540 on PPE (gown, gloves, N95, and goggles or face shield) use when escorting residents outside to smoke. · On [DATE] at 4:54 P.M. education was provided to all facility staff by RN #406 via text application. The RN sent all staff education including all staff must wear PPE (gown, gloves, N95 mask, and goggles or face shield) when assisting residents outside to smoke who are residing in the quarantine areas (housed residents with COVID-19 exposure). PPE must be worn while assisting the residents. · On [DATE] at 6:00 P.M. reeducation was provided to Admission/Marketing #334 on proper mask wearing and removal and disposal of soiled PPE (gown, gloves, masks, goggles/face shield). Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: On [DATE] at 8:00 A.M. upon arrival to the facility the Administrator revealed the facility was in a COVID-19 outbreak from a positive staff member. Review of the facility's floor plan provided by the Administrator revealed the East building B unit had five resident rooms (Resident #18, #19, #20, #21 and #23's room) barriered off with plastic and labeled as a yellow quarantine unit for COVID-19 exposure. Further review revealed the West Building F unit had seven rooms (Resident #67, #68, #69, #70, #70, #72 and #73's room) barriered off with plastic and labeled as a red COVID-19 unit which housed the facility's COVID-19 positive residents. The three remaining rooms on the F unit (#65, #66 and #75) were labeled as a yellow quarantine unit. Additionally, the entire G unit of the West building was labeled as a yellow quarantine unit for COVID-19 exposure. Review of the COVID-19 test results provided by the facility revealed STNA #300 tested positive for COVID-19 on [DATE] at which time the entire G unit was placed on quarantine for COVID-19 exposure as well as five resident rooms on the B unit contained in the West building. Review of the Outbreak Timeline provided by the facility revealed on [DATE] mass testing was completed for both staff and residents following a COVID-19 positive staff result on [DATE]. Five residents (#22, #47, #61, #128 and #383) tested positive for COVID-19 and were moved to the West building F unit which contained the COVID-19 positive unit. Review of the COVID-19 test results provided by the facility revealed STNA #301 tested positive for COVID-19 on [DATE]. The facility conducted mass testing on [DATE] and an additional seven residents (#44, #52, #59, #64, #115, #384 and #482) tested positive for COVID-19. The entire F unit was then converted to the COVID-19 unit. Additionally, LPN #302 tested positive for COVID-19 on [DATE]. Review of the CDC guidelines revealed for residents with new-onset suspected or confirmed COVID-19 test results the facility should: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [CONDITION(S)]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross transmission. If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [CONDITION(S)]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). On [DATE] at 11:18 A.M. through 12:30 P.M. an initial observation of the G hallway, quarantine unit for COVID-19 exposure, revealed two red plastic biohazard totes sitting on the left side of the hallway with overflowing soiled PPE. Further observations revealed each resident room was not allotted a PPE storage container or a biohazard container to discard soiled PPE prior to leaving various resident rooms. STNA #303, LPN #304 and Housekeeper #305 were observed entering and exiting quarantine rooms without having a covering over their N95 mask or changing their N95 mask upon exiting resident rooms. Additionally, the staff failed to cleanse their goggles between resident rooms. Three unidentified residents who were in quarantine were outside the exit door at the end of the hallway smoking without social distancing between residents and STNA #303. STNA #303 was not utilizing the required mask, eye protection, gown and gloves while supervising the quarantined residents who were smoking. On [DATE] at 1:11 P.M. observation of STNA #302 revealed she exited Resident #32 and Resident #74's room, who were on quarantine for COVID-19 exposure, without a covering on her N95 or changing her N95 mask, carrying a clear plastic bag of soiled linen. The STNA walked to the end of the hallway and placed the soiled linen in a black plastic covered trash can and entered Resident #36's room, who was on quarantine for COVID-19 exposure, without changing her N95 mask or washing her hands and assisted Resident #36. Interview with STNA #304 confirmed she did not change her N95 mask or wash and/or sanitize her hands. On [DATE] at 1:12 P.M. observation of Housekeeper #305 revealed she exited Resident #62 and Resident #83's room who were on quarantine for COVID-19 exposure without a covering to her N95 mask or changing her mask. She placed her housekeeping cart on the right side of the hallway and exited the G unit (quarantine unit) with the same N95 mask she had on in the above-named resident room and failed to wash or sanitize her hands. Interview with Housekeeper #305 confirmed she had not changed her N95 mask or washed and/or sanitized her hands. Observation on [DATE] at 1:14 P.M. revealed STNA #307 exited Resident #87's (quarantined for COVID-19 exposure) room after providing care, walked to a black covered trash can, removed gown and gloves and walked down the hallway. Interview with STNA #307 verified at the time of the observations she had not sanitized her hands or changed her N95 mask once she completed her care for Resident #87. On [DATE] at 1:22 P.M. Activity Assistant #306 was observed exiting the G unit (quarantine unit) with a mechanical lift without sanitizing the equipment prior to exiting the unit. After surveyor intervention, Activity Assistant #306 stopped RN #468 and asked if she was supposed to do anything with the mechanical lift. On [DATE] at 2:07 P.M. the G unit (quarantine unit) meal cart was delivered by an unidentified dietary aide wearing an N95 mask. The dietary aide's goggles were sitting on top of his head. The dietary aide was observed exiting the unit with the same N95 mask and failed to cleanse his hands and goggles. On [DATE] at 2:11 P.M. observation of STNA #307 revealed she delivered Resident #284, who was in quarantine, his lunch meal with a gown, gloves, N95 mask and goggles in place. She exited the room, walked down the hallway to the meal cart and obtained Resident #131's lunch tray. The STNA walked back to Resident #131's room and entered the room. The resident refused the meal after the STNA placed the tray on the resident's bedside table. STNA #307 exited the room, walked across the hallway and placed the meal tray in an empty wheelchair sitting against the wall. The STNA verified the observations and was unable to verbalize who the empty wheelchair belonged to. Further observations revealed LPN #304, STNA #303, and STNA #307 continued to deliver resident meal trays without washing and/or sanitizing hands between changing PPE. Interview with STNA #303, STNA #307 and LPN #304 verified the lack of handwashing and/or sanitizing their hands when changing PPE. On [DATE] at 2:27 P.M. observation of LPN #304 revealed she exited Resident #43 and Resident #125's room, who were in quarantine for COVID-19 exposure, with a soiled N95 mask on, walked across the hallway to the plastic cart containing clean PPE, removed the soiled N95 mask and placed it on top of the plastic cart containing clean PPE. The LPN then donned a gown, gloves, and a N95 mask. LPN #304 failed to wash and/or sanitize her hands or cleanse her goggles prior to donning the clean PPE. LPN #304 then picked the soiled N95 mask up and walked to a biohazard trash can and discarded the mask. LPN #304 then removed a tray from the meal cart to deliver. Interview with LPN #304 confirmed she placed a soiled N95 mask on the clean PPE container, failed to wash and/or sanitize her hands, and did not cleanse her goggles prior to donning the clean PPE. On [DATE] at 4:20 P.M. observation of STNA #506 revealed the STNA exited Resident #383's (COVID-19 positive resident) room wearing full PPE, walked to other end of the COVID-19 unit to the biohazard bin, took off her PPE, did not wash hands, washed her eye protection, donned clean PPE then washed hands. The STNA verified that she walked across the covid unit with soiled PPE and did not wash her hands after removing the soiled PPE. On [DATE] at 9:03 A.M. observation of STNA #539 revealed the STNA was wearing her eye protection on top of her head, not covering her eyes, while cleaning up a breakfast tray from Resident #65 in the unit lounge. Interview at the time of the observation with STNA #539 confirmed she was not wearing eye protection appropriately while providing resident care. Observation on [DATE] at 9:48 A.M. revealed Resident #73 (a quarantined resident) was outside smoking with STNA #423 assisting. The only PPE STNA #423 was utilizing was an N95 mask and a face shield, she did not have gloves or a gown on, and was not social distancing. Interview on [DATE] at 9:50 A.M. with RN #406 stated she would expect staff to wear full PPE when taking a quarantine resident out to smoke. Interview on [DATE] at 9:55 A.M. with STNA #423 and RN #406 present confirmed STNA #423 did not utilize all appropriate PPE while assisting a resident to smoke who was under quarantine status for COVID-19 exposure. On [DATE] at 3:37 P.M. observation of Admission/Marketing #336 exiting Resident #52's room, who was in quarantine for COVID-19 exposure, revealed she removed her N95 mask at the resident's door and put on a clean N95 mask. She then placed the soiled mask into her pocket and exited the G unit (quarantine unit for COVID-19 exposure) in the West building. Admission/Marketing #336 confirmed by pulling out the soiled N95 mask from her pocket and state, I don't know what to do with it. Review of the CDC guidelines Sparkling Surfaces: Stop COVID-19's Spread revealed the virus that causes COVID-19 can be spread by indirect contact with contaminated surfaces. Surfaces that were touched frequently increase the chance that germs could be spread to residents and staff. On surfaces which look clean, pathogens might be present. The coronavirus causing COVID-19 has been shown to survive on surfaces from several hours to days. Review of the facility policy titled, Care for the Patient with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19), last revised on [DATE], revealed the facility had designated specific areas within the facility, with facility staff to care for known or suspected COVID-19 patients with options for extended use of respirators, facemasks and eye protection on such units or patient areas. The facility would follow the CDC recommendations in caring for the known or suspected COVID-19 patient. Patients with known or suspected COVID-19 should be cared for in a single person room with the door closed with a private bathroom and/or bedside commode as able. A sign would be placed on the door and PPE will be placed outside of the resident room. N95 masks or disposable masks should be discarded after exiting the patient's room and/or quarantine unit or care area (COVID-19 unit) and closing the door. The staff member should then perform hand hygiene after discarding the respirator or facemask. Put on eye protection (goggles and/or disposable face shield) that covers the front and sides of the face upon entry to the patient's room or care area. Reusable eye protection must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use. Staff should put on clean, non-sterile gloves upon entry into the patient room or care area. Remove and discard gloves when leaving the patient room or care area and immediately perform hand hygiene. The facility would utilize PPE items in facility and patient care areas in accordance to current guidance per local, state or federal guidance. Dedicated medical equipment should be used when caring for patients with known or suspected COVID-19 as able. All non-dedicated, non-disposable medical equipment used for patient care will be cleaned and disinfected according to manufactures instructions and cleaning schedule. This deficiency substantiates Complaint Number OH 920.

Based on closed record review, review of an emergency medical service (EMS) run report, facility Post-Mortem policy and procedure review, facility Abuse/Neglect policy and procedure review, staff interview, interview with Emergency Medical Service/Paramedic #545 and #546 and interview with Contracted Funeral Home Transport #543, the facility failed to provide adequate and immediate post-mortem care to Resident #128 following the resident's death in the facility on [DATE] resulting in neglect of the resident's corpse. This resulted in Immediate Jeopardy, when on [DATE] at approximately 8:00 A.M. Resident #128's body was released to the funeral home without evidence of post-mortem care having been provided by facility staff. On [DATE] interviews with Contracted Funeral Home Transport #543, Agency Licensed Practical Nurse (LPN) #542 and Anonymous Staff #544 revealed postmortem care had not been completed following the resident being pronounced deceased on [DATE] at 3:46 A.M. Resident #128 was found lying on the floor in his room, where cardiopulmonary resuscitation (CPR) had been provided, with his eyes and mouth open, in urine and feces, with his cut clothes, defibrillator paddles and an intravenous line still attached to the resident. Actual harm occurred as the reasonable person concept involves caring for a deceased resident's body with sensitivity and in a manner consistent with a resident's religious and cultural beliefs. Post-mortem care should be provided immediately or as soon as possible to prevent tissue damage or disfigurement of a resident's body as the body starts decomposition immediately after death. The body should be preserved to delay decomposition so funeral services may take place. This affected one resident (#128) of three residents reviewed for death. The facility census was 134. On [DATE] at 3:30 P.M. the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services/Registered Nurse #406 were notified Immediate Jeopardy began on [DATE] at 3:46 A.M. when LPN #542 failed to complete post-mortem care following the resident's death at that time. On [DATE] at approximately 7:00 A.M., Anonymous Staff #544 observed the resident lying on the ground in his urine, without any postmortem/dignity care provided. At approximately 8:00 A.M. (approximately three hours and 14 minutes after death) the Contracted Funeral Home Transport #543 arrived at the facility to transport Resident #128 to the funeral home and observed the resident lying on the floor in feces, urine, with his eyes and mouth open and medical equipment still attached to his decomposing body. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 5:30 P.M. Senior DON #540 and Unit Manager/LPN #324 reviewed the medical records for all current in-house residents to verify code status order, care plan, and documentation to ensure all are congruent in the medical record. · On [DATE] at 4:30 P.M. Regional Director of Clinical Services #406 initiated education for all licensed staff on timely postmortem care. Education was completed on [DATE] from 4:30 P.M. for nine Licensed Practical Nurses (LPNs), three Registered Nurses (RN), 14 State tested Nurse Assistants (STNA), 10 administrative staff, three regional staff, dietary staff and activity staff, and two therapy staff. A plan for no licensed staff to be permitted to work until education was received was implemented. · On [DATE] at 4:50 P.M. Regional Director of Clinical Services #406 initiated online education for all staff with competencies via survey monkey for all licensed nurses regarding timely postmortem care. Seven RNs, 23 LPNs, 46 STNAs, 10 administrative staff, five activities staff, 11 dietary staff, 19 laundry and housekeeping, and eight therapy staff. A plan for no licensed staff to be permitted to work until education was received was implemented. · On [DATE] at 5:30 P.M. the DON reviewed the last three months of resident facility deaths, and interviewed staff to ensure there were no other like instances regarding the absence of timely postmortem care. No like instances were noted. · On [DATE] at 8:20 P.M. the Administrator sent the education packet to their three contracted staffing agencies (ConnectRN, VIP, and Buckeye) to have their staff educated on providing postmortem care. They are to send a sign off sheet to the Regional Director of Clinical Services #406. The staff are to have the education provided to the facility before they are able to return to the facility. · On [DATE] a plan for education competencies to be reviewed by Regional Director of Clinical Services #406 to be completed on 10 random staff members daily for two weeks (via survey monkey) and then 10 random staff members three times weekly for two weeks via survey monkey) to ensure competencies of the processes related to timely postmortem care. · On [DATE], at 7:00 P.M. the facility Quality Assessment and Performance Improvement (QAPI) Committee, including the Administrator, Regional Director of Clinical Service #406, SSD #481, Minimum Data Set (MDS) Nurse #453, Dietician #488, housekeeping and laundry #447, marketing #336, Human Resources (HR) #420, Director of Nursing (DON), activities #452, Therapy Director #548, Maintenance Director #346, Assistant DON (ADON)/LPN #304, and Physician Assistant #549 reviewed the Immediate Jeopardy deficiencies, the plan of action, the policies and procedures related to timely post mortem care and a root cause analysis was completed. · On [DATE] a plan for audits of closed resident records reviewed for deaths to be completed by the DON/designee daily for five days a week for four weeks to ensure postmortem care was completed by staff timely. When she is informed of a death, she will be following up immediately and completing a postmortem audit form. · On [DATE] a plan for weekly for four weeks QAPI meetings per the Administrator to ensure postmortem care and neglect policies and procedures were being followed. · On [DATE] at 4:31 P.M. Regional Director of Clinical Services #406 initiated online education for all facility staff regarding the Neglect policy and the policy for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . · On [DATE] at 5:00 P.M. Regional Director of Clinical Services #406 initiated education for all contracted agency staff regarding the Neglect policy and the policy for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Although the Immediate Jeopardy was removed on [DATE], 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #128 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident was a Full Code related to advance directives. The resident expired in the facility on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 12 indicating the resident had moderate cognitive impairment. The assessment revealed the resident required extensive assistance from one staff for bed mobility and toilet use, extensive assistance from two staff for transfers, supervision with one staff assistance for locomotion and limited assistance from one staff for personal hygiene. Review of Resident #128's care plan, dated [DATE] revealed the resident/family chose CPR would be attempted during [CONDITION(S)] with interventions to inform new caregivers of code status, nursing staff to provide chest compressions when the resident was in [CONDITION(S)] and call ambulance for transport to the hospital, and notify family of changes in condition. Review of Resident #128's medical record revealed the resident was not receiving Hospice services and/or palliative care during his stay at the facility. The plan of care revealed the resident's goal was to return home. A nurse's note, dated [DATE] at 4:23 A.M. revealed the resident continued to refuse all care this shift. Certified Nurse Practitioner (CNP) #547 was notified at 2:48 A.M. and gave a new order to send the resident to the emergency room for further evaluation. Paramedics (EMT) were contacted for transport. The nurse's notes revealed the resident was unresponsive upon EMT arrival at 3:10 A.M. and CPR was started, the resident was pronounced dead at 3:46 A.M. and CNP #547 was notified. A note, dated [DATE] at 8:45 A.M. revealed the resident was discharged . Review of Resident #128's medical record revealed no evidence facility staff provided Resident #128 any type of postmortem care. The medical record contained no information related to when the resident's body was released to the funeral home. Review of the Local Fire Department Report, dated [DATE] revealed a call/dispatch to transport Resident #128 on [DATE] at 3:01:18 A.M. The report showed staff enroute at 3:02:32 A.M., on the scene at 3:08:53 A.M. and at the patient (Resident #128) at 3:21:50 A.M. Resident #128 was pronounced deceased at 3:46 A.M. The report revealed Resident #128 was unresponsive and pale, he was in [CONDITION(S)]. The narrative report revealed when they arrived at the patient, he was slumped over in his wheelchair and wasn't breathing. EMS slid the resident from the wheelchair onto the floor and manual CPR was performed. The local fire department was notified of the arrest and to send an engine for additional manpower. Paddles were placed on the resident's chest and the resident was assessed to be in ventricular fibrillation. The resident was shocked, and CPR continued. The report revealed the other patient was lying in his bed in the same room and stated he could hear Resident #128 moaning but had not heard a noise from him for at least 20 minutes. The next rhythm check, per monitor, showed Resident #128 had pulseless electrical activity and his blood sugar was 141. [MEDICATION(S)] was administered to the patient via an Intraosseous Line (IO) and CPR continued but the resident remained without a pulse. CPR was discontinued after 20 minutes and the resident was pronounced dead. On [DATE] at 11:21 A.M. interview with EMT/Paramedic #545 revealed when they arrived at the resident's room, the resident was slumped over in his wheelchair with dried bodily fluids on his shirt and in his nares and CPR was not in progress. Paramedic #546 moved the resident to the ground and initiated manual CPR while Paramedic #545 went back out to the ambulance to retrieve a [NAME] Device (portable device that delivers consistent chest compression). On [DATE] at 1:01 P.M. interview with a staff member who wished to remain anonymous (Staff #544) revealed she worked the day shift on [DATE] and the resident was lethargic, had refused all care and was spitting at staff. Staff #544 revealed she notified the certified nurse practitioner (CNP) and the CNP revealed this was typical behavior of the resident, to refuse care and to notify the CNP if it continued. Staff #544 revealed the resident would let her check his oxygen saturation which was about 96% on room air but stated the resident wouldn't allow her to take any other vital signs. Staff #544 revealed on [DATE] when she arrived to work, around 7:00 A.M.-7:15 A.M. she found Resident #128 deceased on the floor. Staff #544 revealed she had to provide personal care to the resident. Staff #544 revealed no staff had provided post-mortem care to Resident #128 immediately after he passed away. Staff #544 revealed funeral transport arrived to the facility at approximately 8:00 A.M. and she did offer to assist moving the resident off the floor but they declined. Staff #544 revealed she had not notified anyone related to the condition of the resident because the resident had been deceased for hours and she assumed someone had known and would have already notified administrative staff. On [DATE] at 2:21 P.M. interview with the DON revealed the expectation following a resident's death would be for post-mortem care to be completed once everything had calmed down. The DON revealed it should not be multiple hours after a after the resident's death. On [DATE] at 2:43 P.M. interview with Contracted Funeral Home Transport (CFHT) #543 revealed when he arrived at the facility around 8:00 A.M. Resident #128 was laying on the floor, in soiled clothes (stated urine and feces), his skin had not been taken care of, his mouth and eyes were wide open and his arms were at his side. CFHT #543 revealed he did not recall what the resident's shirt looked like, but stated he had to wipe dried [MEDICATION(S)] off the resident's face and nose. CFHT #543 revealed he had to pull the defibrillator paddles off of him, remove the IV from his arm and stated the resident was still in the clothes EMS staff cut off of him. CFHT #543 revealed when he rolled the resident, blisters on his legs were popping, his skin was noted with skin slippage. CFHT #543 revealed the resident's body was definitely starting to decompose. On [DATE] at 3:55 P.M. and again on [DATE] at 1:14 P.M. interview with Agency LPN #542 revealed she was the nurse assigned to care for Resident #128 on [DATE]. Agency LPN #542 revealed Resident #128 had been refusing care (medications and meals) during the shift and the CNP was notified. The CNP reported the resident was just having normal behaviors and to monitor the resident. Agency LPN #542 revealed the resident was then subsequently unresponsive and without vital signs and was provided CPR which was unsuccessful. The resident was pronounced deceased by paramedic staff. Agency LPN #542 revealed paramedic staff covered Resident #128 with a sheet, but the resident didn't have any funeral home listed so she asked a supervisor. Agency LPN #542 revealed about an hour later she was provided information on which funeral service to use so she set up the transport. Agency LPN #542 revealed there were no state tested nursing assistant (STNA) staff working with her on the unit, she was working by herself and just left the resident on the floor covered with the sheet awaiting the funeral home to arrive. Agency LPN #542 verified the resident had urine and feces on him at the time he passed away and verified she had not provided any type of personal or post-mortem care to the resident. Agency LPN #542 revealed she left the facility at the end of her shift around 7:00 A.M., at which time the funeral home had not arrived. Agency LPN #542 indicated she was not sure what time the funeral home arrived that morning. During the interview, Agency LPN #542 verified she did not complete post-mortem care for Resident #128, the agency LPN revealed if you have help you can do the care, but she didn't have any help. Agency LPN #542 revealed she was not sure what the facility policy was on post mortem care so she wasn't sure if it was unacceptable the care wasn't provided. On [DATE] at 11:55 A.M. interview with EMS/Paramedic #546 revealed when they arrived at the resident, he was slumped over in his wheelchair. EMS #546 revealed himself and a nurse on duty assisted the patient to the floor while the other EMS/Paramedic ran to the truck to grab the [NAME] Device. The resident was in [CONDITION(S)] and was not breathing, his skin was warm, he had dried [MEDICATION(S)] all over his clothes and he looked like he had been unresponsive. Review of the facility policy and procedure titled, Post-Mortem Care, dated [DATE] revealed residents who expire in the building receive the care appropriate for transporting to a receiving facility. The policy revealed post-mortem care was provided for a resident after their death had been pronounced and appropriate persons and agencies had been notified. The policy indicated the resident should be treated with dignity and respect; nurses would remove intravenous lines (IVs), tubes, catheters and replace soiled dressings; the residents' body should be washed carefully and the clothes should be changed if soiled. Review of the facility policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated [DATE] revealed neglect was defined as the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Mistreatment was defined as the inappropriate treatment or exploitation of a resident.

Based on observation, closed record review, review of an Emergency Medical Service (EMS) squad run report, review of a staff witness statement, review of the facility emergency response policy, staff interview and interview with Paramedic (EMT) #545 and EMT #546, the facility failed to initiate timely and adequate Cardio-pulmonary Resuscitation (CPR) for Resident #128 who was a full-code and required CPR after being found unresponsive and without vital signs. This resulted in Immediate Jeopardy on [DATE] at approximately 3:21 A.M. when Resident #128 was observed unresponsive. The facility failed to ensure EMS had timely access to the facility and failed to provide CPR timely for the resident. On [DATE] at 3:21 A.M., EMS arrived on-site and identified facility staff were not providing CPR to a resident whom staff had identified as unresponsive and coding. EMS staff immediately initiated CPR for the resident, however CPR efforts were not successful and the resident expired. The lack of immediate and adequate CPR and delay in staff allowing EMS into the facility resulted in life threatening harm and death for Resident #128. This affected one resident (#128) of three residents reviewed for death. The facility identified 75 residents who were a full code in the facility. The facility census was 134. On [DATE] at 3:30 P.M. the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services/Registered Nurse #406 were notified Immediate Jeopardy began on [DATE] at approximately 3:21 A.M. when facility staff, including Licensed Practical Nurse (LPN) #542 failed to initiate immediate CPR procedures for Resident #128 after he stopped breathing. Resident #128 subsequently expired in the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 5:30 P.M. Senior DON #540 and Unit Manager/LPN #324 reviewed the medical records for all current in-house residents to verify code status order, care plan, and documentation to ensure all were congruent in the medical record. · On [DATE] at 5:00 P.M. the facility layout was reviewed and assigned identifying numbers (related to code status), the numbers were placed on the doors by Maintenance Director #346 and Central Supply #329. · On [DATE] at 7:15 P.M. the Administrator contacted the Local Fire Department and informed them of their new facility layout and door identification system. · On [DATE] at 5:30 P.M. with day shift and at 7:00 P.M. with night shift Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #304 conducted code blue drills with all working staff which included 27 STNAs, 14 LPNs, four RNs, 10 administrative staff, three regional staff, three dietary staff, three activities staff, and two therapy staff to ensure knowledge of the policy and procedure for a code blue. A code blue is initiated when a patient is unresponsive in cardiopulmonary arrest and staff are required to initiate CPR. · On [DATE], at 7:00 P.M. the facility Quality Assessment and Performance Improvement (QAPI) Committee, including the Administrator, Regional Director of Clinical Service #406, SSD #481, MDS #453, Dietician #488, housekeeping and laundry #447, marketing #336, HR #420, Director of Nursing (DON), Activities #452, Therapy Director #548, Maintenance Director #346, ADON/LPN #304, and Physician Assistant #549 reviewed the Immediate Jeopardy finding, facility plan of action, the policies and procedures related to timely post mortem care, code blue, CPR, and the new floor plan and postings, and a root cause analysis was completed. · On [DATE] 4:30 P.M. the Regional Director of Clinical Services #406 initiated education for all licensed nurses on the CPR code policy, code-blue drills (the code called when someone was identified to require CPR), timely post-mortem care, and new process with labeled doors to alert to location for entrance or exit. Education was completed on [DATE] from 4:30 P.M. for nine Licensed Practical Nurses (LPNs), three RNs, 14 STNAs, 10 administrative staff, three regional staff, dietary staff and activity staff, and two therapy staff. A plan for no licensed staff to be permitted to work until education was received was implemented. · On [DATE] at 4:50 P.M. Regional Director of Clinical Services #406 initiated online education for all staff with competencies via survey monkey for all licensed nurses on the CPR code policy, code-blue drills, timely postmortem care, and new process with labeled doors to alert to location for entrance or exit. Seven RNs, 23 LPNs, 46 STNAs, 10 administrative staff, five activities staff, 11 dietary staff, 19 laundry and housekeeping, and eight therapy staff. A plan for no licensed staff to be permitted to work until education was received was implemented. · On [DATE] at 5:30 P.M. the DON reviewed the last three months of resident facility deaths to ensure there were no other like instances. No like instances were noted. · On [DATE] at 8:20 P.M. the Administrator sent an education packet to the facility three contracted staffing agencies (ConnectRN, VIP, and Buckeye) to have their staff educated on their new facility policies and procedures and to verify all nurses were CPR certified. They were to send a sign off sheet to the Regional Director of Clinical Services #406. The staff were to have the education provided to the facility before they are able to return to the facility. · On [DATE] a plan for code-blue drills to be completed by the ADON/LPN #304 and the DON/designee every shift for three days and then weekly for four weeks on random shifts to ensure competencies of the process for a code blue. · On [DATE] a plan for education competencies to be reviewed by Regional Director of Clinical Services #406 to be completed on 10 random staff members daily for two weeks (via survey monkey) and then 10 random staff members three times weekly for two weeks via survey monkey) to ensure competencies of the processes related to timely postmortem care, code blue, CPR, and the new floor plan and postings. · On [DATE] a plan for audits of closed resident records reviewed for deaths to be completed by the DON/designee daily for five days a week for four weeks to ensure postmortem care was completed by staff timely. When she is informed of a death, she will be following up immediately and completing a post mortem audit form. · On [DATE] a plan for weekly for four weeks QAPI meetings per the Administrator to ensure policies and procedures were being followed. Although the Immediate Jeopardy was removed on [DATE] 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 plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #128 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident was a Full Code related to advance directives. The resident expired in the facility on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 12 indicating the resident had moderate cognitive impairment. The assessment revealed the resident required extensive assistance from one staff for bed mobility and toilet use, extensive assistance from two staff for transfers, supervision with one staff assistance for locomotion and limited assistance from one staff for personal hygiene. Review of Resident #128's care plan, dated [DATE] revealed the resident/family chose CPR would be attempted during cardiac arrest with interventions to inform new caregivers of code status, nursing staff to provide chest compressions when the resident was in cardiac arrest and call ambulance for transport to the hospital, and notify family of changes in condition. Review of Resident #128's medical record revealed the resident was not receiving Hospice services and/or palliative care during his stay at the facility. The plan of care revealed the resident's goal was to return home. Review of Resident #128's care plan, dated [DATE] revealed the resident was tested and confirmed positive for COVID-19 with interventions to administer medications per physician orders, administer oxygen per physician orders, be alert for changes in activities of daily living assistance required, be alert for new or worsening symptoms including increased difficulty breathing, back or abdominal pain, increased lethargy and weakness, altered mental status and notify physician if this occurs, and follow Centers for Disease Control (CDC) and facility policies for isolation precautions related to COVID-19. Review of the physician's orders revealed an order, dated [DATE] for the resident to be placed on droplet precautions for 10 days due to COVID-19. The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the nurse's notes revealed on [DATE] at 5:49 P.M. Resident #128 was aware of his rapid positive COVID-19 test result and moved to the facility COVID unit. A nurse's note, dated [DATE] at 4:23 A.M. revealed the resident continued to refuse all care this shift. Certified Nurse Practitioner (CNP) #547 was notified at 2:48 A.M. and gave a new order to send the resident to the emergency room for further evaluation. Paramedics (EMT) were contacted for transport. The nurse's notes revealed the resident was unresponsive upon EMT arrival at 3:10 A.M. and CPR was started, the resident was pronounced dead at 3:46 A.M. and CNP #547 was notified. A note, dated [DATE] at 8:45 A.M. revealed the resident was discharged . Review of the Local Fire Department Report, dated [DATE] revealed a call/dispatch to transport Resident #128 on [DATE] at 3:01:18 A.M. The report showed staff enroute at 3:02:32 A.M., on the scene at 3:08:53 A.M. and at the patient (Resident #128) at 3:21:50 A.M. Resident #128 was pronounced deceased at 3:46 A.M. The report revealed Resident #128 was unresponsive and pale, he was in cardiac arrest, and the only delay to the patient was a delay at the scene, documenting there was a delay to patient access. The narrative report revealed they had been dispatched for a medic run and upon arrival, at the front door of the facility it took several minutes for the nursing staff to come to the front door to tell the medics they needed to go to the side of the building to the isolation area. Facility staff indicated the patient was COVID positive and needed to be transported for further evaluation. The crew took the cot to the end of the building, knocked on the door and another staff member wouldn't open the door and then told them they needed to go around to the back of the building. The cot was taken back by the medic so they would drive to the back of the building. Facility staff came out to the medic and stated staff told them to drive to the back of the other building and apologized for the delay. They drove to the back of the building and found a staff member walking to take them to the correct door. When emergency medical staff entered the building a staff member shouted, CPR in progress. The report indicated this was 14 minutes after EMS arrival. The EMS crew continued to Resident #128's room and found the resident slumped over in his wheelchair with no CPR in progress. Resident #128 wasn't breathing and was in cardiac arrest. Nursing staff reported the physician was called by (a facility staff member via phone) at 2:38 A.M. and the resident was nonverbal but was moaning and the staff member was unsure when the resident's last normal activity was. The resident's skin was warm. EMS slid the resident from the wheelchair onto the floor and manual CPR was performed. Columbus Fire Department was notified of the arrest and to send an engine for additional manpower. Paddles were placed on the resident's chest and the resident was assessed to be in ventricular fibrillation. The resident was shocked, and CPR continued. The report revealed the other patient was lying in his bed in the same room and stated he could hear Resident #128 moaning but had not heard a noise from him for at least 20 minutes. The next rhythm check, per monitor, showed Resident #128 had pulseless electrical activity and his blood sugar was 141. [MEDICATION(S)] was administered to the patient via an Intraosseous Line (IO) and CPR continued but the resident remained without a pulse. CPR was discontinued after 20 minutes and the resident was pronounced dead. On [DATE] at 11:21 A.M. interview with EMT/Paramedic #545 revealed they received a call around 3:00 A.M. that a resident was refusing his medications and care and needed an evaluation at the hospital. He stated they (himself and EMT #546) arrived at the facility a few minutes later but had not been notified the resident they were going to pick up was COVID positive, so they went to the front entrance door. Two staff were sitting behind the counter staring at them and didn't get up and answer the door. EMT/Paramedic #546 started aggressively pounding on the door until someone answered who directed them to another door stating they were going to an isolation door. When they arrived at the second door, they felt they woke the staff up and that staff stated the resident was on another isolation wing and sent them to a third door on the other side of the building. They loaded up the cot they had, and a staff member apologized for the confusion. They headed to the third door and changed their respirators to be prepared for a covid positive resident. When they finally got into the third door about eight to twelve feet into the hall, they heard a staff member saying CPR in progress. He stated the ball game had changed at this point because they were told this was a simple transport to the hospital. When EMT staff arrived at the resident's room, there were no staff in the room, the resident was slumped over in his wheelchair with dried bodily fluids on his shirt and in his nares and CPR was not in progress. EMT #545 revealed even if CPR had been initiated, it wouldn't have been effective (as the resident was in a wheelchair). Paramedic #546 moved the resident to the ground and initiated manual CPR while Paramedic #545 went back out to the ambulance to retrieve a [NAME] Device (portable device that delivers consistent chest compression). When he got back into the facility Paramedic #546 was still doing CPR with no staff assisting him. He stated he also had the [NAME] Device in his arms and the resident's wheelchair was still in front of the resident's door, no one helped move the wheelchair so he had to set the [NAME] Device down to move the wheelchair himself, then pick the [NAME] Device back up and apply it to the resident. He shocked the resident once with the defibrillator, but no vital signs were noted. EMT #545 revealed he wasn't sure who he stated this to, but said he was denied access so many times, he told one of the staff he would be getting into the facility on e way or another even if he had to call the sheriff to let him in. Paramedic #545 further revealed the resident's roommate shared with him that he heard Resident #128 moaning that morning for quite some time. On [DATE] at 11:55 A.M. interview with EMS/Paramedic #546 revealed they were called for a medic run to the facility and when they arrived at the main entrance staff were standing around the front desk looking at the EMS like they were stupid. It took staff a few minutes to come to the door and staff directed EMS to go to the other side of the building as the resident, Resident #128 was in isolation. EMS went to the other side of the building and there was a lady sitting in a chair who looked like she was asleep. EMS had to beat on the door which scared the lady but she wouldn't let them in. The lady was yelling at them through the door to go to the isolation unit. Paramedic #546 reported they didn't know where that was. The sidewalk had ended and the area where she was pointing them to go required EMS to load the cot back up into the truck and drive around the building. As they were in this process, a woman who they thought was a manager apologized for the confusion and EMS #546 stated he told her it was a good thing this wasn't a true emergency because as long as they had been at the facility the patient could be dead. They pulled around to the other side of the building and as they were approaching the ramp, the staff on the unit were heard saying CPR in progress. EMS staff got to Resident #128's room and the resident was slumped over in his wheelchair with no CPR in progress by facility staff. EMS #546 revealed himself and a nurse on duty assisted the patient to the floor while the other EMS/Paramedic ran to the truck to grab the [NAME] Device. The resident was in cardiac arrest and was not breathing, his skin was warm, he had dried [MEDICATION(S)] all over his clothes and he looked like he had been unresponsive. EMS #546 revealed if he had to speculate, he would have said the resident had been down for approximately 10 minutes. EMS staff radioed for a fire engine and he did CPR until the [NAME] Device was hooked up. He stated they utilized the defibrillator on the resident and continued CPR. The resident's roommate stated to the EMS staff the resident was moaning for quite awhile, but he hadn't heard the resident making noise for 20 minutes to a half hour. He stated getting into the building was the biggest delay of getting to Resident #128 and the nurse on duty had no sense of urgency or worry. When asked what made him think the resident was unresponsive for approximately 10 minutes, he stated he just looked like he had been like that for a while. On [DATE] at 3:55 P.M. and again on [DATE] at 1:14 P.M. interview with Agency LPN #542 revealed she was working in the facility on [DATE] and assigned to care for Resident #128. The LPN revealed when she got onto the unit Resident #128 was refusing medications, meals and care and he did the same during her night shift. She stated around 10:30 P.M. the CNP was called for new orders and she stated the resident was just having a behavior, it was his normal and staff could just monitor him. LPN #542 revealed around 2:00 A.M. or something CNP #547 told staff to send the resident out for an evaluation. LPN #542 revealed she printed everything for EMS and called the paramedics. LPN #542 revealed she saw the resident around five minutes before EMS arrived and he was fine, then she went to answer another resident's call light and when she came out to let EMS in, she noticed the resident was unresponsive in his chair. LPN #542 revealed she and the paramedics got the resident out of the wheelchair and started CPR. They did CPR for about 30 minutes until they pronounced the resident deceased . At the time of the incident, LPN #542 revealed she was the only staff member working on the COVID unit. There were no STNAs or other staff with her on the unit, it was just herself, but she didn't think she needed any STNAs to help as she did okay on her own. LPN #542 verified there was a delay in the time it took EMS to get to the resident because they went to the wrong door as the COVID positive unit was in the back of the building. LPN #542 revealed she knew the resident's code status when EMS arrived because she saw it on his chart when she printed the information for EMS but had not started CPR for the resident prior to EMS arriving to the room even though the resident was unresponsive. Review of LPN #542's signed witness statement, dated [DATE] at 6:00 A.M. revealed on [DATE] at 10:45 P.M. Resident #128 continued to refuse medications, meals and personal care. Resident #128 was sitting in his room in a wheelchair with no signs of respiratory distress noted. The on-call provider was called and notified of the refusals and no new orders were received. On [DATE] at 2:48 A.M. the resident continued to refuse care. CNP #547 was notified and gave a new order to send the resident to the emergency room for an evaluation. Paramedics were contacted for transport. The resident was unresponsive as EMS arrived and CPR was started at 3:10 A.M. via EMS. He was pronounced dead at 3:46 A.M. The resident's provider was contacted, the DON was contacted, and funeral services were contacted. Review of the facility policy and procedure titled, Medical Emergency Response, dated [DATE] revealed in the event of a medical emergency any staff member, visitor or resident may initiate a medical emergency response. Staff would immediately notify the nurse in charge of the unit and they would announce a code blue and the general location. Staff in the vicinity would respond to the area immediately. The (resident's) code status would be verified by the nurse, staff would obtain a crash cart and 911 would be called. Once CPR was initiated, responders would continue until a physician provided the order to stop, the resident recovered with heart beat and breaths or emergency response team arrived and took over and transported the resident to a higher level of care.

Based on observation, record review and interview the facility failed to provide adequate supervision and/or assistive devices to prevent falls and/or resident injury. Actual Harm occurred on 10/31/21 when Resident #35, who required extensive assistance from two (plus) staff for bed mobility sustained a fall out of bed resulting in a fractured nose when State tested Nursing Assistant (STNA) #407 was providing bed mobility without a second staff member assisting. Actual Harm occurred on 10/07/21 when Resident #33, who was dependent on two staff for transfers sustained an injury/hematoma with increased excruciating pain and subsequent two week hospitalization with surgical intervention during a staff assisted mechanical (Hoyer) lift transfer. This affected four residents (#12, #33, #35 and #93) of six residents reviewed for accidents. Findings include: 1. Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses included [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Review of a fall risk evaluation, dated 03/30/21 revealed Resident #35 was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/17/21 revealed the resident required extensive assistance from two plus staff members for bed mobility, dressing and personal hygiene and total dependence from two plus staff members for transfers and toilet use. Review of an incident report, dated 10/31/21 revealed Resident #35 was positioned on his left side during personal care. The resident then rolled to the side of the bed and off of the bed landing face down. The resident's nose was bleeding with a significant amount of blood noted. The resident was assessed to have a laceration to the nose and an abrasion to the knee. Resident #35 was transported to the emergency room for an evaluation. A hospital after summary report revealed Resident #35 was to have a follow up appointment with plastic surgeon for a fracture of his nose. On 11/01/21 at 1:49 P.M. Resident #35 was observed in his room in a wheelchair with purplish bruising around both eyes and a laceration to the bridge of his nose with dried blood. At the time of the observation, the resident revealed he had a broken nose. The resident revealed an STNA was turning him over (in bed) and rolled him out of bed. The resident indicated he hit the floor with his face and shoulder. On 11/01/21 at 2:41 P.M. interview with Licensed Practical Nurse (LPN) #497 revealed STNA #407 was turning Resident #35 in bed by herself and when she turned him he rolled out of bed. Review of a statement from STNA #407 revealed she was in (Resident #35's) room doing last check and change on Resident #35. The statement indicated the resident was rolled over on his left side and as the STNA was cleaning him up, he rolled out of bed on the floor and landed on his left side. The statement revealed the nurse was immediately notified. 2. Review of Resident #33's medical record revealed an original admitted [DATE] with the latest readmission of 10/21/21 with the admitting diagnoses of diabetes mellitus, sleep apnea, [CONDITION(S)], hypertension, [CONDITION(S)], severe [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], chronic respiratory failure and gastro-[CONDITION(S)] reflux disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score 15. The resident required extensive assistance of two persons for bed mobility and toileting and was dependent on two staff for transfers and bathing. Review of a telehealth note, dated 10/01/21 at 12:00 A.M. revealed the nurse reported the resident's left foot was bumped during a transfer yesterday and the resident was now complaining of pain, in addition to bruising and swelling. An x-ray of the left foot/ankle were ordered and nursing to continue to monitor and care team was notified. Review of a nursing note, dated 10/01/21 at 5:45 P.M. revealed Resident #33 asked the nurse to look at her left foot due to pain. The top of the resident's left foot was noted with [CONDITION(S)], redness and was warm to touch, with the area measuring 6.0 cm in length by 6.0 cm width. Bruising was noted to the left side of the foot measuring 8.0 cm in length. The resident rated her pain an 8 out of ten (on a scale of one to ten with ten being the most severe pain) and was medicated with Tylenol 650 milligrams (mg) for pain. The resident's foot was elevated on a pillow. The nursing note revealed the resident stated her foot was bumped on 09/30/21 during a transfer with the Hoyer (a mechanical lift device used for transfers). Review of the facility investigation revealed a skin alteration report, dated 10/01/21 at 5:58 P.M. which indicated Resident #33 reported left foot pain to the floor nurse and an assessment was completed. Bruising across the top of the resident's foot to lateral side of the foot was noted. The resident stated, They bumped my foot. There was no indication of any new intervention(s) being initiated following this incident to decrease the resident's risk for injury associated with staff assisted transfers using the Hoyer (mechanical)+ lift. Review of a nursing note, dated 10/02/21 at 8:00 A.M. revealed the left foot x-ray received on night shift had negative results. The nurse practitioner (NP) on call was notified. The resident was medicated with Tylenol 650 mg for pain with positive results. The resident's left foot continued with [CONDITION(S)], slightly red on top of foot and bruising continues with [CONDITION(S)], slightly red on top of foot and bruising on outer foot. Review of a telehealth progress note, dated 10/07/1 at 12:00 A.M. revealed nursing reported a large purple bump to the resident's shin. The nurse stated the resident was in excruciating pain and had concerns for blood clot. The nurse revealed the resident's foot was warm to touch with [CONDITION(S)] and [CONDITION(S)] noted. The resident was given Tylenol but it was ineffective. A one time dose of Oxycodone (narcotic [MEDICATION(S)]) 5 mg was administered. The nurse attempted to assess capillary refill and vital signs but nursing was concerned for the resident's pain at this time, therefore the resident was sent (to the hospital) for further evaluation. Review of a skin altercation report, dated 10/07/21 at 3:53 P.M. revealed (during a transfer) an STNA reported standing beside Resident #33 while a second STNA was lowering the resident into her motorized wheelchair. The report indicated the first STNA had placed one hand on the front of each lower extremity to assist with placement the in wheelchair. The resident yelled out and voiced her lower leg hurt. The STNA lowered the resident to leave her in a safe position and immediately called for nurse. Upon assessment by the nurse a four cm long by four cm wide bruise was observed to the resident's left lower leg with the bruising continuing to spread down her leg. A subsequent assessment revealed a bruise to the resident's left lower leg measured 24.0 cm in length by seven cm width at the time the resident was transferred to the local emergency room . The resident was admitted to the hospital. Review of a statement from Nurse Aide (NA) #506, revealed staff were lifting the resident up in the Hoyer pad to transfer her to her chair. The statement revealed during the transfer the staff separated the resident's legs and the resident instantly started to cry in pain after noticing bruising on her left shin. The statement indicated the staff stopped and put the resident down. The statement revealed the bruise continued getting bigger and bigger and the resident was still crying in pain. Review of the local hospital discharge instructions, dated 10/21/21 revealed the resident was hospitalized from 10/07/21 to 10/21/21 for a hematoma to her left lower leg. The resident required an incision and drainage surgical procedure and placement of a negative pressure wound vacuum to the wound for healing. Review of the resident's admission assessment, dated 10/21/21 revealed Resident #33 was readmitted to the facility with a surgical incision to her left lower leg measuring 22.0 cm in length by 21.0 cm width. Review of the resident's monthly physician's orders for November 2021 revealed an order, dated 11/01/21 to cleanse left lower leg wound with normal saline, pat dry, apply Xeroform and ABD pad, wrap with Kerlix and secure with medical tape every shift and as needed. On 10/25/21 at 12:43 P.M. interview with Resident #33 revealed staff hit her foot on the Hoyer causing a bruise and then again (on at later date) hit her leg on the Hoyer and she had to go to the hospital and have surgery. On 11/01/21 at 2:40 P.M. interview with NA #506 revealed Resident #33 required the use of a Hoyer lift for transfers. During the transfer on 11/07/21, NA #506 revealed the resident's legs were positioned on the right side of the Hoyer and they swung her whole body around so she would be on the left side of the Hoyer and when staff lowered her into the wheelchair, the resident started screaming, looked down and noticed a big purple bump growing rapidly. On 11/02/21 at 3:30 P.M. Licensed Practical Nurse (LPN) #304, LPN #453 and LPN #480 were observed providing the physician ordered treatment to Resident #33's left lower leg. The nurse set up the required supplies on a barrier on a bedside table. LPN #304 washed her hands and applied gloves. She placed a disposable chux under the resident's leg. LPN #304 removed the soiled dressing from the resident's left lower leg. The dressing was saturated with a blood tinged drainage. Then assessed the wound to measure 22.0 cm in length by 18.75 cm width with 0.5 cm depth with the wound bed reddish pink in color. The wound was covered with Xeroform, covered with ABD pad, wrapped with Kerlix and secured with tape. The facility failed to provide any additional information regarding the injury to Resident #33's left leg that occurred on 11/07/21 during staff care that required hospitalization and surgical intervention. Review of the facility policy titled, Hoyer Lift Transfer, dated 07/2018 revealed staff would follow procedure to assist and/or transfer residents in a safe manner to reduce the risk of injury to residents or staff. One person utilized and stabilized the lift while a second person guided and stabilized the resident. Guide the sling with the resident slowly and steadily, until over the surface the resident was being transferred to. Don't allow the sling with the resident to swing freely. 3. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including [CONDITION(S)] disorder, personal history of traumatic brain injury, [CONDITION(S)], hypertension, major depressive disorder, epileptic seizures, disorientation and repeated falls. Review of the plan of care, dated 05/14/21 revealed Resident #12 had potential for falls with history of falls at previous facility, impaired cognition communication and poor safety awareness. Interventions for Resident #12 included foot board to bed, perimeter mattress to bed, non-skid footwear while out of bed and to observe for side effects of [CONDITION(S)] medications. Resident #12's plan of care was revised on 07/13/21 to include encourage resident to walk to and from meals in dining areas. Resident #12's care plan was revised again on 10/23/21 to include resident to lay resident down after meals as tolerated. Review of the Fall Risk Evaluations for Resident #12, dated 07/13/21, 07/29/21 and 10/23/21 all indicated the resident was at high risk for falls. Additionally, Resident #12 was noted to have falls on 07/13/21 and 10/23/21. On 10/25/21 at 3:54 P.M. Resident #12 was observed to be asleep in bed A of his room, which was not the resident's bed. Resident #12 was observed to be wearing regular socks rather than non-skid socks and the call light was on the floor, not within the resident's reach. On 10/25/21 at 3:56 P.M. interview with STNA #485 confirmed Resident #12 was asleep in the wrong bed, wearing regular socks and without access to the call light. STNA #485 shared activities staff assisted Resident #12 in bed earlier and they must not have known which bed was his and did not ensure fall interventions were in place. On 10/27/21 at 8:45 A.M. Resident #12 was observed asleep in his wheelchair at the dining table, in the resident lounge with wearing non-skid socks. At 8:53 A.M. Resident #12 was observed away from the dining table with a gait belt around his waist, and wheeling himself to the hall. Agency STNA #539 was observed to ask Resident #12 where he was going. On 10/27/21 at 8:53 A.M. interview with Agency STNA #539 revealed she does not know what fall precautions should be in place for Resident #12. Agency STNA #539 revealed she assisted Resident #12 to walk the halls with his walker and gait belt, at times which helped with the resident's restlessness. Agency STNA #539 revealed they (she and the resident) had just finished walking a little while ago. Agency STNA #539 confirmed Resident #12 was not wearing non-skid socks and also confirmed she had not encouraged the resident to lay down following breakfast. 4. Review of the medical record for Resident #93 revealed an admitted [DATE]. Resident #93's diagnoses included [CONDITION(S)] disorder, coronary artery disease, muscle weakness, hypertension and repeated falls. Review of the plan of care, dated 04/16/21 revealed Resident #93 was at risk for falls related to cognitive communication deficits, not recognizing limitations, presence of [CONDITION(S)] medications, balance problems and incontinence of bowel and bladder. Interventions for Resident #93 included to ensure call light was within reach at all times, assist with transfers and monitor for side effects of [CONDITION(S)] medications. Review of the Fall Risk Evaluations, dated 04/16/21 and 07/16/21 revealed Resident #93 was at high risk for falls. Review of the quarterly MDS 3.0 assessment, dated 07/15/21 revealed Resident #93 required extensive assistance from one staff for bed mobility, transfers and toileting. On 10/25/21 at 10:20 A.M. Resident #93 was observed sitting in a chair near his bed. Resident #93 was observed to ask for help getting in bed. The call light was observed to be on the other side of the bed, resting on the floor and not in reach of Resident #93. On 10/25/21 at 11:35 A.M. Resident #93 was observed laying in bed and the call light was laying on the floor and not within reach of the resident. On 10/25/21 at 11:36 A.M. interview with Agency STNA #539 confirmed Resident #93's call light was on the floor and not within reach of the resident. Additional observations on 10/26/21 at 9:06 AM and 10:21 A.M. revealed Resident #93 was laying in bed and his call light was laying on the floor. On 10/26/21 at 10:21 A.M. interview with STNA #485 confirmed Resident #93's call light was on the floor and there was not clip on the call light to keep it near the resident. On 10/28/21 at 2:30 P.M. and on 11/01/21 at 10:30 A.M. Resident #93 was observed in bed with the call light on the floor. The resident had no access to the call light which was a fall risk intervention. On 11/01/21 at 10:30 A.M. interview with STNA #485 confirmed Resident #93's call light was on the floor and there was not a clip to enable to call light to attach the resident or the blanket. STNA #485 revealed she did know how to put in maintenance order and request a clip.

Based on observation, record review and interview the facility failed to ensure Resident #99, who was dependent on staff for activities of daily living (ADL) care (including toileting and personal hygiene) and had moisture associated skin damage (MASD) received timely and adequate incontinence care to promote optimal hygiene and skin integrity. Actual harm occurred on 08/02/21 when staff failed to provide timely incontinence care resulting in the resident being observed crying and begging staff to help her. Initial requests for assistance were not immediately provided to the resident resulting in a delay in treatment and sustained levels of pain voiced by the resident. This affected one resident (#99) of three sampled residents. Findings Include: Review of the medical record for Resident #99 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/20/21 revealed the resident had adequate hearing and vision, clear speech that was usually understood, and usually understood verbal communication. The resident was assessed to have moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of nine of 15. The assessment revealed the resident required total dependence from two or more staff for bed mobility and transfers and was totally dependent on one staff for dressing, toileting and personal hygiene. The assessment revealed the resident utilized a wheelchair for mobility, had a suprapubic (urinary) catheter and was always incontinent of bowel. A plan of care, dated 05/30/21 revealed the resident had a need for assistance with ADLs related to cognitive and communication deficits. Interventions included a geriatric chair when out of bed to correct posture when leaning, provide incontinence care with routine rounds and as needed (PRN). Resident #99 also had a plan of care which indicated she was incontinent of bowel and bladder. Interventions included providing incontinence care every two hours and as needed. A non-pressure skin grid, dated 07/27/21 revealed Resident #99 had MASD that had developed on 07/06/21 which the facility documented as healed as of 07/27/21. On 08/02/21 at 11:39 A.M. Resident #99 was observed in a chair sitting at the nurse's station verbalizing she wanted to lay down. The resident was heard verbalizing she was tired and had been up in chair since 6:30 A.M. The resident continued to vocalize crying and begging please help me and stating nobody will help me. At the time of the observation, Licensed Practical Nurse (LPN) #200 was observed standing at the nurses' station right in front of the resident. LPN #200's back was toward the resident. LPN #200 turned around and told the resident she would help Resident #99 shortly. On 08/02/21 at 11:45 A.M. Resident #99 remained up in the chair at the nurse's station and continued to cry out begging please. On 08/02/21 at 11:48 A.M. interview with LPN #200 revealed she was unsure what time staff had assisted Resident #99 out of bed and into the chair on this date. At the time of the interview, observation of Resident #99 revealed she continued to cry out stating, my (explicit) hurts so bad, help me, please put me cream on down there, please put cream on me, I'm in pain, On 08/02/21 at 11:54 A.M. Resident #99 continued to yell out in pain stating, if you don't hurry and put me in the bed, I'm going to throw myself, I don't care if I die, it hurts so bad, please help me, I hurt, I'm burning, I'm burning, help me please. On 08/02/21 at 11:55 A.M. (16 minutes after the surveyors initial observation), LPN #205 and LPN #99 were observed to assist Resident #99 to bed. At the time of the observation, interview with LPN #205 revealed she was not sure what time staff had assisted Resident #99 out of bed that A.M. or what time she had last been checked/changed for incontinence. On 08/02/21 at 11:58 A.M. interview with State tested Nursing Assistant (STNA) #207 revealed she had assisted with getting Resident #99 out of bed that morning and indicated it was at 7:30 A.M. During the interview, STNA #207 denied laying the resident down or checking her for incontinence since that time (over four hours earlier). The STNA later indicated she wasn't sure what time she had assisted with getting the resident out of bed, but that it was before breakfast (served at 8:30 A.M.) On 08/02/21 at 12:00 P.M. STNA #207 was observed providing incontinence care to Resident #99. The resident was observed screaming in pain during the procedure and was observed to have bright red pinpoint bleeding, reddened surrounding skin, and excoriated skin in between her thighs and buttocks. The resident had been incontinent of bowel. The resident begged for barrier cream to be applied stating she was in so much pain. The resident was observed to tighten all her muscles and was screaming out in pain while being cleansed with the washcloth. LPN #205, who was present in the room for the observation confirmed the condition of the resident's skin having pinpoint bleeding and excoriation. At the completion of care, Resident #99 remained in bed crying out in pain. On 08/03/21 at 2:10 P.M. interview with the Director of Nursing (DON) revealed it would not be appropriate for a resident to be left in bed or in their chair when they were requesting to get up or to lay down. On 08/09/21 at 11:42 A.M. interview with the DON revealed incontinent residents were checked and changed every two hours during rounds, as needed, upon request and per the resident's preference. This deficiency substantiates Complaint Number OH 357.

Based on observation, record review, interview with staff and a visitor, review of a facility Self-Reported Incident report (SRI) and review of the facility's abuse policy, the facility failed to ensure Resident #256 was free from physical abuse. This resulted in Immediate Jeopardy when Resident #256 was deliberately pushed so forcefully in her wheelchair by State tested Nursing Aide (STNA) #53, that the resident was ejected from her wheelchair, falling to the ground head first sustaining injury. This affected one of three residents reviewed for abuse (Resident #256). The facility census was 171. On 07/17/15 at 2:35 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 06/23/15 at approximately 5:30 P.M. when Resident #256, who was cognitively impaired and required extensive assistance from staff for wheelchair mobility, was pushed so forcefully in her wheelchair by STNA #53 that the resident was ejected out of her chair to the ground landing head first and sustaining a laceration above her left eye and a hematoma to the head. The incident was witnessed by Visitor #1 who alerted Registered Nurse (RN) #64 that the incident was deliberate, not accidental, and that STNA #53 was rough with Resident #256. The Immediate Jeopardy was removed on 07/19/15 when the facility initiated the following corrective actions: · On 07/17/15 and continuing through 07/18/15, the facility unit managers conducted resident interviews with residents on A hall with a Brief Interview for Mental Status (BIMS) score of 10 or greater and/or residents who presented with a level of understanding related to the allegation of abuse/neglect with negative findings. Residents on the unit with a BIMS score of less than 10 were monitored over a 24 hour period during this time period for signs of being at risk for abuse with systems in place to report, timely investigate and protect. · On 07/17/15 and continuing through 07/19/15, Staff Development Coordinator (SDC) #61 provided training for 46 RNs and licensed practical nurses (LPNs), 89 STNAs, 30 Dietary staff members, 1 business office manager, 4 social services staff members, 1 medical record staff member, 1 activity director, and 2 maintenance staff on the residents ' right to be free from abuse. As of 07/19/15, employees in the therapy department and housekeeping departments as well as one employee from the business office had not received this education. A plan was in place to ensure these staff would also receive training by the SDC #61. · On 07/17/15, SDC #61 implemented an education program for all new hires in the orientation program, and then at least quarterly, on residents' rights with freedom from abuse. In addition, all staff will be educated by SDC #61 on signs and symptoms of burnout and how to recognize this in coworkers, superiors, etc. This in-service will be conducted in orientation and on a quarterly basis. · On 07/17/15, the facility implemented a monitoring program to interview random residents and randomly monitor weekly through the next thirty days, and then bi-monthly for two months, and then at least quarterly thereafter. A summary of these interviews will be completed by the Staff Development Coordinator and/or designee and forwarded to the quality assurance performance initiative committee for further recommendations and/or to bring to resolution. Tracking and trending will be done and will be reported to the committee. · On 07/19/15 at 6:52 P.M., interview with the DON revealed no reports of abuse in the last 24 hours. · On 07/19/15 interview with STNAs #68, #204, #257 and #350 revealed they were knowledgeable of the facility's abuse policy and procedure. Although the Immediate Jeopardy was removed on 07/19/15, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for than minimal harm that is not Immediate Jeopardy) as not all staff had been educated regarding the facility's abuse policy, on-going random audits and interviews and monitoring by the facility to ensure that continued resident safety and provision of care for residents with an opportunity to express concerns could not be evaluated. Findings include: Review of the medical record for Resident #256 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders, dated 05/13/15, revealed the resident had an order for [REDACTED]. Review of a device assessment revealed an initial assessment for use of physical restraint, dated 05/15/15 which assessed the use of the lap buddy for positioning and to facilitate participation in activities. On 07/17/15 at 12:59 P.M., interview with RN #53 revealed Resident #256 never attempted to remove the lap buddy so the nurse did not know if the resident could independently remove it or not. Record review revealed a plan of care for activities of daily living (ADL) impairment, dated 05/26/15 indicated the resident was at risk for impairment because she required assistance to perform and complete ADL care, used assistive devices, and self-performance varied. The care planned interventions included if the resident refused care, do not attempt to force care, provide for safety and return at a later time to complete care and use two care givers as needed to provide safe care. Review of the plan of care for communication deficit, dated 05/26/15 indicated the resident was at risk due to problems making herself understood and problems understanding others due to dementia. Interventions included encouraging the resident to communicate and wait for responses, communicate with resident during routine care by speaking and interacting with the resident. A plan of care related to fall risk, dated 06/01/15, revealed an intervention to check placement of the resident's feet prior to pushing the wheelchair to prevent injury during transport. In addition, the fall prevention care plan stated lap buddy to wheelchair for positioning and help prevent falls, check placement every two (2) hours and as needed. Review of Resident #256's treatment administration record for June 2015 revealed from 06/01/15 to 06/23/15 staff documented the lap buddy placement was checked every 30 minutes. Review of Resident #256's nursing progress notes dated 06/12/15 at 2:00 A.M. revealed the resident was anxious and resisted care at times. The resident had an unsteady gait and propelled self in wheelchair. On 06/13/15 at 3:00 A.M. the resident was anxious and resisted care at times. The resident had an unsteady gait and used a wheelchair for mobility. On 06/16/15 at 2:00 A.M. the notes stated the resident resisted care at times, had an unsteady gait and was able to propel self in wheelchair. The note dated 06/17/15 revealed the resident resisted care. On 06/18/15 this resident ' s antipsychotic medication ([MEDICATION NAME]) was decreased. Review of the nursing note, dated 06/23/15 at 5:30 P.M. revealed Resident #256 was in a wheelchair propelled by staff in the dining room and leaned forward in the wheel chair and fell forward out of the wheel chair onto the floor. The resident had a laceration above the left eye and an area of indentation. The resident was assessed and the nurse noted the resident's pupils were sluggish to react, she moved all extremities, hand grasps were equal, and the resident was alert but confused. Ice was applied to the left forehead until paramedics arrived. The resident was transported to the emergency room via ambulance at 6:00 P.M. Review of the discharge MDS 3.0, dated 06/23/15 revealed the resident was discharged from the facility with a fall with major injury. Review of the initial emergency room report dated 06/24/15 at 7:50 A.M. revealed the resident had a cervical (C2) fracture and significant dementia. The note indicated she was not an operative candidate and would be admitted to the hospital. Subsequently this resident was transferred to larger hospital with a trauma unit. Review of the discharge summary, dated 06/24/15 at 2:13 P.M. from the trauma hospital revealed a computerized tomography scan (CT) of the neck showed a C2 fracture. Following a neurosurgeon consult with an additional CT scan revealed a healing fracture and no need for a cervical collar. During the investigation, the timing of when the cervical fracture had occurred could not be determined and it also could not be determined the fracture was a result of the fall sustained on 06/23/15. Review of the facility ' s SRI dated 06/24/15, revealed an allegation of neglect reported by Visitor #1. The report indicated on 06/23/15 at approximately 6:00 P.M., STNA #53 used improper technique while pushing Resident #256 in the wheelchair. The SRI indicated the incident resulted in Resident #256 sustaining a contusion/abrasion to the forehead with slight amount of bleeding noted. No other visual signs of injury were noted and the resident was transported to the emergency room for further neurology workup. As a result on an investigation, the facility concluded STNA #53 forcefully pushed Resident #256, neglected to check placement of Resident #256's feet and neglected to check the placement of the lab buddy to ensure it was positioned properly. Following the incident, STNA #53's employment was terminated. On 07/15/15 at 10:30 A.M., interview with STNA #75 revealed she was working on 06/23/15. STNA #75 stated, at around 5:30 P.M., she was in the A unit dining area feeding another resident when she heard a large noise and immediately ran to assist. She stated she found Resident #256, on the floor in the A unit dining room, lying face down on the ground, completely out of her wheelchair and described the scene as awful as there was blood everywhere. On 07/16/15 at 8:20 A.M. interview with Visitor #1 revealed she was feeding Resident #114 on 06/23/15 when she witnessed the incident between STNA #53 and Resident #256. She stated she saw that Resident #256 had a lap buddy in place, and the resident was bent over, reaching for her feet in the wheelchair. She stated this was between 5:15 P.M. and 5:45 P.M. STNA #53 was observed telling Resident #256 to raise up, so the STNA could take the resident to the dining room table to assist feeding her. She said a few times to the resident to raise up and attempted to physically pull the resident back, by pulling the wheel chair backward in an unsuccessful attempt to get the resident to return to an upright seated position. Visitor #1 said what caused her to actually look up was the STNA's voice was getting louder and she could tell the STNA was getting frustrated. The STNA then proceeded to push the resident forward really hard. The resident's legs bent under her wheelchair and the resident was described as catapulted out of her wheelchair, falling forward straight down to the ground. Visitor #1 indicated the lap buddy that was on the wheelchair came out due to the force used to push the resident. Visitor #1 described the loud sound of her head hitting the ground as a bowling ball hitting the floor. The resident was yelling and crying, blood was everywhere, and there was a huge goose egg on the resident ' s forehead. STNA #53 was heard saying she didn't know what happened and Visitor #1 told her to go get towels to apply pressure to the wound. The STNA went and got towels, but then went over and started to feed another resident and did not assist in the care of Resident #256. Visitor #1 said she reported to STNA #75 immediately after the incident that STNA #53 threw Resident #256 out of her wheelchair as she pushed her too hard. Visitor #1 said she also immediately reported the incident and what she saw to RN #64, telling the RN that this was not an accident, that STNA #53 pushed her too hard. Visitor #1 described STNA #53 as frequently harsh with residents and tended to lose patience with the residents easily. During interview with RN #64 on 07/15/15 at 9:35 A.M., the RN indicated she heard a scream and a thud on 06/23/15 at approximately 5:30 P.M. and saw STNA #53 behind the wheelchair and Resident #256 on the ground. RN #64 stated she could not believe the lap buddy did not keep the resident in the wheelchair. The RN saw Visitor #1 was visibly upset and acknowledged the visitor reported to her that STNA #53 was rough with Resident #256. RN #64 told Visitor #1 that if she thought it was serious that she needed to report it to the DON and Visitor #1 told her she would. Additional interview with RN #64 on 07/16/15 at 4:20 P.M. revealed STNA #53 routinely worked on the on the A unit (a secure dementia unit) and had worked on the unit prior to this RN starting work on this unit in August 2014. RN #64 stated after Resident #256 was ejected from her wheel chair STNA #53 went to a sink in the dining room, and then proceeded to feed another resident in the A unit dining room. RN #64 stated she thought STNA #53 just panicked as a result of Resident #256 ' s accident. RN #64 stated STNA #53 acted like nothing happened. During interview with the DON on 07/16/15 at 10:07 A.M., the DON revealed Visitor #1 reported to her on 06/23/15 at approximately 6:00 P.M., she observed STNA #53 forcefully push Resident #256 forward causing the resident to fall forward hitting her forehead on the floor. Visitor #1 reported to her during the conversation that she had witnessed STNA #53 push Resident #256 a little too hard on another occasion but did not report this to the facility staff. The DON stated the conversation with Visitor #1 lasted about 15 to 20 minutes and, following the conversation, the DON went to the unit, removed STNA #53 from her assignment and suspended the STNA until further investigation was completed. The DON confirmed the STNA had not worked since suspended and was subsequently terminated. Interview with the DON revealed the facility investigation of the incident involved interviews with RN #64, STNA #53, STNA #75 and Visitor #1. No other staff or residents with potential knowledge of the incident or prior knowledge of the care provided by STNA #53 were interviewed and the facility did not reassess the other residents residing on the same unit as Resident #256 for signs of potential abuse. During an interview with SDC #61 on 07/16/15 at 10:45 A.M., the coordinator revealed the last time staff received education related to the topic of abuse was on 03/10/15. Review of the abuse and neglect education sign in sheets revealed STNA #53 did not attend this training. Interview with the DON on 07/17/15 at 11:23 A.M. revealed STNA #53 last received abuse education on 01/12/15. Observation of Resident #256 on 07/17/15 at 10:59 A.M. revealed the resident was in the A unit dining room seated in a reclined geriatric chair. The resident was positioned with pillows and her feet were elevated. The resident had a small scabbed area above her left eye and her left temple area had a greenish/yellow bruised area. The resident had no purposeful movement, was mumbling, and her eyes were closed. An attempt to interview the resident resulted in no verbal, physical, or gestural response. The resident would mumble at times but not in response to questions. Review of the facility's abuse and neglect prevention policy and procedure, dated 01/01/2014, revealed residents had the right to be free from abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm or pain, or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The facility was to identify, correct, and intervene in situations in which abuse is more likely to occur including the supervision of staff for inappropriate behaviors such as rough handling. This deficiency substantiates Self Reported Incident Control Number OH 706.

Based on observation, resident interview, staff interview, review of the medical record, review of the policy and procedure for pain management, and review of the policy and procedure for oral examination, the facility failed to address a resident's dental pain by not following up with the dentist in a timely fashion and by not assessing and treating the resident's dental pain. This affected one of three residents reviewed for pain management (Resident #9). The facility identified 69 residents on pain management programs. Harm occurred when Resident #9 did not receive dental services and was not appropriately assessed and treated for [REDACTED]. Findings include: On 09/30/11 at 9:30 A.M., observation of Resident #9 revealed the two front upper teeth were discolored and jagged, and the teeth beside each front upper tooth revealed only a small portion of each tooth was left and was blackened in color. On 09/30/11 at 9:39 A.M., interview with Resident #9 revealed the resident had been scheduled a dental appointment at the facility on 10/05/11. On 09/04/11, Resident #9 had several pieces of his two front teeth break off. Resident #9 stated he had approached the facility on 09/06/11 to request to be seen by a dentist before the scheduled appointment on 10/05/11. Resident #9 then stated he had an appointment scheduled for 09/16/11 but when Resident #9 arrived at the dental appointment, the dental clinic refused to see him. Upon return to the facility, Resident #9 was informed he would have to wait until 10/05/11 to be seen for dental services. Resident #9 further stated he had dental pain every day which he requested [MEDICATION NAME] (pain medication) for and the [MEDICATION NAME] did relieve the pain but did not take the pain away entirely. On 09/28/11 at 10:00 A.M., review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the nursing evaluation dated 08/30/11 revealed Resident #9's oral assessment indicated the resident had caries and decay. Review of the Minimum Data Set (MDS) assessment on admitted d 09/06/11 revealed Resident #9 had an obvious or likely cavity or broken teeth. The assessment identified the resident had almost constant pain described as very severe. Review of the physician order [REDACTED]. Review of the history and physical dated 09/06/11 revealed Resident #9's front teeth were blackened and unusually shaped as if some parts had been broken off. Review of the plan of care dated 09/08/11 revealed a problem identified as altered oral mucous membrane related to broken, loose, and carious teeth with a goal identified as Resident #9 would have no reports of pain. The approach was identified as the facility would refer to dental as appropriate, monitor and report any symptom of pain or infection, and administer medications as needed Review of the progress note completed by Social Service (SS) Staff #50 on 09/09/11 revealed Resident #9 requested to see the dentist and did not want to wait for the appointment in October 2011 and an appointment was made on 09/16/11 to be seen at a dental clinic. Review of a nurse's note dated 09/16/11 revealed Resident #9 was out to a dental appointment and returned with no new orders. On 09/28/11 at 2:05 P.M., interview with SS Staff #50 revealed Resident #9 had approached her to request a dental appointment prior to 10/05/11 and indicated this was due to his teeth breaking off. SS Staff #50 stated an appointment was made for 09/16/11 but Resident #9 had been refused to be seen by the dental clinic after he arrived for the appointment and Resident #9 would be seen on 10/05/11 for dental services. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #9 was not assessed for the level of pain experienced prior to pain medication administration or the effectiveness of the pain medication on 20 occasions. The level of pain, when assessed, was documented on most occasions at a level 8 on a scale of one to ten and reduced to a level 4 after pain medication administration. Additionally, Resident #9 was not assessed for location of pain on 50 occasions out of the 51 occasions Resident #9 received [MEDICATION NAME]. There was no documented evidence of dental pain. On 09/29/11 at 12:40 P.M., interview with Licensed Practical Nurse (LPN) #52 revealed Resident #9 did complain of mouth pain on one occasion upon requesting [MEDICATION NAME] for pain management. On 09/30/11 at 10:30 A.M., review of the facility's policy and procedure for Oral Examination (dated 11/18/05) revealed the facility was to consult with the dentist as necessary for abnormalities noted and schedule an appointment if necessary. The facility was also to notify the physician of abnormalities noted and obtain new orders if applicable. On 09/30/11 at 10:35 A.M., review of the facility's policy and procedure for Pain Management (dated 04/28/09) revealed the procedure for pain management included the facility was to determine the characteristics of pain to include intensity and location of pain and monitor the effectiveness of the pain medication within an hour of medication administration. On 09/28/11 at 2:05 P.M., interview with SS Staff #50 verified Resident #9 did request to be seen by a dentist sooner than the visit when the dentist was scheduled to visit the facility on 10/05/11 since Resident #9 stated he had several teeth that had broken off and Resident #9 had not yet been seen by a dentist. On 09/28/11 at 3:39 P.M., interview with the director of nursing (DON) revealed Resident #9 received [MEDICATION NAME] on 51 occasions from 09/06/11 through 09/28/11 and on 50 occasions the location of pain was not assessed. Additionally, on 20 occasions the level of pain the resident was having prior to medication administration or the effectiveness of the pain medication after pain medication had been administered was not evaluated after the medication was administered. The DON verified when the level of pain had been assessed it was found to be a level eight and only reduced to a level four on most occasions.

Based on observation, resident interview, staff interview, review of the medical record, review of the policy and procedure for pain management, and review of the policy and procedure for oral examination, the facility failed to provide timely dental services for two of three residents reviewed for dental concerns (Residents #9 and #205). Harm occurred when Resident #9 did not receive dental services timely dental services, resulting in unrelieved mouth pain daily. Findings include: 1. On 09/30/11 at 9:30 A.M., observation of Resident #9 revealed the two front upper teeth were discolored and jagged, and the teeth beside each front upper tooth revealed only a small portion of each tooth was left and was blackened in color. On 09/30/11 at 9:39 A.M., interview with Resident #9 revealed the resident had been scheduled a dental appointment at the facility on 10/05/11. On 09/04/11, Resident #9 had several pieces of his two front teeth break off. Resident #9 stated he had approached the facility on 09/06/11 to request to be seen by a dentist before the scheduled appointment on 10/05/11. Resident #9 then stated he had an appointment scheduled for 09/16/11 but when Resident #9 arrived at the dental appointment, the dental clinic refused to see him. Upon return to the facility, Resident #9 was informed he would have to wait until 10/05/11 to be seen for dental services. Resident #9 further stated he had dental pain every day which he requested [MEDICATION NAME] (pain medication) for and the [MEDICATION NAME] did relieve the pain but did not take the pain away entirely. On 09/28/11 at 10:00 A.M., review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the nursing evaluation dated 08/30/11 revealed Resident #9's oral assessment indicated the resident had caries and decay. Review of the Minimum Data Set (MDS) assessment on admitted d 09/06/11 revealed Resident #9 had an obvious or likely cavity or broken teeth. The assessment identified the resident had almost constant pain described as very severe. Review of the physician order [REDACTED]. Review of the history and physical dated 09/06/11 revealed Resident #9's front teeth were blackened and unusually shaped as if some parts had been broken off. Review of the plan of care dated 09/08/11 revealed a problem identified as altered oral mucous membrane related to broken, loose, and carious teeth with a goal identified as Resident #9 would have no reports of pain. The approach was identified as the facility would refer to dental as appropriate, monitor and report any symptom of pain or infection, and administer medications as needed Review of the progress note completed by Social Service (SS) Staff #50 on 09/09/11 revealed Resident #9 requested to see the dentist and did not want to wait for the appointment in October 2011. An appointment was made on 09/16/11 to be seen at a dental clinic. Review of a nurse's note dated 09/16/11 revealed Resident #9 was out to a dental appointment and returned with no new orders. On 09/28/11 at 2:05 P.M., interview with SS Staff #50 revealed Resident #9 had approached her to request a dental appointment prior to 10/05/11 and indicated this was due to his teeth breaking off. SS Staff #50 stated an appointment was made for 09/16/11 but Resident #9 had been refused to be seen by the dental clinic after he arrived for the appointment and Resident #9 would be seen on 10/05/11 for dental services. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The level of pain when assessed was documented on most occasions at a level 8 on a scale of one to ten and reduced to a level 4 after pain medication administration. Additionally, Resident #9 was not assessed for location of pain on 50 occasions out of the 51 occasions Resident #9 received Vidodin. There was no documented evidence of dental pain. On 09/29/11 at 12:40 P.M., interview with Licensed Practical Nurse (LPN) #52 revealed Resident #9 did complain of mouth pain on one occasion upon requesting [MEDICATION NAME] for pain management. On 09/30/11 at 10:30 A.M., review of the facility's policy and procedure for oral examination dated 11/18/05 revealed the facility was to consult with the dentist as necessary for abnormalities noted and schedule an appointment if necessary. The facility was also to notify the physician of abnormalities noted and obtain new orders if applicable. On 09/30/11 at 10:35 A.M., review of the facility's policy and procedure for Pain Management (dated 04/28/09) revealed the procedure for pain management included the facility was to determine the characteristics of pain to include intensity and location of pain and monitor the effectiveness of the pain medication within an hour of medication administration. On 09/28/11 at 2:05 P.M., interview with SS Staff #50 verified Resident #9 did request to be seen by a dentist sooner than the visit when the dentist was scheduled to visit the facility on 10/05/11. SS Staff #50 verified Resident #9 stated he had several teeth that had broken off and Resident #9 had not yet been seen by a dentist. On 09/28/11 at 3:39 P.M., interview with the director of nursing (DON) revealed Resident #9 received [MEDICATION NAME] on 51 occasions from 09/06/11 through 09/28/11. On 50 occasions the location of pain was not assessed. Additionally, the DON verified on 20 occasions the level of pain the resident was having prior to medication administration or the effectiveness of the pain medication after pain medication had been administered was not evaluated after the medication was administered. The DON verified when the level of pain had been assessed it was found to be a level eight and only reduced to a level four on most occasions. 2. Review of Resident #205's medical record revealed the Minimum Data Set (MDS) assessment dated [DATE] identified the resident had loose fitting dentures. Review of the nursing assessment dated [DATE] revealed the dentures section was left blank. The plan of care dated 01/19/11 revealed the resident was at nutritional risk, at risk for dehydration and depression related to poor fitting dentures. The intervention was to refer to the dentist as needed. The Care Area Assessment Summary revealed dental care was triggered due to the loose fitting dentures and the area was to be addressed on the plan of care. On 09/28/11 at 1:50 P.M., interview with the Director of Nursing (DON) revealed the social service notes indicated Resident #205 was offered ancillary services and declined the services. The DON stated she was unable to find specific information regarding dental and the loose fitting dentures or if anyone discussed this specifically with her. On 09/28/11 at 1:00 P.M., interview with Registered Nurse (RN) #53 revealed she added Resident #205 to "the book" for dental services after identifying the loose fitting dentures and the social services staff scheduled the resident to see the dentist. There was no evidence provided the resident had been referred to the dentist or that the resident had refused such services. On 09/28/11 at 2:00 P.M., interview with Social Service Director #50 revealed the social services notes revealed she didn't meet with the family on some of the care conferences and documented no referrals on 04/14/11. She stated referrals could mean dental, podiatrist, vision or psychiatric. On 07/18/11, the notes stated reviewed ancillary services, no referrals. She stated they have a book at the nurses' station and any staff member can make a referral to the dentist. She stated there was no referral made after the resident was identified to have loose fitting dentures in January 2011.