Every finding on record at Embassy of Woodview

Based on observations and staff interviews the facility failed to provide a safe, sanitary, and comfortable environment for residents, staff, and the public. This had the potential to affect all residents who reside in the facility. The census was 64. Findings include: Observation of the facility on 07/27/26 from 8:15 A.M. to 8:45 A.M. with the Administrator revealed the following: 1) On the Short Coral/West Wing in front of room [ROOM NUMBER] there was an infection control bin outside the doorway; and on the floor beside the bin was a bunched up pile of medical gloves with employees walking past the area. 2) On the Long Coral/West Wing there were two pairs of medical gloves on the floor between the rooms [ROOM NUMBERS].3) Observation of Resident #200's room, revealed the resident sitting in a chair eating her breakfast and there was a 10 inch 10 inch round dried up orange, brown like substance under her feet on the floor. Resident #200 stated it was betadine solution that was spilled from a treatment she received on her feet the day before and no one cleaned the floor.4) Resident #205 was observed in her bed and a dirty white blanket, white sheet and incontinence pad lying on the floor at the end of her bed. 5) On the Long Green/East Wing in front of rooms #214 and #215 there was a trail of spilled coffee in the hallway. During an interview on 07/27/26 at 8:45 A.M., the Administrator verified the findings observed during the initial tour. Interview on 07/27/26 at 9:00 A.M., Housekeeping Director #102 stated the housekeepers have a daily schedule to ensure the facility's common areas, residents' rooms and hallways are cleaned daily and as needed. Housekeeping Director #102 stated it was the responsibility of the staff the inform the department when immediate assistance was needed . This deficiency represents non-compliance investigated under Complaint Number 3107033. This is an example of continued non-compliance from the survey date 07/20/26.

Based on observation, interview, and record review, the facility failed to ensure Resident #31's bathroom was clean; the facility failed to ensure a packaged terminal air conditional (PTAC) was functional in Resident #2's room; and the facility failed to ensure the hallway floor was clean between rooms [ROOM NUMBERS]. This affected two (Resident #31 and #2) and had the potential to affect all residents residing in the facility. The facility census was 68. Findings include: 1. Interview with Resident #31 occurred between 11:15 A.M. and 11:22 A.M on 07/13/26 in the resident's room. Resident #31 stated the bathroom was dirty and confirmed it was bothersome to her. Observation of Resident #31's bathroom was conducted between 11:15 A.M. and 11:22 A.M on 07/13/26. There were multiple reddish-brown stains and visible dirt on the bathroom floor. Interview with the Director of Maintenance (DM) #328 was conducted at 12:31 P.M. on 07/13/26 in Resident #31's room. DM #328 observed the bathroom floor and confirmed the reddish-brown staining and visible dirt. 2. Observation and interview on 07/13/26 at 10:30 A.M. with Resident #2 stated there was water on the floor from the packaged terminal air conditioner (P-TAC) on the wall under the window. There were several white blankets under the P-TAC unit soaking up dripping water from unit. Interview on 07/13/26 at 10:35 A.M. with Maintenance Director (MD) #328 verified Resident #2 had blankets under her P-TAC unit in her room soaking up dripping water from P-TAC unit. MD #328 also verified that there was a cable outlet, that was hanging off the wall in Resident #2 room by her television. MD #328 stated it was not connected to electric but was an eye-soar looking at it. Observation and interview on 07/14/26 at 3:48 P.M. with Resident #2 who had two blankets on the floor at P-TAC unit. Licensed Practical Nurse (LPN) #341 verified the yellow and white blankets were saturated with water, under the P-TAC unit in Resident #2 room. Observation and interview on 07/15/26 at 8:15 A.M. with Certified Nurse Aid (CNA) #349 verified there was a yellow blanket, and it was on the floor under the air conditioning unit in Resident #02 room soaked in water. 3. Observation of the facility on 07/13/26 from 10:13 A.M. to 10:16 A.M. revealed that the floor in the hallway from room [ROOM NUMBER] to 222 had over 20 dried spill marks spread all over the floor. Interview with Licensed Practical Nurse (LPN) #149 on 07/14/2026 at 10:16 A.M. revealed that there were over 20 dried spill marks spread throughout the hallway floor from rooms 200 to 222. Interview with Housekeeper #136 on 07/13/2026 at 10:16 A.M. revealed that the floor had coffee that was spilled and dried on the floor due to residents spilling their drinks while walking in the hall. Housekeeper #136 stated it should not have been left this long. Review of the facility policy titled, Routine Cleaning and Disinfection, (revised 10/01/22) states that routine cleaning and disinfection of frequently touched or visible soiled surfaces will be performed in resident rooms. The policy states the facility will ensure the provision of routine cleaning in order to provide a safe, sanitary environment. This deficiency represents non-compliance investigated under Complaint Numbers 3091777, 3053671, 3074181, 2983827, 2808181, 2806310, 2806222, 2800143, 3015985, 2980228, 2967824, and 2790656.

Based on record review and interview, the facility failed to staff a Registered Nurse (RN) for at least 8 hours a day and 7 days a week. This deficiency had the potential to affect all 68 residents. The facility census was 68.Findings include: Review of the staffing schedule for 06/27/26 revealed RN #110 was scheduled to work 7:00 A.M. to 7:00 P.M. Review of the Payroll Based Journal (PBJ) date revealed no evidence RN #110 or any other RN was scheduled to work 06/27/26. Interview on 07/20/26 at 3:32 P.M. with Human Resources Regional Manager (HRRM) #219 verified there was no evidence of RN #110 or any other RN working on 06/27/26. Review of the Facility Assessment approved by the Administrator on 03/04/26 stated one to six RNs were necessary to care for facility residents per day. This deficiency represents non-compliance investigated under Complaint Numbers 2982837, 2806222, and 2800143.

Based on observation, interview, and record review, the facility failed to maintain a water heater to ensure residents had access to hot water. This affected all residents residing on the coral area of the facility (Residents #3, #4, #5, #6, #8, #12, #13, #14, #15, #17, #18, #20, #23, #26, #27, #28, #29, #30, #31, #35, #36, #38, #40, #43, #47, #48, #51, #52, #54, #60, #64, #65, #81, and #82). The facility census was 68. Findings include: Interview with Resident #31 occurred between 11:15 A.M. and 11:22 A.M on 07/13/26 in the resident's room. Resident #31 stated that the bathroom did not have hot water. Interview with the Director of Maintenance (DM) #328 was conducted at 12:25 P.M. on 07/13/26. DM #328 confirmed that the hot water heater servicing the coral side of the building (about half the residents' rooms) was out. DM #328 did not know exactly how long the hot water heater had been out, but knew it had been out since DM #328 started their job about 4 weeks ago. Observation was conducted with DM #328 in two resident rooms to confirm the hot water outage on the coral side of the building. Hot water temperature reading was conducted at 12:31 P.M. on 07/13/26 in the bathroom faucet of room [ROOM NUMBER] and registered 84 degrees Fahrenheit. Likewise, hot water temperature reading was conducted at 12:35 P.M. on 07/13/26 in the bathroom faucet of room [ROOM NUMBER] registered 84 degrees Fahrenheit. Interview with DM #328 during that time confirmed hot water temperature reading in both rooms. Interview with Regional Director (RD) #201 was conducted at 11:08 A.M. on 07/14/26. At that time, RD #201 provided a handwritten timeline of the hot water heater outage. RD #201 confirmed that a problem with the hot water heater was identified 03/09/26. RD #201 confirmed there is no evidence of action from the procurement team on a new water heater between 03/09/26 and 06/06/26. RD #201 confirmed a new tank had been ordered. Review of an email from Plumbing Company #1 to the facility dated 07/13/25 stated install for the new water heater was slated for 07/15/26. Observation on 07/15/26 at 9:37 A.M. confirmed work to install the new water heater. Review of the facility policy titled, Resident Environmental Quality, (revised 11/29/22) states the facility (will) be equipped and maintained to provide a safe, function, and comfortable environment to residents. The policy states all essential mechanical and patient care equipment will be maintained in safe operating condition. This deficiency represents non-compliance under Complaint Number 3067976, 2983827, 2971306, 2808181, 2800685, and 2790656.

Based on observation, interview, and record review, the facility failed to maintain sanitary food services. This had the potential to affect 68 residents who eat food from the kitchen. The facility census was 68.Findings include: 1. Observation of the kitchen occurred between 8:27 A.M. and 9:03 A.M. on 07/13/26. Observation of the walk-in refrigerator revealed a number of containers with opened items that were not labeled with an open or use by date. These items included cheese sauce, mashed potatoes, beef Stroganov, diced onions, shredded cheddar cheese, and sliced tomatoes. Interview with [NAME] #140 occurred at 8:44 A.M. on 07/13/26. [NAME] #140 confirmed containers of cheese sauce, mashed potatoes, beef Stroganov, diced onions, shredded cheddar cheese, and sliced tomatoes were open and undated. [NAME] #140 stated open items in the fridge should have a 7 day expiration. Additionally, observation of three bins of cereal were stored on a stainless steel countertop. A bin of cheerios and a bin of corn flakes were labeled as a use by date of 04/19/26. Interview with [NAME] #140 occurred at 9:00 A.M. on 07/13/26. [NAME] #140 confirmed the use by date on the two cereal bins was 04/19/26 and stated the cereal should be dated for 30 days (after opening.) Review of the facility policy titled, Dating for Food Storage, (undated) states all foods that require temperature control should be labeled with the name of the food, date container was open, and the use by date. The policy further states that if an item is shelf stable and is removed from its original packaging, use the standard storage guidelines established by the USDA for determining the length of time a shelf stable item can remain in dry storage. 2. Observation of the kitchen dry storage room occurred between 8:50 A.M. and 8:59 A.M. on 07/13/26. Visible caked on dirt was on the floor in the kitchen dry storage room and in the hallway from the kitchen to the dry storage room in front of the chemical storage door. Interview with [NAME] #140 occurred at 8:59 A.M. on 07/13/26. [NAME] #140 confirmed the caked on dirt on the floor of the kitchen dry storage room and the hallway from the kitchen to the dry storage room in front of the chemical storage door. [NAME] #140 stated a new floor was needed. A document provided by the facility titled, Infection Control Overview, (undated) states that infection control in the Food and Nutrition Services Department shall be maintained and monitored to promote food safety and prevent foodborne illness. 3. Observation of the kitchen dry storage room occurred between 8:50 A.M. and 8:59 A.M. on 07/13/26. Two containers of chemicals were stored among food items in kitchen dry storage room. The items were a box of Sanitize RTU food contact sanitizer and a bucket of SparClean high temp rinse aid. Interview with [NAME] #140 occurred at 8:59 A.M. on 07/13/26. [NAME] #140 confirmed the storage of the two chemicals in the in kitchen dry storage room. [NAME] #140 stated these chemicals should be stored in the chemical closet. Review of the U.S. Food and Drug Administration Food Code states poisonous or toxic materials shall be stored so they cannot contaminate food (7-201.11 Separation.) 4. Observation of the residential refrigerator located in the central lounge was conducted between 8:36 A.M. and 8:49 A.M. on 07/14/26. A sign on the outside of the refrigerator states refrigerators are to be cleaned out every Friday. Inside the refrigerator was a 2% gallon of milk labeled for Resident #20 and dated with an expiration date of 06/22/26. Also inside the refrigerator was a red velvet cake with no resident name labeled with an expiration of 07/11/26. Also inside the refrigerator was a Burger King bag and a Kentucky Fried Chicken bag, neither of which was labeled with a name or date. Interview with Licensed Practical Nurse (LPN) #155 was conducted at 8:45 A.M. on 07/14/26. LPN #155 confirmed the presence of expired milk and cake in the fridge as well as the unlabeled Burger King and Kentucky Fried Chicken bags. Review of the policy titled, Food Brought by Family/Visitors, (revised 6/18) states residents and families are asked that containers be labeled with the resident's name, the item, and the date. The policy states the resident / family is responsible for maintaining the foods in the refrigerator and discarding perishable foods that are past their use by or expiration date or that are visibly rotten on rotting. The nursing or housekeeping staff will discard such foods when not done so by the resident or family. This deficiency represents noncompliance investigated under Complaint Number 2806222.

Based on record reviews, observations, interviews, and facility policies, the facility failed to ensure staff practiced hand hygiene. This affected two (Residents #7 and #62); The facility failed to have signage posted for residents on enhanced barrier precautions. This affected two (Resident #4 and #11); The facility failed to ensure a nurse wore a gown during wound care for a resident on enhanced barrier precautions. This affected one (Resident #67); The facility failed to ensure a catheter bag was off the floor to prevent contamination. This affected one (Resident #12). This deficient practice affected six (Residents #7, #62, #4, #11, #67, and #12) of six residents reviewed for infection control. The facility census was 68. Findings include: 1. Observation on 07/15/26 from 8:24 A.M. through 8:26 A.M. revealed Certified Nurse Aide (CNA) #112 entered Resident #7's room to set her up in bed. CNA #112 practiced hand hygiene. CNA #112 asked CNA #128 to help him reposition Resident #7 in her bed, to help her sit up better. CNA #128 did not perform hand hygiene before entering Resident #7's room. CNA #128 did not apply gloves on her hands. CNA #128 repositioned Resident #7 in bed, touched her linens, and repositioned her in bed. CNA #128 then left Resident #7's room, and never practiced hand hygiene. CNA #128 then took a meal tray from the metal food bin with her bare hands and entered Resident #62's room. CNA #128 never practiced hand hygiene. CNA #128 moved personal items on Resident #62's bedside table and placed her meal tray on her bedside table. CNA #128 set up Resident #62's meal tray, by opening the meal lid, and arranging her meal tray. CNA #128 then left Resident #62's room and never practiced hand hygiene. Interview on 07/15/26 at 8:27 A.M. CNA #128 verified she never practiced hand hygiene before or after Resident #7's room. CNA #128 verified that she touched Resident #7's bed linens and repositioned her in the bed. CNA #128 verified she got Resident #62's meal tray off the metal food bin and took it to Resident #62's room. CNA #128 verified that she set up Resident #62's meal tray on her bedside table after moving personal items on her table. 2. Review of the medical record for Resident #04 revealed an admission date of 06/25/26 with diagnoses including but not limited to injury of unspecified body region, type two diabetes, and spinal stenosis. Review of the Minimum Data Set (MDS) assessment, dated 06/20/26, revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Review of Resident #04's orders revealed an order for wound care and an order for intravenous solutions. The resident did not have an active order for Enhanced Barrier Precautions (EBP). Review of the Care Plan for Resident #04, initiated 06/25/26, revealed an intervention to maintain EBP per facility protocol. Observation made on 07/13/26 at 8:22 A.M. revealed Resident #04 had a tote of protective equipment outside of his room, including gloves and gowns. Observation further revealed the resident did not have signage on his door for EBP. Interview on 07/13/26 at 11:35 A.M. with CNA #131 revealed staff wear gloves and gowns when providing care to Resident #04 but was unable to confirm whether the resident was on EBP. 3. Review of the medical record for Resident #11 revealed an admission date of 06/13/26 with diagnoses including, but not limited to anoxic brain damage, chronic respiratory failure, and dysphagia. Review of the MDS assessment dated [DATE], revealed the resident's BIMS was unable to be obtained due to the resident being rarely or never understood, and further indicated the resident had a severe cognitive impairment. Review of Resident #11's physician's orders revealed an active order dated 06/15/26 for an eternal tube feeding. Additionally, the resident had an active order dated 06/18/26 for cleaning the gastric tube site. Review of the Care Plan for Resident #11, initiated 06/13/26, revealed an intervention for EBP as indicated. Observation on 07/14/26 at 9:30 A.M. revealed Resident #11 did not have a sign on his door for EBP. Interview on 07/14/26 at 9:31 A.M. with CNA #112 confirmed Resident #11 had a gastric tube, had intravenous fluids hanging in his room, and did not have EBP signage on his door. A second observation was made on 07/15/26 at 9:38 A.M. revealed the resident did not have signage for EBP. Interview on 07/15/26 at 9:38 A.M. with CNA #121 confirmed the resident had a gastric tube and confirmed the resident did not have EBP signage. Review of the facility policy titled, 'Enhanced Barrier Precautions,' dated 07/13/22 revealed an order for EBP will be obtained for residents with wounds and/or indwelling medical devices. Additionally, the policy states clear signage will be posted on the door or wall outside of the resident's room indicating the type of precautions. 4. Record review of Resident #67 revealed an admission date of 05/08/26 with diagnoses that include but are not limited to Major Depressive Disorder, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease. Review of the MDS assessment dated [DATE] revealed a BIMS score of six, indicating the resident was cognitively impaired. Review of Resident #67's physician orders revealed an order for EBP due to wound care. Observation of wound dressing changes for Resident #67 on 07/16/26 at 10:33 A.M. revealed Licensed Practical Nurse (LPN) #153 did not wear a gown. Review of the policy titled, Enhanced Barrier Precautions, last reviewed 07/13/22 revealed that EBP are to be ordered and implemented for high-contact resident care activities including wound care: any skin opening requiring a dressing. 5. Resident #12 was admitted to the facility on [DATE] and had diagnoses that included benign prostatic hyperplasia, obstructive and reflux uropathy and chronic kidney disease. Review of the MDS assessment dated [DATE] indicated the resident was cognitively intact. Review of the care plan for Resident #12 revealed the resident was at risk for potential complications of catheter related trauma and urinary tract infection related to the use of a foley catheter used of obstructive uropathy. Observation of Resident #12 was conducted between 10:38 A.M. and 10:48 A.M. on 07/14/26 in Resident #12's room. Resident #12's catheter bag was uncovered on the floor under a walker. Resident #12 rang the call light for assistance. Interview with Regional Registered Nurse (RRN) #205 was conducted at 10:58 A.M. on 07/14/26 when RRN #205 responded to the call light. RRN #205 confirmed that the urinary catheter drainage bag was uncovered on the floor and stated it should be affixed to an unmovable part of the bed. Review of the facility policy titled Catheter Care (revised 6/1/24) states that residents with indwelling catheters (will) receive appropriate catheter care. Review of the Association for Professionals in Infection Control and Epidemiology (APIC) guideline for Preventing Catheter- Associated Urinary Tract Infections (03/2025) states to keep the catheter drainage bag off the floor to prevent a backflow of urine which increases the risk of infection. Findings include: Review of the staffing schedule for 06/27/26 revealed RN #110 was scheduled to work 7:00 A.M. to 7:00 P.M. Review of the Payroll Based Journal (PBJ) date revealed no evidence RN #110 or any other RN was scheduled to work 06/27/26. Interview on 07/20/26 at 3:32 P.M. with Human Resources Regional Manager (HRRM) #219 verified there was no evidence of RN #110 or any other RN working on 06/27/26. Review of the Facility Assessment approved by the Administrator on 03/04/26 stated one to six RNs were necessary to care for facility residents per day. This deficiency represents non-compliance investigated under Complaint Number 2800143, and 2790656.

Based on medical record review, Self-Reported Incidents (SRI) review, interviews, and facility policy, the facility failed to complete thorough investigations following allegations of abuse. This affected four residents (#01, #73, #88, and #89) of four residents reviewed for abuse. The facility census was 68. Findings include:1. Review of SRI dated 06/25/26 revealed an allegation of neglect/mistreatment to Resident #01. Review of the investigation revealed no interviews with interviewable residents within the facility and no skin checks for residents who were unable to be interviewed. Interview on 07/20/26 at 2:06 P.M. with the Regional Administrator confirmed there were no interviews or skin checks for residents included in the SRI investigation. The Regional Administrator was unable to provide further documentation during the survey process. 2. Review of SRI dated 03/09/26 revealed an allegation of physical abuse to Resident #73. Review of the investigation revealed no staff education for physical abuse. Interview on 07/20/26 at 2:06 P.M. with the Regional Administrator confirmed there was no staff education on abuse following the abuse allegation involving Resident #73. The regional administrator was unable to provide further documentation during the survey process. 3. Review of SRI dated 01/21/26 revealed an allegation of physical abuse to Resident #88. Review of the investigation revealed no skin assessments completed for residents in the facility who were unable to be interviewed. Interview on 07/20/26 at 2:06 P.M. with the Regional Administrator confirmed there was no skin checks to other residents. The Regional Administrator was unable to provide further documentation during the survey process. 4. Review of SRI dated 06/25/26 revealed an allegation of neglect/mistreatment to Resident #89. Review of the investigation revealed no interviews with interviewable residents within the facility and no skin checks for residents who were unable to be interviewed. Interview on 07/20/26 at 2:06 P.M. with the Regional Administrator confirmed there were no interviews or skin checks for residents included in the SRI investigation. The Regional Administrator was unable to provide further documentation during the survey process. Review of the facility policy titled 'Abuse, Neglect, and Exploitation, revised 11/25/25, revealed written procedures for the investigation include identifying and interviewing all involved persons including others who might have knowledge of the allegations and providing complete and thorough documentation of the investigation. Staff will receive annual education through planned in-services and as needed. In addition, the facility policy revealed the facility will take all necessary actions as a result of the investigation including training staff on changes made and demonstration of staff competency following the training. This deficiency represents non-compliance investigated under Complaint Numbers 2790656 and 2808181.

Based on observation, interview, record review, and policy review, the facility failed to ensure staff accompanied residents to smoking. This affected two (Residents #35 and #32) of three residents observed for smoking. The facility census was 68. Findings include: 1. Resident #35 was admitted to the facility on [DATE] and had diagnoses that included type 2 diabetes mellitus, alcohol dependance, and dementia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #35's care plan (revised 06/25/26) revealed the resident was non-compliant with the facility smoking policy and staff were directed to report any behaviors that could affect other residents. The care plan further stated Resident #35 was a potential hazard related to smoking and that, while smoking, the resident will have supervision by staff or a family member. Observation of Resident #35 was conducted at 4:26 P.M. on 07/13/26. Resident #35 was seated outside in the courtyard by the sliding glass door of the central lounge. Resident #35 was smoking with a cigarette in his right hand and was unsupervised. Interview was conducted with Certified Nursing Assistant (CNA) #150 at 4:26 P.M. on 07/13/26. CNA #150 witnessed Resident #35 in the courtyard and confirmed the resident was smoking and was not supervised. CNA #150 stated the resident does that sometimes. A second observation of Resident #35 was conducted at 8:19 A.M. on 07/14/26. Resident #35 was seated outside in the courtyard by the sliding glass door of the central lounge. Resident #35 was smoking with a cigarette in his right hand and was unsupervised. Interview was conducted with Licensed Practical Nurse (LPN) #335 at 8:19 A.M. on 07/14/26. LPN #335 witnessed Resident #35 in the courtyard and confirmed the resident was smoking and was not supervised. LPN #335 stated Resident #35 is non-compliant with the smoking policy. 2. Review of the medical record for Resident #32 revealed an admission date of 06/01/26. Diagnoses included schizophrenia, altered mental status, and nicotine dependence with cigarettes. Review of the care plan dated 06/23/26 revealed Resident #32 was noncompliant in care and will hide used cigarette butts to smoke later. Review of the facility document titled, Smoking Evaluation, dated 06/24/26 revealed Resident #32 required supervision when smoking. Resident #32 was cognitively impaired. Review of the care plan dated 06/25/26 revealed Resident #32 had potential for safety hazards or injury related to smoking. Resident #32 was able to smoke with supervision by staff or family. Interventions included explain that smoking was to be done in designated area only, no smoking inside the facility, family and visitors will be informed of the facility smoking policy, notify management if resident was observed being unsafe during smoking, observe clothing for burn holes, educate resident and encourage resident to stop smoking, provide a copy of facility smoking policy, resident family will provide their own cigarettes, and smoking materials to be returned to nurse's station. Observation on 07/13/26 at 9:00 A.M. revealed the facility had a garden with two patios enclosed in the center of the facility. Resident #32 was smoking unsupervised. Interview on 07/13/26 at 9:10 A.M. with Certified Nurse Aid (CNA) #349 verified that Resident #32 was smoking outside with no supervision. Interview on 07/20/26 at 1:00 P.M. with Mobile Director of Nursing (MDON) #328 stated some residents were noncompliant and smoked without staff. All residents at the facility were supposed to be supervised by staff. Review of the facility policy titled, Resident Smoking, (revised 01/16/25) states that all safe smoking measures will be documented in the resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. This policy is to provide a safe and healthy environment for residents, visitors, and employees. This deficiency represents noncompliance investigated under Complaint Numbers 2983827 and 2806222.

Based on record review, interview and observation the facility failed to ensure weekly skin assessments were completed as ordered to potentially prevent pressure ulcers. This affected one resident (#57) of four residents reviewed for pressure ulcers. The census was 68. Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses that include but are not limited to acute respiratory failure with hypoxia, obesity and acute kidney failure with acute cortical necrosis. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Review of physician orders for Resident #57 revealed an order for skin observations every night shift every Monday and Triad Paste to be applied to the buttocks as a preventative skin measure every shift. Review of the skin assessments document for Resident #57 revealed no skin assessments were completed between 03/06/26 and 03/31/26. The skin assessment dated [DATE] revealed a stage three pressure ulcer on the left buttock had been identified. Review of the progress notes for Resident #57 revealed that on 03/31/2026 while performing wound rounds, the CNP discovered a new pressure injury to patient's left buttock. The wound was treated and new orders were implemented. Interview with Resident #57 on 07/20/26 at 9:35 A.M. revealed that staff were not completing skin checks as ordered. Interview with Wound Nurse #221 on 07/20/26 at 11:00 A.M. revealed that the pressure ulcer was not reported until 03/31/26 and it was a stage three upon the initial assessment. Wound Nurse #221 verified weekly skin assessments were not completed as ordered. Review of policy titled Pressure Injury Prevention and Management last reviewed on 01/08/2025 revealed that licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission and weekly. Findings will be documented in the medical record. This deficiency represents non-compliance investigated under Complaint Numbers 3072001, 2808181, 2800685, 2806310, 3030196, 2980228, 2983827, 2806222 and 2806505.

Based on medical record review and staff interview, the facility failed to complete weekly skin assessments as ordered. This affected one (Resident #48) of three residents reviewed for skin. The facility census was 68. Findings include: Resident #48 was admitted to the facility 02/07/26 and had diagnoses that included anxiety disorder, morbid obesity, and chronic obstructive pulmonary disease (COPD.) Review of the MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of the medical record for Resident #48 revealed an order written on 02/09/26 for skin observation weekly on Wednesday. Review of the assessments record for Resident #48 found no skin assessments between 04/15/26 and 06/18/26. Interview was conducted with Licensed Practical Nurse (LPN) #335 at 9:57 A.M. on 07/16/26. LPN confirmed there were no skin assessments recorded on the assessments tab (of the electronic medical record) between 04/15/26 and 06/18/26. This deficiency represents non-compliance investigated under Complaint Numbers 3072001, 2980228, 2983827, and 2806222.

Based on medical record review, review of care conferences, and interviews, the facility failed to complete care conferences quarterly. Additionally, the facility failed to ensure care plans reflected a resident's current status. This affected one (Resident #05) of one resident reviewed for care planning. The facility census was 68. Findings include:Review of the medical record for Resident #05 revealed an admission date of 04/22/26 with diagnoses including, but not limited to, acute cerebrovascular insufficiency, post-traumatic stress disorder, and depression. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 11, identifying Resident #05 as having a moderate cognitive impairment. Review of the care conferences for Resident #05 revealed care conference dates of 10/13/25, 02/05/26, and 07/02/26, and further revealed four months between the first and second care conference and five months between the second and third care conference. Interview on 07/16/26 at 1:50 P.M. with Social Services #211 revealed care conferences with residents are to be completed every three months/quarterly. Social Services #211 confirmed Resident #05 has not been receiving care conferences every three months/quarterly. Review of the facility document titled, Smoking Evaluation, dated 06/22/26 revealed Resident #5 smoked and required supervision for smoking. Review of the care plan dated 02/13/26 revealed no goals or interventions in place for smoking. Observation on 07/13/26 at 9:00 A.M. revealed Resident #05 was outside smoking with another resident and no staff present. Interview on 07/20/26 at 1:00 P.M. with Mobile Director of Nursing (MDON) #328 verified Resident #05 did not have a smoking care plan and was an active smoker at the facility. MDON stated the facility needed a smoking care plan to establish Resident #05's plan on smoking while at the facility.

Based on review of medical records, review of Self-Reported Incidents (SRI), interviews, and policy review, the facility failed to report an allegation of neglect when a resident eloped to the State Agency (SA). This affected one (Resident #85). Additionally, the facility failed to report an allegation of resident-to-resident physical abuse to the SA. This affected two (Residents #35 and #59). This affected three (Residents #85, #35, and #59) of three residents reviewed for abuse. The facility census was 68. Findings include:1. Review of medical record for Resident #85 revealed an admission date of 07/19/24 and a discharge date of 06/07/26 with diagnoses of, but not limited to, Chronic Obstructive Pulmonary Disease, type two diabetes, absence of limb, depression, and a history of homelessness. Review of the progress notes for Resident #85 revealed a note dated 06/07/26 which stated a nurse went into Resident #85's room to administer medications and found that the resident was not in their room. The facility staff checked the facility grounds, and the resident was unable to be found, administration was made aware, and a police report was made. The progress notes further revealed Resident #85 did not return to the facility. Review of the SRI's for the facility revealed no SRI for Resident #85's elopement. Interview on 07/15/26 at 10:37 A.M. with the Regional Administrator revealed they were unable to locate an investigation regarding the incident with Resident #85. Interview on 07/15/26 at 11:21 A.M. with the Business Office Manager revealed no knowledge of an investigation done by the facility related to the incident with Resident #85. 2. Resident #35 was admitted to the facility on [DATE] and had diagnoses that included Type 2 diabetes mellitus, alcohol dependance, and dementia. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Resident #59 was admitted to the facility on [DATE] and had diagnoses that included alcohol dependance, chronic obstructive pulmonary disease, and depression. Review of the resident's MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Interview was conducted at approximately 11:51 A.M. on 07/15/26 with Resident #49 and Resident #59 in the courtyard. Both residents recounted an event that happened on 05/26/26 in which Resident #35, allegedly drunk, shoved Resident #59 into a chair. The residents reported a police report was filed on the alleged assault and police did visit the facility on that day. Resident #59 would later provide a card from the Columbus Division of Police indicating the report number of the police visit on 05/26/26. Review of Columbus Division of Police report dated 05/26/26 at 7:31 P.M. revealed officers spoke to the victim (Resident #59) who reported the suspect (Resident #35) pushed her into a chair. Resident #35 waved his cane in the air in an intimidating manor while looking at her. Review of the facility's SRIs revealed no SRI reported about the altercation between Resident #59 and Resident #35. Interview was conducted at 11:41 A.M. on 07/16/26 with Business Office Manager (BOM) #303 verified there was no investigation. Review of the facility policy titled, Abuse, Neglect and Exploitation, (revised 11/25/25) revealed the facility will have procedures for reporting all alleged violations (of abuse) to the Administrator, state agency, adult protective services, and to all other required agencies within specified timeframes. The policy further states if an allegation involves abuse, reporting will be made immediately, but not less than 2 hours after the allegation is made. This deficiency represents non-compliance investigated under Complaint Numbers 2790656 and 2808181.

Based on record review, observations, interviews, and facility policies, the facility failed to provide a fitted sheet for a resident to promote a homelike environment. This affected one (Resident #30) of one resident reviewed for environment. The facility census was 68. Findings include: Resident #30 was admitted to the facility on [DATE] and had diagnoses that included chronic obstructive pulmonary disease (COPD), urinary or dual incontinence, and Type 2 diabetes mellitus. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Interview was conducted with Resident #30 at 10:16 A.M. on 07/13/26. Resident #30 stated the facility did not provide a fitted sheet to go on her bariatric bed mattress. Observation of Resident #30 in bed in the resident's room was conducted at 10:16 A.M. on 07/13/26. The bariatric bed she was lying on did not have a fitted sheet on the mattress. Interview was conducted at 12:18 P.M. on 07/15/26 with Certified Nursing Assistant (CNA) #349. CNA #349 observed the mattress in Resident #30's room and confirmed that the mattress did not have a fitted sheet. CNA #349 went to retrieve a fitted sheet for Resident #30's mattress at that time. Observation and interview were conducted with Resident #30 at 2:33 P.M. on 07/15/26. The resident's mattress had a fitted sheet. Resident #30 stated a fitted sheet is preferred. Review of the facility policy titled Resident Rights (revised 06/01/24) states that the facility will ensure that all direct care and indirect care staff members are educated on the rights of residents and the responsibility of the facility to properly care for residents. The policy further states that the resident has the right to a comfortable and homelike environment including receiving support for daily living. This deficiency represents non-compliance investigated under Complaint Numbers 3074181, 3012001, 2983827, 2808181, 2806504, 2806310, 2800685, 2806222, 2800143, and 2790656.

Based on observation, interview, and record review, the facility failed to administer oxygen as ordered to Resident #23 and Resident #48. This affected two (#23 and #48) of three residents investigated for respiratory care. The facility census was 68.Findings include: 1. Resident #48 was admitted to the facility 02/07/26 and had diagnoses that included anxiety disorder, morbid obesity, and chronic obstructive pulmonary disease (COPD.) Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #48's physician orders revealed an order written 02/07/26 for oxygen to be administered per nasal cannula at a rate of 3L (liters per minute) every shift related to chronic respiratory failure with hypoxia and unspecified asthma. Observation was conducted at 12:13 P.M. on 07/13/26 of the oxygen concentrator in Resident #48's room supplying oxygen to Resident #48's via nasal cannula. The oxygen concentrator was set to a flow rate of 1.5L. Interview was conducted with Licensed Practical Nurse (LPN) #341 at 12:13 P.M. on 07/13/26. LPN #341 confirmed the oxygen flow rate on Resident #48's oxygen concentrator was set to less than 2L. Later, at 12:18 P.M., LPN #341 confirmed the oxygen flow rate was ordered to be at 3L. 2. Resident #23 was admitted to the facility on [DATE] and had diagnoses that included diabetic neuropathy, morbid obesity, and chronic obstructive pulmonary disease (COPD.) Review of the Resident's MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of the care plan (revised 09/30/24) for Resident #23 stated to administer oxygen as prescribed due to impaired gas exchange respiratory failure. Review of Resident #23's physician orders revealed an order written 10/07/25 for oxygen to be administered per nasal cannula at a rate 2L every shift related to chronic obstructive pulmonary disease. Observation was conducted at 9:58 A.M. on 07/13/26 of the oxygen concentrator in Resident #23's room supplying oxygen to Resident #23 via nasal cannula. The oxygen concentrator was set to a flow rate of 3L. Interview was conducted with LPN #341 at 12:20 P.M. on 07/13/26. LPN #341 confirmed the oxygen flow rate on Resident #23's oxygen concentrator was a little above 3L and confirmed the oxygen flow rate order was for 2L. Review of the facility policy titled, Oxygen Administration, (undated) states that oxygen is administered to residents under orders of physician and consistent with professional standards of practice. This deficiency represents noncomplinace investigated under Complaint Numbers 2983827 and 2806222.

Based on record review, observation, and interview, the facility failed to provide timely incontinence care for one resident (#21). This affected one (Resident #21) of one resident observed for incontinence care. The facility census was 68. Findings include: Review of the medical record revealed Resident #21 was admitted on [DATE]. Diagnoses included type two diabetes, dementia, heart failure, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated she was cognitively impaired. Resident #21 was dependent upon staff for toileting, personal hygiene, and bathing. Review of the care plan dated 03/17/26 revealed Resident #21 was incontinent of bowel and bladder. Interventions included to provide incontinence care every two hours and as needed. Observation on 07/14/26 at 11:14 A.M. revealed Resident #21 sitting in her specialized wheelchair at nurses' station at 200-hall. Resident #21 was dressed and covered in a blanket. No incontinence care was provided at this time. Observation on 07/14/26 at 11:25 A.M. revealed Certified Nurse Aide (CNA) #112 took Resident #21 to the dining room for lunch meal. At 1:12 P.M. an unknown aide brought Resident #21 back to the 200-hall nurses' station after her lunch was finished. No incontinence care was provided during this time. Observation and interview on 07/14/26 at 2:57 P.M. revealed CNA #112 provided incontinence care to Resident #21. Resident #21's incontinent brief smelled of strong urine odor and was saturated with urine. CNA #112 verified Resident #21 required 2-hour incontinence checks and he had not checked Resident #21 since 11:00 A.M. CNA #112 verified Resident #21's incontinence brief was heavily saturated and smelled strong of urine odor. This deficiency completes non-compliance under Complaint Number 3074181, 3015985, 2808181, 2806310, 280065, 2806222, 2983827, and 2790656.

Based on medical record review and staff interview, the facility failed to monitor a resident's blood glucose levels and oxygen saturations as physician ordered. This affected one (Resident #150) of three residents revied for changes in condition. The facility census was 74. Findings include:Review of the medical record for Resident #150 revealed an admission date of 07/14/25 and a discharge date of 07/16/25. Diagnoses included ischemic cardiomyopathy, type two diabetes mellitus (DM), and heart disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #150 had intact short-term memory and was independent for daily decision-making abilities. Review of Resident #150's physician orders for July 2025 revealed the orders included Humulin R 500-unit (U) Kwikpen (insulin), inject 40 units subcutaneous in the morning and inject 60 units in the evening for type two DM and Trulicity three milligram (mg) per 0.5 milliliter (ml), inject 0.5 ml subcutaneous once a day, every seven days for DM. There were also orders for blood glucose monitoring four times a day, notify the physician if blood sugar reading was less than 60 milligram per deciliter (mg/dL) or greater than 400 mg/dL. Review of the medication administration record (MAR) and treatment administration record (TAR) for the month of July 2025 revealed Resident #150's blood glucose was not documented as being obtained per physician ordered or monitored while at this facility. Interview on 08/29/25 at 1:39 P.M. with Regional Nurse #185 confirmed Resident #150's blood glucose monitoring and oxygen levels were not being monitored by the facility staff as the physician had ordered them to be. Regional Nurse #185 claimed Resident #150 was wearing a Free Style blood glucose monitoring system that would record blood sugar readings on her personal phone but confirmed these readings had not been recorded in this resident's medical record. This deficiency represents non-compliance investigated under Complaint Number 2572438.

Based on interviews, record reviews, hospital documentation, observation and review of facility policy, the facility failed to initiate treatment and complete an accurate assessment for a suspected deep tissue injury (SDTI) [persistent non-blanchable deep red, maroon or purple discoloration of the skin] to the bilateral buttocks upon admission on 04/29/25 for Resident #174. Actual Harm occurred on 05/07/25 when Resident #174's SDTI to the bilateral buttocks worsened to four stage III pressure ulcers (full thickness skin loss in which the fat is visible in the ulcer and granulation tissue as well as rolled wound edges are often present) due to not following the Wound Certified Nurse Practitioner's recommendations. The facility also failed to implement pressure ulcer wound care treatments timely for two additional residents (#27 and #47) that placed the residents at risk for the potential for more than minimal harm that was not actual harm. This affected three of three residents reviewed for pressure ulcer treatments and care. The facility census was 70. Findings include: 1. Review of the medical record for Resident #174, revealed an admitted [DATE]. Diagnoses included but were not limited to acute embolism and thrombosis unspecified deep veins of left lower extremity, anxiety disorder, need for assistance with personal care, muscle weakness, unspecified lack of coordination, and Type two Diabetes Mellitus without complications. Review of the hospital discharge documentation dated 04/24/25 for Resident #174 revealed a SDTI to the bilateral buttocks that measured 6 centimeters (cm) x 12 cm x 0.5 cm with a treatment of zinc oxide hydrophilic paste (triad) cream to be applied twice a day and as needed. Review of the admission assessment dated [DATE] revealed the resident required one-person assist with toilet hygiene, bathing and bed mobility. Further review revealed a skin assessment with scattered wounds described as wounds, scrapes, redness with bleeding and weeping on the entire body. The assessment had no documented measurements and no documentation of the SDTI to the bilateral buttocks as indicated on the hospital paperwork. There was no documentation of Resident #174 refusing a full body assessment. Review of a Brief Interview for Mental Status (BIMS) dated 04/29/25 revealed Resident #174 scored a 15 out of 15 indicating the resident was cognitively intact. Review of the plan of care dated 04/29/25 for Resident #174 revealed the potential for alteration in skin integrity with the intervention including but not limited to a complete head to toe assessment upon admission. Resident #174 additionally had a care plan focus of actual area of skin impairment with interventions including but not limited to initiate wound treatment and continue treatments as ordered by the MD/NP. Review of Resident #174's Braden Scale for Predicting Pressure Sore Risk dated 04/29/25 revealed a score of 11.0 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at high risk for skin breakdown. Review of Resident #174's physician orders dated 04/29/25 revealed the triad cream to the SDTI twice daily and as needed was not included in the physician orders as indicated in the hospital discharge documentation. Review of a skin grid pressure documentation dated 04/30/25 for Resident #174 revealed a SDTI on the bilateral buttocks with no measurements indicating it was acquired in the hospital on 04/21/25. The skin grid revealed the resident refused a full assessment with no indication of the reason, or education provided for the importance of the evaluation, and no follow up attempt to reassess the area. Review of Wound Certified Nurse Practitioner #203's (CNP) note dated 04/30/25 at 2:16 P.M. for Resident #174 revealed when hospitalized prior to admission, it was noted the resident had a SDTI to his bilateral buttocks and was treated with triad cream upon discharge. The Wound CNP #203 documented they were unable to do a complete assessment of the bilateral buttocks at this time due to resident pain, per hospital records recommends triad application twice a day and as needed following the hospital's treatment and will plan to reevaluate and amend recommendations at next visit. Review of the physician's orders from 04/30/25 through 05/07/25 for Resident #174 revealed the treatment for the SDTI to the bilateral buttocks of triad cream twice a day and as needed, as recommended by Wound CNP # 203, was not present in the orders. Further review of Resident #174's record revealed no attempts to reassess the SDTI area and complete a full body assessment. Interview on 05/07/25 at 8:35 A.M. with Resident #174 revealed the facility had not been applying any cream to his buttocks since he had been at the facility and he only refuses care due to pain, if he is medicated prior, he is willing to comply with treatments and care. Interview on 05/07/25 at 8:43 A.M. with the Director of Nursing (DON) revealed when a resident is admitted , the floor nurse does the full body assessment which includes measurements of all wounds and skin conditions. The DON stated Resident #174 was admitted on [DATE], he did not want a full body assessment due to pain, so the admitting nurse described the all over skin in the assessment. Upon assessment of the potential SDTI to the bilateral buttocks on 04/30/25 it was not fully completed due to the resident refusing so she stated she used the last hospital assessment of the wound prior to admission to the facility for the wound type and wound measurements and confirmed she did not actually assess Resident #174's SDTI to the bilateral buttock. Observation on 05/07/25 at 9:45 A.M. of Resident #174's SDTI to the bilateral buttocks with Wound CNP #203 revealed no triad cream present on the SDTI of the bilateral buttocks. There were four areas to the bilateral buttocks observed that were stage III pressure ulcers. The areas were: left inferior buttock measured 1 cm x 0.5 cm x 0.2 cm, left medial buttock measured 1 cm x 1 cm x 0.2 cm, left lateral buttock measured 1.5 cm x 2 cm x 0.2 cm and the right buttock measured 11 cm x 7 cm x 0.3 cm. Treatment orders for all four areas were ordered to be cleanse with wound cleanser, apply medical grade honey, and silver alginate, secure with abdominal pad with triad twice a day and as needed. Interview on 05/07/25 at 10:09 A.M. with Wound CNP #203 revealed she is a consulting company for the facility for wound care and comes to the facility on ce a week. The facility is required to enter her orders, and the house physician signs off on the treatments. She completes her notes prior to leaving the facility for the day so her recommendations can be entered for the residents. When she first assessed Resident #174 on 04/30/25, she reviewed his discharge paperwork from the hospital and he had SDTI to the bilateral buttocks and she was unable to fully assess the area herself, so she recommended continuing the triad cream twice a day and as needed continuing the hospital recommended treatment and felt it was an appropriate treatment. Interview on 05/07/25 at 11:26 A.M. with the DON revealed the facility did not reattempt to do a full body assessment upon admission on 04/29/25 of Resident #174 with no documentation of the resident refusing due to pain. The DON also verified no re attempts to assess the SDTI to the bilateral buttocks from 04/30/25 through 05/07/25 since the assessment on 04/30/25 was copied from the hospital paperwork and not an actual assessment completed by the facility. The DON was also aware this resident was receiving triad cream in the hospital for the SDTI to bilateral buttocks, but it was not ordered upon admission through 05/07/25 even after CNP #203 recommended it on 04/30/25. Interview via telephone on 05/13/25 at 2:20 P.M. with Facility CNP #202 revealed for wound care, she refers to Wound CNP #203 for all recommendations and treatments. She would also expect the facility to reattempt a full body skin assessment on admission and an assessment of a potential pressure ulcer area if unable to do so at the first attempt. Review of the facility policy titled Pressure Injury Prevention and Management revised 01/08/25 revealed a licensed nurse will conduct a full body skin assessment on all residents upon admission and weekly and treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. 2. Review of the medical record for Resident #27, revealed an admitted [DATE]. Diagnoses included but were not limited to dementia, cerebral infarction, muscle weakness, anxiety disorder, and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of nine indicating moderate cognitive impairment. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also assessed to have a Foley catheter, to always be incontinent of bowel and to be at risk for pressure ulcer injury. Review of the plan of care dated 3/30/25 for Resident #27 revealed this resident has an actual area of skin impairment related to pressure ulcers and potential for alteration in skin integrity with no interventions involving treatments as ordered. Review of the admission assessment dated [DATE] for Resident #27 revealed a left elbow unstageable pressure ulcer that measured 4 cm x 5 cm x 0.1 cm. Review of the medical record for Resident #27 from admission on 03/30/25 through 03/31/25 at 2:46 P.M. revealed no treatment order for the left elbow unstageable pressure ulcer. Review of the physician order dated 03/31/25 at 2:46 P.M. for Resident #27 revealed wound care for the left arm (elbow) cleanse with normal saline, pat dry. Apply mepilex and change every three days. Review of the skin grid pressure assessment dated [DATE] for Resident #27 revealed a pressure ulcer stage II to the scrotum that measured 1.5 cm x 0.3 cm x 0.10 cm. Review of the medical record for Resident #27 from 04/02/25 through 04/04/25 at 5:20 P.M. revealed no treatment order for the scrotum stage II pressure ulcer. Review of physician orders dated 04/04/25 at 5:20 P.M. for Resident #27 revealed a scrotal wound, cleanse with wound cleanser, pat dry, apply triad paste to wound base and leave open to air every shift and as needed. Interview on 05/12/25 at 11:35 A.M. with the Director of Nursing (DON) verified for the left elbow unstageable pressure ulcer documented on admission on 03/30/25, no treatments were in place until 03/31/25 at 2:46 P.M. The DON also verified for the scrotum stage II pressure ulcer documented on 04/02/25, no treatments were in place until 04/04/25 at 5:20 P.M. Review of the facility policy titled Pressure Injury Prevention and Management revised 01/08/25 revealed treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. 51524 3. Review of the medical record revealed Resident #47 admitted to the facility on [DATE]. Diagnoses included a pressure ulcer of the left heel, deep tissue and a pressure ulcer of the right heel, unstageable. Review of Resident #47's physician's order dated 09/24/24 revealed she was to wear pressure relief boots daily for preventative skin and comfort. There was no end date for the order. Review of Resident #47's medical record revealed the order was discontinued by the facility staff on 10/14/24. Interview with DON on 05/13/25 at 1:36 P.M. confirmed the order was discontinued by the facility staff and there was no corresponding order from the physician to discontinue donning the boots daily. Review of Resident #47's physician order dated 10/25/24 revealed the left heel wound was to be cleansed with normal saline, betadine and wrapped with gauze daily. Review of Resident #47's medical record revealed there was no documentation the treatments were completed 10/26/24, 10/27/24 and 10/30/24. Review of Resident #47's physician order dated 10/25/24 revealed the right heel wound was to be cleansed with normal saline, betadine applied and wrapped with gauze daily. Review of Resident #47's medical record revealed there was no documentation the treatments were completed 10/26/24, 10/27/24 and 10/30/24. Interview with DON on 05/13/25 at 1:38 P.M. confirmed the treatments were not completed as ordered. Review of the facility policy titled Wound Treatment Management, dated 1/08/25, revealed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change.

Based on observation, interview, record review and facility policy review, the facility failed to implement enhanced barrier precautions for Resident #174. This affected one resident of one resident reviewed for enhanced barrier precautions and had the potential to affect all 23 residents on the hall. The facility census was 70. Findings include: Review of the medical record for Resident #174, revealed an admitted [DATE]. Diagnoses included but were not limited to acute embolism and thrombosis unspecified deep veins of left lower extremity, anxiety disorder, need for assistance with personal care, muscle weakness, unspecified lack of coordination, and Type II Diabetes Mellitus without complications. Review of a Brief Interview for Mental Status (BIMS) dated 04/29/25 revealed Resident #174 to be a 15 indicated cognitive intactness. Review of the plan of care dated 04/29/25 for Resident #174 revealed the resident had an actual area of skin impairment with no interventions for enhanced barrier precautions. Review of a skin grid pressure documentation dated 04/30/25 for Resident #174 revealed a SDTI on the bilateral buttocks. Review of the physician's orders dated 04/30/25 through 05/07/25 for Resident #174 revealed no order for enhanced barrier precautions. Observation on 05/07/25 at 9:40 A.M. of Resident #174's room revealed no sign for enhanced barrier precautions and no enhanced barrier precautions cart with items for staff to wear when entering the residents room. Verified with the Assistant Director of Nursing this resident was supposed to be on enhanced barrier precautions, and he was not. Review of the facility policy titled Enhanced Barrier Precautions revised 07/13/22 revealed an order for enhanced barrier precautions will be obtained for residents with wounds. Also, implementation of enhanced barrier precautions which includes making gowns and gloves available immediately outside of the residents room and positioning of a trash can inside the resident room and hear the exit for discarding of the personal protection equipment after removal.

Based on observations, resident interviews, staff interviews and record review, the facility failed to ensure there was a sufficient supply of washcloths, hand towels and bath towels to complete resident care. This shortage affected two residents (#8 and #21) and had potential to affect all 70 residents residing in the facility. The facility census was 70. Findings include: Resident #8 was admitted to facility on 10/27/22 with primary diagnosis of Parkinson's Disease and additional diagnoses of congestive heart failure, Type II Diabetes, anxiety and depression. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 02/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Interview on 05/08/25 at 8:28 A.M. with Resident #8 revealed she believed there was a shortage of washcloths and towels every other day. Resident #8 said because of the shortage, her showers had been delayed until 3rd shift on multiple occasions. Resident #8 stated her preference was to receive a shower after breakfast in the morning on day shift. Review of shower schedule revealed Resident #8 was scheduled to receive showers on Mondays and Thursdays between 7:00 A.M. and 7:00 P.M. Interview on 05/08/25 at 9:24 A.M. with Director of Nursing (DON) revealed the shower schedule did not change from week to week between day shift and night shift. Review of facility documentation of Resident #8's shower record revealed on 04/28/25, Resident #8 received a bed bath during 3rd shift between 7:00 P.M. and 7:00 A.M. There was no documentation of Resident #8 either receiving or refusing a bath or shower on day shift of 04/24/25. There was documentation from 04/24/25 that Resident #8 refused a shower the evening of 04/24/25 during third shift. Interview on 05/08/25 at 8:35 A.M. with Certified Nursing Assistant (CNA) #135 revealed the CNA prioritized which residents received towels based on who woke up first. Observation on 05/08/25 at 8:49 A.M. of the room shared by Resident #39 and Resident #4 revealed no washcloths, hand towels or towels were available in the room. Observation on 05/08/25 at 8:59 A.M. of the linen closet revealed a single towel in the linen closet. Staff #147 verified the single towel in the linen closet at the time of the observation. Observation on 05/08/25 at 9:00 A.M. of the laundry room revealed 11 washcloths, no hand towels and no towels on shelving. Interview on 05/08/25 at 9:00 A.M. in the laundry room with Environmental Services Staff #160 confirmed there were no hand towels or towels on shelving. She said they were all being laundered. Observation on 05/08/25 at 9:05 A.M. in the shared room of Resident #54 and Resident #18 revealed no washcloths, hand towels or bath towels in the room. Resident #54 was present during the observation and confirmed the room had no bath linen available. Observation on 05/08/25 at 9:07 A.M. of the room shared by Resident #2 and Resident #23 revealed no washcloths, hand towels, towels or toilet paper in the room. Resident #23 was present during the observation and verified there were no bath linens present and stated at the moment she was more concerned with not having toilet paper. 2. Resident #21 was admitted to the facility on [DATE] with a primary diagnoses of respiratory failure with hypoxia and additional diagnoses of deep vein thrombosis, discitis, morbid obesity, muscle weakness and depression. Review of Resident #21's Minimum Data Set (MDS) assessment, dated 04/18/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. Observation on 05/08/25 at 9:48 A.M. revealed no washcloths, hand towels or towel in Resident #21's room. Interview with Resident #21 on 05/28/25 at 9:48 A.M. the resident stated the towels were in the room and were taken away to be used for someone else which upset her since she was waiting to be cleaned up. Resident #21 said she really wanted to wash her face. Observation on 05/08/25 at 11:38 A.M. of the laundry room revealed an out of order sign on a dryer and empty linen shelving with no washcloths, hand towels or towels. Interview on 05/08/25 at 11:30 A.M. with Environmental Services Staff #160 who confirmed dryer had been out of order at least since the previous Friday (six days). She confirmed the cart was usually empty. She said they were always coming up short on linens though noted it has been especially bad lately. She said she had asked management multiple times for more. She said staff has tried to take the linens off the stretchers when residents came from the hospital in order to use those, but those sheets didn't fit the beds. She said they are short on washcloths, hand towels, towels, sheets and Hoyer pads. Interview on 05/08/25 at 12:06 P.M. with Certified Nursing Assistant (CNA) #132 who confirmed there were times when there was a shortage of towels, hand towels, and washcloths. CNA #132 attributed this to one of the laundry machines being out of order, though noted this was an ongoing issue. The aide shared that more than once when he was unable to find towels in the storage closet, in the laundry room, or on the other unit, he had to resort to using a pillowcase in place of a towel to dry the resident. He said he would rather do this than to not bathe the resident.

Based on observation, interview and record review the facility failed to ensure one (Resident #47) had access to her personal property a motorized wheel chair. This affected one (#47) of two reviewed for personal property. The facility census was 70. Findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses which included acquired absence of left and right leg below the knee, congestive heart failure, chronic obstructive pulmonary disease, osteoarthritis, pain and peripheral vascular disease. Review of Resident 47's admission record reveals she arrived to the facility with an electric wheelchair. Review of the medical record revealed there was no assessments completed for the safe use of the electric wheelchair. Review of the admission minimum data set (MDS) 3.0 dated 02/22/25 revealed Resident #47 mobility is severely limited and requires the use of a wheelchair. Review of progress note dated dated 08/18/24 at 8:23 P.M. revealed Resident #47 ran into another resident in her electric wheelchair. Resident #47 was to be evaluated by occupational therapy for safe operation of her electric wheelchair. Review of Resident #47's record revealed on 09/27/24 occupational therapy noted Resident #47 had poor depth perception when operating a chair and should be evaluated by an optometrist. Review of Resident #47's record revealed on 10/07/24 Resident #47 was discharged from occupation therapy and deemed incapable of safely operating her custom power wheelchair. In an interview with Resident #47 on 05/05/25 at 10:18 A.M. she revealed the facility had taken her electric wheelchair, which was preventing her from being able to move around the premises as she wanted to. Interview with Occupational Therapist (OT) #141 on 05/13/25 at 10:26 A.M. revealed Resident #47 had not yet had her vision evaluated. Interview with DON on 05/13/25 at 10:31 A.M. revealed due to the determination by occupational therapy that Resident #47 could not safely operate her wheelchair, on 12/18/24 the control panel for the wheelchair was moved to the back of the chair so the resident would not be able to operate it herself. During an interview on 05/13/25 at 10:35 A.M., DON and OT #188 verified there was no order, assessment or plan of care for restricting Resident #47's electric wheelchair operation. They both acknowledged that by limiting the resident's ability to operate the electric wheelchair, it restricted her mobility.

Based on observation, medical record review, review of hospital records, review of physician's notes and wound assessments, appointment reminder notice review, interviews with residents, family, outside entities, and staff, and policy review, the facility failed to provide adequate, timely and necessary care and services, including timely re-scheduling of vascular surgeon appointments for Resident #100, who had vascular wounds to meet the resident's total care needs. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm beginning on 07/16/24 when a vascular surgery follow-up appointment (with plans to discuss blood flow to the resident's lower extremities) was canceled with no evidence of attempts by facility staff to re-schedule or schedule a new vascular surgery consult until 08/14/24, when an appointment was made for the following week with a new vascular surgeon. However, prior to the appointment, on 08/18/24, Resident #100 suffered a significant change in condition with increasing lower extremity pain unrelieved by as-needed opioid narcotic analgesics and bleeding from his lower extremity wounds resulting in the resident being transferred to a local hospital. Resident #100 was admitted to the intensive care stepdown unit and required a 25-day inpatient hospitalization for sepsis (systemic infection) and infected vascular wounds. The hospital vascular surgeon noted the resident's potential for lower extremity re-vascularization procedures as limited if not non-existent. Resident #100 required lengthy courses of multiple intravenous antibiotics, extensive wound care, and his hospital course was complicated by an acute kidney injury requiring temporary hemodialysis treatments. Resident #100's wounds and overall health continued to decline, and on 09/06/24, Resident #100's legs were documented to be not salvageable with discussion of possible emergent amputations. Resident #100 and his family considered the options and ultimately decided against amputations and opted for end-of-life care with hospice at another skilled nursing facility. Additionally, the facility failed to transcribe and schedule appointments for Residents #27 and #34, whose hospital after visit summaries listed the need for follow up appointments with outside specialists, which placed Residents #27 and #34 at risk for the potential for more than minimal harm that was not Immediate Jeopardy. This affected three residents (#100, #27, and #34) of eight residents reviewed for missed appointments and changes in condition. The facility census was 72. On 09/19/24 at 10:29 A.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RCDS) #490 were notified Immediate Jeopardy began on 07/16/24 when Resident #100 arrived at a scheduled follow-up appointment and was notified the appointment had been canceled. Resident #100, who was accompanied by a facility staff member, returned to the facility. There was no evidence of attempts by facility staff to re-schedule or schedule a new vascular surgery consult until 08/14/24, when an appointment was made for the following week with a new vascular surgeon. On 08/18/24, Resident #100 suffered a change in condition with increasing lower extremity pain unrelieved by his as-needed opioid narcotic analgesics and bleeding from lower extremity wounds, for which he was transferred to a local hospital. Resident #100 was admitted to the intensive care stepdown unit and required a 25-day inpatient hospitalization for sepsis (systemic infection) and worsening vascular wounds. The hospital vascular surgeon noted the resident's potential for re-vascularization procedure as limited if not non-existent. Resident #100 required lengthy courses of intravenous antibiotics, extensive wound care, and his hospital course was complicated by an acute kidney injury and progressive gangrene to his left lower extremity. Resident #100's wounds and overall health continued to decline, and on 09/06/24 Resident #100's legs were recorded as not salvageable and discussed possible emergent amputations. Resident #100 and his family considered the options and ultimately decided against amputations and opted for end-of-life care with hospice at another skilled nursing facility. The Immediate Jeopardy was removed on 09/23/24 when the facility implemented the following corrective actions: On 08/18/24, Resident #100 was transferred to the hospital and admitted for treatment. The resident did not return to the facility. On 09/19/24 at approximately 11:00 A.M., the Administrator, RDCS #490 and Regional Director of Operations (RDO) #485 educated DON, Licensed Practical Nurse (LPN)/ Assistant Director of Nursing (ADON) #238 and Scheduler #376 on proper documentation, uploading of new orders, and setting up transportation for new appointments. On 09/19/24 at approximately 1:25 P.M., all staff education was completed on the facility abuse policy. This was completed by the Administrator. On 09/19/24 at approximately 2:45 P.M., an initial audit of all outside resident appointments for all current residents was completed by the DON and Scheduler #376. Any discrepancies were fixed immediately. On 09/19/24 at 3:25 P.M., all current residents received a head-to-toe assessment completed with no change in conditions or negative outcomes noted. This was completed by LPN #392, Agency Registered Nurse (RN) #645 and Agency RN #678. On 09/19/24 at 3:37 P.M., the DON notified facility Medical Director (MD) #900 of the concerns involving Resident #100 identified by the State agency. On 9/19/2024 at approximately 3:50 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) committee met to review the facility appointment scheduling process. The Administrator, DON, RDCS #490 and RDO #485 attended. On 09/19/24, a new tracking log was implemented to track additional details of residents outside appointments. The log included the resident's name, the appointment date and time, transportation arrangements, the need for staff assistance, whether the appointment was completed, whether the appointment needed re-scheduled, and if there was any follow up needed. Scheduler #376 is responsible for maintaining and updating the log five days per week with oversight from the Administrator. Pertinent information regarding appointments will be shared with the interdisciplinary team five days a week, weekly on an ongoing basis. Beginning on 09/19/24, the DON or designee will monitor 24-hour report and all new orders 5 days a week on an ongoing basis. Beginning on 09/19/24, an ongoing audit of post-admission chart reviews will be completed to ensure the admitting nurse accurately transcribed physician's orders. This will be completed by LPN/ADON #238 on the first business day following resident admission or re-admission, with the DON as a back-up reviewer. Beginning on 09/20/24, an ongoing audit of appointments and transportation will be conducted to ensure appointments are accurately transcribed into the resident's record and are added to the appointment tracking log for verification of appointment attendance. This will be completed by the DON or designee, five times weekly, on an ongoing basis and communicated to the interdisciplinary team during morning meetings. Beginning on 09/20/24, an ongoing audit of outside resident appointments and transportations as listed on the appointment tracking log and will be conducted three times weekly, on random days of the week, by the Administrator. This will be completed 3 times/week on an ongoing basis. Beginning on 09/20/24, a staffing huddle was implemented with direct care staff to communicate upcoming scheduled appointments, needs for the appointment, and transportation arrangements. This huddle will occur five times weekly, Monday through Friday, at approximately 10:00 A.M., following the conclusion of morning meeting. Any potential weekend appointments will be communicated on Fridays. The staffing huddle will be coordinated by the Administrator and/or DON or designee. Beginning on 09/23/24, the Administrator will send the appointment tracking log to RDO #485 and RDCS #490, three times weekly on Monday, Wednesday and Fridays, for four weeks. Beginning the week of 09/23/24, a random audit of outside resident appointments and transportations will be conducted weekly, by RDO #485 or RDCS #490, for additional oversight for a duration of 4 weeks. On 09/23/24 at approximately 4:00 P.M., staff nurses were educated on scheduling appointments, transcribing appointment orders, and monitoring appointment attendance. This was completed by the Administrator. On 09/23/24 at approximately 4:30 P.M., two communication binders were implemented and contained pertinent policies, including written appointment scheduling expectations for communication for both agency and staff nurses. Pertinent policies and updates will be placed in the communication book on an ongoing basis by the DON or designee. Results of ongoing audits will be reported and reviewed through the facility QAPI committee for 6 months and randomly thereafter. The next regularly scheduled QAPI meeting is planned for 09/27/24 at 12:30 P.M. During interviews conducted on 09/23/24 between 3:53 P.M. and 1:10 P.M., and on 09/24/24 between 7:21 A.M. and 3:10 P.M., Licensed Practical Nurse (LPN) #392, Registered Nurse (RN) #294, LPN #300, LPN #222, RN #398, RN #334, LPN #305, LPN/ADON #238, and Scheduler #376 verified receiving education on the facility appointment scheduling process. Although the Immediate Jeopardy was removed on 09/23/24, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record for Resident #100 revealed an original admitted [DATE]. Medical diagnoses included peripheral vascular disease (PVD), cellulitis, and an unspecified disorder of arteries and arterioles. Resident #100 was noted to have chronic vascular wounds to his bilateral lower extremities, for which he had been previously hospitalized and treated from 06/02/24 to 06/07/24. Resident #100 was transferred to a local hospital on 08/18/24 and did not return to the facility. A plan of care initiated on 04/25/24 (and revised on 07/03/24), noted Resident #100 had actual areas of skin impairment related to chronic venous stasis ulcers to multiple locations on the bilateral lower extremities. Listed interventions included to provide the ordered treatment, ask resident regarding pain levels prior to dressing changes and medicate as needed, enhanced barrier precautions in place, elevate legs as tolerate, and encourage movement of legs and walking. A plan of care dated 05/10/24, noted Resident #100 had inadequate blood circulation or ineffective tissue perfusion related to peripheral vascular disease (PVD). Listed interventions included to administer medications as ordered, observed for side effects and effectiveness, complete laboratory/diagnostic work as ordered, and to follow up as indicated. An additional focus care plan dated 07/10/24, listed the resident as noncompliant with care and treatment as ordered by the physician, with specifics listing the resident was non-compliant with a post-operative shoe, COVID isolation precautions, and rolling his own tobacco. There were no recorded specifics about the resident refusing ordered wound care or ADL care. Listed interventions included to stop care when resident upset and try again later, approach calmly, without rushing and speak in a calm voice, explain procedures and observe and document mood and behavior changes in the nurse's notes or monthly tracking forms if indicated. Review of Resident #100's physician's orders revealed an original order dated 04/26/24, for a vascular surgery appointment on 07/16/24. The order was revised on 06/27/24 and 07/11/24 to provide transportation details and to add start and end dates. Review of Resident #100's prior hospitalization discharge summary from Hospital #02, dated 06/07/24, noted Resident #100 was transferred from Hospital #01 on 06/02/24 for an evaluation of his lower extremity wounds. Resident #100 was noted to have sepsis secondary to his lower extremity vascular wounds at this time. Resident #100 was noted to have diffuse peripheral arterial disease (PAD)/PVD and recommended a revascularization evaluation. The summary indicated Resident #100 was not able to have any vascular intervention during the hospitalization as the resident lacked decision-making capacity to consent to a surgery with complex risks due to altered mental status. The discharge summary noted no health care power of attorney (HCPOA) was in place and no alternate decision makers were able to be located or contacted. Resident #100's mental status improved during the hospitalization , but the concern was still present regarding capacity to understand the risks and benefits completely for a serious procedure. Resident #100 had shared he was established with Vascular Surgeon #500, who was affiliated with Hospital #01, and wanted to get a second surgical opinion from him post-hospital discharge. The summary indicated the plan was to discharge Resident #100 back to the facility, and for the resident to follow up with Vascular Surgeon #500 as an outpatient at the provider's office. The discharge summary noted there was a poor prognosis for Resident #100's legs without vascular intervention, with salvage unlikely even if revascularization was possible. The discharge summary listed Resident #100 as having a follow up appointment with Vascular Surgeon #500 on 06/18/24 to discuss blood flow to the legs, and to call the office to confirm the appointment. Review of Resident #100's hospital after visit summary, dated 06/07/24, revealed Resident #100 had follow up appointments scheduled prior to hospital discharge. On 06/18/24 at 2:00 P.M., Resident #100 was scheduled for a cardiovascular ultrasound of the carotid (neck) arteries, with the address and phone number listed. A second appointment following the ultrasound was listed for 06/18/24 at 3:00 P.M., with Vascular Surgeon #500. A third appointment was listed for 07/16/24 at 10:00 A.M., also with Vascular Surgeon #500, with the provider's office address and phone number listed. Review of Resident #100's interdisciplinary progress notes revealed a note dated 06/18/24 at 1:30 P.M., which stated the resident was transported to his appointment. He was alert and oriented times three (indicating orientation to person, place and time) with no signs of distress as he was escorted to his appointment. A subsequent note also dated 06/18/24 and timed 2:30 P.M., revealed Resident #100 returned to the facility from appointment in stable condition with no signs of distress. The resident's appointment had been rescheduled to 07/16/24 at 10:00 A.M. Review of an appointment reminder notice, dated 06/18/24, revealed Resident #100 was noted to have an upcoming vascular surgery appointment on 07/16/24 at 10:00 A.M. Listed instructions included to bring photo identification, a current list of medications, and any insurance information and a copayment if required. The office address, phone and fax number were listed on the notice and the notice listed to call the office at a provided number to cancel or reschedule the appointment. Resident #100 had an order dated 07/03/24, for bilateral lower extremity wound dressings. The order instructed to cleanse wounds with normal saline and pat dry. Apply normal saline moist-to-dry dressing, cover with abdominal pads, wrap with kerlix (rolled gauze) and wrap with ACE (compression) wraps, change daily and as needed. Review of Resident #100's Treatment Administration Record (TAR) for July 2024 revealed Resident #100's daily bilateral wound dressings were completed as ordered, except on four days, 07/05/24, 07/07/24, 07/11/24, and 07/19/24, on which the resident was recorded to have refused. The TAR was blank for 07/30/24, indicating Resident #100 did not receive his ordered treatment on this date. Review of a nurse's note for July 2024 revealed there was no notation of education being provided on wound care or rationale for why the resident refused ADL and/or wound care on the days listed. Subsequent review of the progress notes revealed no corresponding documentation on the reason Resident #100 refused his wound care, that education was provided, or that staff had re-approached or re-offered wound care on the dates he refused. Subsequent review of Resident #100's interdisciplinary progress notes between 06/18/24 and 08/14/24, revealed no notes on or around 07/16/24, reflecting attendance to an outside vascular surgery appointment on this date. There were no notes during the time frame regarding any missed appointments, any attempts to reschedule an appointment, or any attempts finding the resident a new vascular surgeon. Resident #100 was recorded as seeing MD #900 on 06/20/24 and 07/10/24, who noted the resident was previously seen by a vascular surgeon while in the hospital who recommended an outpatient visit to discuss a revascularization procedure versus amputation of the lower extremities, and to follow up with Vascular Surgeon #500. Resident #100 was recorded as seeing Certified Nurse Practitioner (CNP) #875 on 06/21/24 and 07/19/24, who noted the resident had a vascular surgery follow up appointment scheduled on 07/16/24. Resident #100 was additionally seen by CNP #825 on 07/01/24, 07/08/24, 07/18/24, 07/22/24, 08/01/24, 08/05/24, and 08/12/24. Each of CNP #825's visits noted the resident needed to follow up with a vascular surgeon. The note dated 08/01/24, indicated specifically to schedule a follow up appointment to discuss bilateral below the knee amputations. CNP #825's note dated 08/05/24, noted a vascular surgery consult was pending, and the note dated 08/12/24, noted Resident #100's prior vascular surgeon no longer accepted his insurance and to refer the resident to a different health system to see a vascular surgeon. A note dated 08/14/24 at 9:00 A.M., authored by LPN/ADON #238 noted an appointment was made with an unnamed vascular surgeon for 08/21/24. Review of Resident #100's Minimum Data Set (MDS) quarterly assessment, dated 08/02/24, revealed the resident had intact cognition. Resident #100 was not recorded to have hallucinations, delusions, verbal or physical behaviors, or rejection of care. Resident #100 was noted to functional limitations in range of motion to both of his lower extremities and required partial/moderate assistance with bathing and applying and removing footwear. Resident #100 required only supervision/set-up assistance with other activities of daily living (ADLs). Resident #100 was non-ambulatory but required only setup or supervision assistance with mobility tasks. Resident #100 was noted to have four venous and/or arterial ulcers at the time of the assessment, for which he received non-surgical dressings. Review of Resident #100's TAR for August 2024 revealed Resident #100's daily bilateral lower extremity wound dressings were documented as administered as ordered on all but two days, 08/10/24 and 08/17/24, on which the resident was recorded as refusing dressing changes. Review of a nurse's note dated 08/18/24 at 5:32 A.M. and 6:55 A.M., noted the resident refused his wound care. A subsequent note dated 08/18/24 at 6:56 P.M., noted the resident refused wound care and ADLs four times. There was no notation education was provided on wound care or rationale for why the resident refused ADL and/or wound care on that day. Subsequent review of the progress notes revealed no corresponding documentation on the reason Resident #100 refused his wound care, that education was provided, or that staff had re-approached or re-offered wound care on the dates he refused. Review of Resident #100's eINTERACT Change in Condition Evaluation, dated 08/18/24, revealed Resident #100 had a noted change to his skin wound or ulcer on 08/18/24. There was no description of what types of wound changes were seen to Resident #100's wounds. Review of Resident #100's eINTERACT Transfer Evaluation, dated 08/18/24, revealed Resident #100 was sent to the hospital on the evening of 08/18/24, due to bleeding from the legs. The form listed the resident as having no pain. The form listed the resident as having pressure ulcers to the lower extremities and provided no description for the number of wounds, appearance of the wound bed or any wound characteristics, nor did the form list what ordered treatments were. Review of Resident #100's emergency department (ED) records, dated 08/18/24, revealed Resident #100 arrived at the ED of Hospital #01 for bilateral lower leg pain. The ED note indicated Resident #100 voiced he had infections in his legs since January 2024 and was scheduled to see a surgeon somewhere in Ohio later that week to discuss possible amputations. Resident #100 told the ED provider the pain in his bilateral legs was what brought him to the ED, and the note indicated Resident #100 was alert and oriented upon arrival. Resident #100 described his pain as usually controlled with as-needed oxycodone (a narcotic opioid analgesic), but on 08/18/24 the pain was out of control. The ED physician's physical examination described Resident #100 as disheveled with poor personal hygiene upon arrival. Resident #100 was tachycardic (heart rate greater than 100 beats per minute). The physician recorded Resident #100's lower extremity dressings as dirty and saturated upon arrival. Multiple open wounds were observed to Resident #100's bilateral lower extremities, with skin sloughed (dead tissue) from the left foot with surrounding erythema (redness) and edema (swelling). The wounds to the bilateral extremities had a foul odor and purulent drainage (indicative of possible infection). The ED physician was unable to palpate pulses in Resident #100's bilateral lower extremities (a sign of impaired blood flow). Resident #100 was noted to have an elevated white blood cell count (WBC) of 21.00 (normal range 4.5-11.0 K/mcL, indicative of infection). A second ED physician saw Resident #100 and noted the lower extremity wounds to the resident's bilateral lower extremities appeared grossly necrotic with foul smelling drainage, and in conjunction with laboratory evaluation and imaging, there was a concern for significant bilateral lower extremity infection. Imaging of Resident #100's leg showed significant vascular compromise, chronic in nature, and noted the patient would benefit from bilateral lower extremity partial amputation once more stabilized. Resident #100 met criteria for admission to the intensive care stepdown unit for sepsis and severe cellulitis of the bilateral lower extremities. Review of Resident #100's vascular surgery consult note dated 08/19/24 while inpatient at the hospital, noted the resident to have chronic limb-threatening ischemia to his bilateral lower extremities and bilateral lower extremity venous ulcers. The note indicated Resident #100 was known to have chronic bilateral lower extremity wounds that had worsened since the last recorded documentation within the hospital system from June 2024. The note indicated Resident #100's options for revascularization may be limited if not non-existent. Additional review of Resident #100's hospital medical records noted the resident required the coordination and care of various specialties throughout a 25-day hospitalization . Resident #100 was seen by an infectious disease physician on 09/19/24. The provider noted leukocytosis (elevated white blood count (WBC) count, indicative of infection), sepsis, and bacteremia (bacteria in the bloodstream) with two multiple infectious organisms identified. The assessment and plan section of the note noted the resident was being treated for bacteremia, bilateral lower extremity wound infections, leukocytosis and PAD. The resident required three intravenous antibiotics to treat the infection and indicated to continue local wound care and supportive care. The note listed Resident #100's prognosis as guarded. Resident #100 was seen by a podiatrist on 08/20/24. The note indicated no podiatric surgery was recommended at that time and agreed with vascular that bilateral below the knee amputations may be the patient's best option. A subsequent note dated 08/22/24, by a second podiatrist noted Resident #100's legs would be salvageable with vascular intervention. The note indicated aggressive surgical intervention could put the resident's legs back together, but without vascular intervention and the levels of disease, an above the knee amputation would be the appropriate course of action. The note stated if Resident #100 did not undergo some procedure, either vascular intervention or above the knee amputation, Resident #100's severe and deep wounds involving the tendons would become severely infected, and Resident #100 would not be able to fight the infection off. Resident #100 saw a nephrologist on 08/23/24, for an acute kidney injury (AKI), severe PAD, hypertension and an elevated vancomycin (antibiotic) level. The note indicated the resident had an AKI related to comorbidity of PAD, receiving intravenous contrast for radiology tests, and multiple intravenous antibiotics with an elevated vancomycin level. The plan indicated the vancomycin was on hold, and nephrology would monitor the patient's laboratory results and symptoms. A subsequent note dated 08/28/24, from an interventional radiologist noted Resident #100 would require the placement of a temporary tunneled internal jugular intravenous line through which the hospital would be able to perform hemodialysis (filtering of the blood when the kidneys are not adequately functioning). Resident #100 received hemodialysis on 08/29/24, 08/30/24, and 08/31/24. A follow-up vascular surgery note dated 09/05/24 revealed the vascular surgeon discussed with Resident #100 that his legs are potentially the source of his deteriorating medical status and that vascular surgery, and his other teams recommend bilateral above the knee amputations. The risks of not proceeding, including worsening infection, sepsis, clinical deterioration to the point of altered mental status (AMS), cardiac arrest, multiorgan failure and death were discussed. Given the risks, Resident #100 declined intervention and was adamant he did not want to live without his legs. The note concluded with a note indicating that the patient was able to properly participate in decision making and the vascular surgery team could not with good conscious proceed with surgery with the patient adamantly declining. The palliative care team was consulted, and after multiple discussions regarding Resident #100's complex and comorbid healthcare needs, Resident #100 and his family ultimately opted to decline amputation and decided to elect for end-of-life care with hospice services at another skilled nursing facility. Interview on 09/12/24 at 10:20 A.M., with Advocate #990, who wished to remain anonymous, revealed familiarity with Resident #100's stays at the facility and hospital admission since 08/18/24. Advocate #990 reported Resident #100, was still inpatient at the hospital, was not doing well. Resident #100 was described as having a lot of pain. Advocate #990 stated Resident #100 and his family had discussed care with the various specialists and elected for end-of-life care with hospice services. Advocate #990 stated Resident #100's legs were so infected that specialists did not believe he would survive a surgery. Advocate #990 stated another concerning aspect to Resident #100's care was that a surgeon was consulted in early June 2024 during a prior hospitalization , and were talking potential lower extremity amputations then, and questioned why Resident #100 did not have any vascular surgery follow up appointments since that time. A telephone interview on 09/12/24 at 10:32 A.M., with Anonymous Individual #860 revealed the individual was familiar with Resident #100's care and hospital stay. Anonymous Individual #860 stated when Resident #100 arrived at the hospital he appeared to have been neglected at the facility. When he arrived at the ED, he was disheveled; his wound bandages to his lower extremities had been on for a long period of time, and once removed, his vascular wounds appeared infected with a foul odor and purulent drainage. Resident #100 was known to have extensive vascular disease with chronic vascular wounds to his legs. He had previously been seen by a vascular surgeon and had discussed a prior amputation. Anonymous Individual #860 wondered what the hold up was? following up with a vascular surgeon and described Resident #100's decline in condition as heartbreaking and horrifying and questioned how it got to this point. An interview on 09/12/24 at 2:10 P.M., with Scheduler #376 revealed she was the staffing scheduler and scheduled transportation for outside resident appointments. Scheduler #376 assisted in updating a spreadsheet of upcoming appointments but was unable to provide a copy of the current or past months' appointment schedule as entries get deleted after the appointment date had passed. An interview on 09/12/24 at 3:35 P.M., with the Administrator revealed the facility was unable to provide a monthly appointment calendar for outside resident appointments. The facility utilized a spreadsheet to track upcoming resident appointments, but once the appointment date/time passed, the facility deleted the resident and appointment from the spreadsheet. The Administrator reported there was no way to see prior months' data, nor was there a way to see prior versions of the log. The Administrator stated the facility's process was to type orders into the resident's electronic health record (EHR), and the scheduler with review the orders for upcoming appointments to ensure transportation was scheduled. When asked about the process of ensuring residents attend scheduled appointments, the Administrator stated nurses should enter a progress note to indicate the resident attended an appointment and to note any new orders reflected on the hospital paperwork following the appointment. Appointment paperwork would then be scanned into the resident's EHR record as the facility does not have any physical charts. An interview on 09/17/24 at 8:58 A.M., with the DON revealed she was familiar with Resident #100's care. She described Resident #100 as having terrible leg wounds that she believed had progressed because the resident was non-compliant with wound care. The DON reported Resident #100 had longstanding vascular compromise and not enough blood flow to his bilateral lower extremities. The DON reported the resident did see a vascular surgeon and went back and forth with a decision to amputate his legs but was unsure when the resident's last appointment with vascular surgery was. An interview on 09/17/24 at 9:28 A.M., with Certified Nursing Assistant (CNA) #214 revealed she had cared for Resident #100 while he was a resident of the facility. CNA #214 revealed occasionally Resident #100 would refuse showers or hygiene care. CNA #214 was not familiar with the state of Resident #100's wounds or why he had wounds. She heard Resident #100 needed leg amputations and was unsure why he did not return to the facility. During an interview on 09/17/24 at 11:54 A.M., with the Administrator and Scheduler #376 past scheduled appointments for Resident #100 were reviewed. The Administrator and Scheduler #376 reported the resident attended an appointment with Vascular Surgeon #500 on 06/18/24 and again on 07/16/24. When prompted to provide evidence the resident was seen, the Administrator checked Resident #100's progress notes and confirmed the progress notes reflected the 06/18/24 appointment was rescheduled to 07/16/24. The Administ [TRUNCATED]

Based on medical record review, observation, review of a facility self-reported incident (SRI), staff and Sexual Assault Nurse Examiner (SANE) #19 interviews, and review of the facility abuse and neglect policy, the facility failed to ensure a resident was free from resident-to-resident sexual abuse. This resulted in Actual Harm when Resident #01 was sexually abused by Resident #02 and subsequently required hospital evaluation/treatment for an abrasion to the fascia of her vagina. This affected one (#01) of three residents reviewed for abuse. Facility census was 70. Findings include: Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, adult failure to thrive, weakness, need for assistance with personal care, hearing loss, hypertension, and urinary incontinence. Review of Resident #01's comprehensive Minimum Data Set (MDS) assessment, dated 02/22/23, revealed the resident had severely impaired cognition. Resident #01 was totally dependent for all activities of daily living except bed mobility, and she was a two person assist. The MDS also revealed Resident #01 did not exhibit any moods or behaviors. The MDS did reveal Resident #01 had an indwelling catheter in place. Review of Resident #01's nurse progress notes dated from 02/23/23 at 1:45 A.M. revealed a head-to-toe skin assessment was completed and no injuries noted. Physician notified and family made aware. On 02/23/23 at 8:45 A.M. the police detective arrived. At 9:00 A.M. Resident #01 was sent to the local hospital to be evaluated. Further review of Resident #01's medical record revealed there were no other documented details as to what incident occurred that would warrant a head-to-toe assessment, physician/family notification, police involvement and/or a transfer to the local hospital. Review of Resident #02's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, nontraumatic chronic subdural hemorrhage, muscle weakness, depressive disorder, and cognitive communication deficit. Resident #02 was discharged from the facility on 02/23/23. Review of Resident #02's quarterly MDS dated [DATE] revealed the resident was cognitively intact. Resident #02's functional status was listed as independent, set up only. The MDS also listed Resident #02 as always continent of urine and bowel. Review of the plan of care dated 12/30/22 revealed Resident #02 was noncompliant with care/treatment as ordered by physician. Resident #02 refused ancillary services, noted removing the Coronavirus Disease 2019 (COVID-19) isolation equipment from room, and frequently refuses to allow staff to remove meal trays from room after meals. Refuses dietary supplements, refusing weights, and noncompliant with facility smoking policy. Further review of Resident #02's medical record revealed there was no documentation regarding any sexually inappropriate behaviors prior to 02/23/23. Review of the Ohio Attorney General's Office Offender Watch sex offender management, mapping and email alert program report dated 02/23/23 revealed Resident #02 was not an offender. Review of a facility SRI dated 02/23/23 at 1:45 A.M. revealed the initial SRI regarding resident-to-resident sexual abuse was started before 24 hours but was not completed as of this date. Review of State tested Nurse Aide (STNA) #100's statement dated 02/23/23 revealed she was walking down the hall towards the nurse's station when she looked into the Resident #01's room and noted Resident #02 was in his wheelchair, leaning over Resident #01. STNA #100 revealed she quietly stepped into the room and saw Resident #02 have his fingers inserted into Resident #01's vagina. STNA #100 revealed she startled Resident #02, and he yanked his hand back. STNA #100 revealed she could see his left hand's ring finger and middle finger were wet. STNA #100 revealed she asked Resident #02 what he was doing in Resident #01's room, and he said he was covering her up. STNA #100 revealed she told Resident #02 to leave the room and he followed her down to the nurse's station. STNA #100 revealed she told the nurse, and the nurse went immediately to do a head-to-toe assessment and Resident #02 was put on one on one. Review of the facility investigation dated 02/23/23 at 1:45 A.M. revealed STNA #100 notified Registered Nurse (RN) #200 at this time, that she witnessed Resident #02 sticking his fingers into Resident #01's vagina and when he noticed her presence in the room he pulled his hand back. Resident #01's brief was pulled to the side and Resident #02's hands were wet with vagina secretions. When interviewed by the nurse (RN #200), Resident #02 said he went into Resident #01's room to cover her up with a blanket. Residents #01 and #02 were immediately separated, and Resident #02 was escorted out of the room to his room. A skin assessment was completed for Resident #01 by RN #200 and no injuries were noted. At 7:20 A.M., nine-one-one (911) was called along with medics to transport Resident #01 to the hospital for examination. Resident #02 was put on one-on-one observation immediately. Resident #01's Power of Attorney (POA), niece, and Clinical Nurse Practitioner (CNP) were made aware. Review of the local hospital record dated 02/23/23 revealed SANE #19 did an examination on Resident #01 but the full report was unavailable at the time of this survey. The hospital notes documented Resident #01 was noted with a small amount of stool and blood in her depends. Resident #01 was treated and released back to the facility. Review of the local law enforcement preliminary investigation report, dated 02/23/23 at 9:59 A.M. revealed a call from the facility came into police station. The officer reported going to the facility at 11:53 A.M. to do an investigation of sexual assault. The report revealed Resident #02 was arrested for rape/sexual assault. Observation of Resident #01 on 02/28/23 at 8:35 A.M. and again at 1:30 P.M. revealed she was blind, hard of hearing, and unable to get out of bed. Resident #01 was not interviewable. Interview on 02/28/23 at 9:10 A.M., with SANE #19 revealed Resident #01 was examined at the hospital on 02/23/23 related to a resident-to-resident sexual abuse allegation. SANE #19 confirmed Resident #01 did have an abrasion of her fascia in her vagina. The fascia is a thin structure separating the vagina and the rectum. Interview on 02/28/23 at 12:06 P.M., with STNA #100, revealed on 02/23/23 at 1:45 A.M. she was doing her rounds and noticed Resident #01's legs could not be seen from the hallway. STNA #100 revealed she went in the Resident #01's room and Resident #02 was leaning over Resident #01 with his fingers in her vagina. STNA #100 revealed she asked him what he was doing in Resident #01's room, and it startled him, and he yanked his fingers out of her vagina and said he was just making sure she was coved up. STNA #100 revealed she asked Resident #02 to leave the room and went and got the nurse (RN #200) who immediately went and did a head-to-toe assessment. Interview on 02/28/23 at 12:52 P.M. with RN #200 revealed on 02/23/23, STNA #100 came to the nurse's station and told her that she witnessed Resident #02 sexually abusing Resident #01. RN #200 revealed Resident #02 kept saying she was wrong, and he wasn't doing anything. RN #200 revealed she did a head-to-toe assessment on Resident #01 and then notified the Director of Nursing (DON) who told her to place Resident #02 on one-on-one and call 911. RN #200 revealed upon entering the Resident #01's room the resident had a facility gown on and her incontinence brief was pulled to the side. RN #200 confirmed Resident #01's representatives were made aware of the resident-to-resident sexual abuse incident and initially did not want Resident #01 transferred to the hospital but later the representatives changed their minds. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2020, revealed the facility failed to implement the policy regarding keeping residents safe from sexual abuse. This deficiency represents non-compliance investigated under Complaint Number OH00140613.

Based on record review, hospital record review, staff interview, and facility policy review, the facility failed to ensure residents were free from significant medication errors. Resident #140 received the medication [MEDICATION(S)] (medication used for heart failure known as a angiotensin receptor blocker) and [MEDICATION(S)] (diuretic to treat fluid retention and swelling caused by congestive heart failure) when the physician ordered these medications to be held. This resulted in Actual Harm when Resident #140 developed a critical potassium level and required hospitalization . This affected one (Resident #140) of four residents reviewed for physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Record review revealed Resident #140 was admitted on [DATE] and readmitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #140's quarterly Minimum Data Set 3.0 (MDS) assessment, dated 07/16/22 , revealed the resident was cognitively intact. Resident #140 was independent with set up help only for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene and was continent of bowel and bladder. The resident was 64 inches tall and weighed 134 pounds with no significant weight loss or gain. Review of the plan of care, revised on 08/19/22, revealed Resident #140 has potential alteration in nutrition or hydration related to increased need for healing bilateral lower extremity surgical wound, fluid/weight balance related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include to follow physician ordered diet, monitor and record meal intake percentages and fluid volumes, and obtain weights as ordered. Review of Resident #140's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 20 milligrams (mg) tablet, give one tablet daily related to acute or chronic systolic congestive heart failure. Start 02/28/22 and discontinue on 08/16/22. -[MEDICATION(S)] 20 mg tablet, give one tablet daily for heart failure. Start on 08/20/22 and discontinue on 08/22/22. -Daily weights and send with him to heart failure clinic appointments one time a day for cardiac issues. Start on 08/22/22. -[MEDICATION(S)] 24-26 mg tablet, give one tablet two times a day for heart failure. Start on 02/27/22 and discontinue on 08/16/22. -[MEDICATION(S)] 20 milligram (mg) tablet, give one tablet daily for cardiac issues. Start 08/22/22. Record review revealed on 04/15/22 Resident #140 weighed 134 pounds; 05/06/22, 128.8 pounds; on 06/14/22, 130.2 pounds; on 07/15/22 , 134.2 pounds; and on 08/14/22, 147.6 pounds. Review of the document from the heart failure clinic, titled After Visit Summary, dated 08/01/22, documented to obtain a weight every morning with Resident #140's current weight for this visit being 132.6 pounds. On the medication list, there was a line drawn through the medication [MEDICATION(S)] 20 milligrams (mg), and [MEDICATION(S)] 24-26 mg with a handwritten note that said HOLD Review of the heart failure clinic After Visit Summary dated 08/08/22, documented the daily weights were not on track. Again a line was drawn through the medication [MEDICATION(S)] with a handwritten word HOLD. Weight noted for this visit was 134 pounds. Review of Resident #140 's encounter document, dated 08/16/22, created by Certified Nursing Practitioner (CNP) #200 revealed, Patient was seen in the heart failure clinic today. He was sent to the emergency department for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, he needs a consult to social work to assess his current extended care facility (ECF) as they have continued to not follow recommendations that were provided via phone and printed. On 08/01/22, Resident 140 had an increased blood urea nitrogen and creatinine (tests for kidney function) and an elevated potassium at 5.5 (normal 3.5 to 5). ECF was provided with an updated after visit summary with instructions to stop the medications [MEDICATION(S)] and [MEDICATION(S)]. This nurse was also called with instructions to stop [MEDICATION(S)] and [MEDICATION(S)]. On 08/08/22 patient returned to the heart failure clinic. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Potassium remained elevated at 5.5. A new after visit summary was sent and the facility was instructed to stop the [MEDICATION(S)]. Per health failure nurse documentation dated 08/08/22 Patient comes to us from ECF, brought updated medication list with him. Upon reviewing his list, it appears that [MEDICATION(S)] and [MEDICATION(S)] were not held as ordered last week. Also, patient is to be weighted daily, per patient that had not been completed. Call placed to ECF, spoke with Director of Nursing (DON). Relayed to her that orders were not carried out from last week. We now need to contact the DON with any medication changes. On 08/16/22 the patient returned to the heart failure clinic. MAR from facility dated 08/16/22 shows he continued to receive [MEDICATION(S)]. Potassium 6.3. Sent to emergency room . Review of Resident #140's emergency room triage notes, dated 08/16/22 revealed Resident #140 presents from a skilled nursing facility due to high potassium levels. Patient reports that he has been living at a facility since December of 2021 because he had part of his foot amputated. Patient reports that this facility has been giving him the wrong medications I guess which has caused his high potassium levels. Patient denies any nausea/vomiting this part week. Patient denies headache. Patient denies muscle cramping. This patient presented to the emergency department from heart failure clinic due to elevated potassium levels. In reading through the notes from the heart failure clinic, they have been trying to get his facility to adjust his medications and they have not been doing that. He has no complaints for me. Repeat potassium here is 6.4. No EKG changes consistent with [CONDITION(S)] were noted. We did advise the team from the heart failure clinic at their concerns with the living arrangements that need to go through the Ohio ombudsman, and they can file a complaint. In the meantime however we will provide patient with potassium for cardioprotective effects and Lokeima (indicated for the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #140's After Visit Summary from the heart failure clinic, dated 08/22/22, revealed a handwritten note at the top of the page that read Please have the Director of Nursing call heart failure clinic as soon as possible. Resident #140's weight for the day of this visit was 136.6 pounds. Highlighted was the following orders: daily weight and record, check blood pressure and record, 2000 milligram low sodium diet, [MEDICATION(S)] 10 mg daily. Also highlighted was the order for the [MEDICATION(S)] 20 mg with instructions to change the order. During interview on 08/23/22 at 10:45 A.M., the Director of Nursing (DON) stated it was identified that two medications were to be held and daily weights to be obtained as per consult notes. This was identified after Resident #140's appointment on 08/16/22. The DON stated she spoke to the physician's office after Resident #140's appointment on 08/22/22 to confirm the orders and they actually discontinued the [MEDICATION(S)]. Review of facility policy titled Medication and Treatment Orders, dated 03/01/22 revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing. The person receiving the order will be the one to document the order in the medical record. This deficiency substantiates Complaint Number OH 076.

Based on review of a Self-Reported Incident (SRI), review of the facility's investigation of the SRI, review of the nursing schedule, review of employee time reports, record review, resident interview, staff interview, review of employee personnel files, and policy review, the facility failed to ensure a resident was free from neglect when State tested Nurse Aide (STNA) #200 failed to respond to the resident's calls for assistance to have her basic care needs met. This resulted in Immediate Jeopardy with the potential for serious physical, mental, and/or psychosocial harm and wellbeing, when Resident #11 had her call light on waiting for assistance and called out for help to STNA #200 who walked by her room. STNA #200 deliberately chose not to respond to the resident's call light, nor did she acknowledge Resident #11's verbal calls for assistance as she passed by her door. Resident #11 was incontinent of urine and was requesting assistance to get ready for bed. STNA #200 was the only staff member on the unit at the time Resident #11 required assistance. STNA #200 had been avoiding entering that room and caring for those residents, as she felt Resident #11's roommate (Resident #45) had lied about her. This affected two (Residents #11 and #45) of four residents reviewed for neglect. The facility's census was 65. On 05/24/22 at 2:12 P.M., the Administrator, Director of Nursing (DON), Regional Operations Director #700, and Regional Nurse Consultant #720 were notified Immediate Jeopardy began on 05/09/22 at 7:30 P.M. when STNA #200 refused to respond to Resident #11's requests for assistance to have basic care needs met. STNA #200 was the only staff member working on the hall where Resident #11 resided. STNA #200 deliberately chose not to provide care to those residents in that room in response to Resident #11's roommate (Resident #45) allegedly telling lies on her. The Immediate Jeopardy was removed on 05/24/22, when the facility implemented the following corrective actions: · On 05/09/22 at 7:30 P.M., Resident #11 reported to Licensed Practical Nurse (LPN) #130, who was one of the nurses on duty at that time, that STNA #200 walked past her room while her call light was on. STNA #200 did not come into her room to provide care to the resident. Resident #11 stated she needed assistance with incontinence care. A family member of Resident #45, who was Resident #11's roommate and who was present at the time of the incident, provided care to Resident #11. Resident #11 also reported snacks and ice water had not been passed to her on that shift as well. · On 05/09/22 at 8:00 P.M., LPN #130 spoke with STNA #200 and instructed her on the need to provide care to all the residents on her assigned hall. · On 5/10/22 at 11:00 A.M., LPN #130 notified the DON of the incident. · On 05/10/22 at 4:00 P.M., the DON and the Minimum Data Set (MDS) assessment nurse LPN #167 interviewed Resident #11. The resident was assured by the DON and MDS nurse, STNA #200 would not work on her unit. An initial investigation was opened at that time. · On 05/10/22 at 5:00 P.M., the Administrator was notified of the alleged incident by the DON. · On 05/10/22 at 7:00 P.M., LPN #130 issued a written warning to STNA #200 regarding the occurrence. · On 05/11/22 at 9:00 A.M., the Administrator submitted the initial SRI. · On 05/11/22 at 6:30 P.M., the Administrator met with STNA #200 and requested a written statement about the alleged incident. STNA #200 provided her statement and was taken off the schedule pending the results of the investigation. · On 05/12/22 at 11:00 A.M., 50 residents were interviewed regarding whether they felt safe in the facility. All 50 residents that were interviewed indicated that they did feel safe. The remaining 20 residents, who were non-communicative or had a BIMS score below 11 were not interviewed. No concerns of any allegations of abuse/neglect were made known as a result of those interviews. · On 05/12/22 at 1:00 P.M., staff education was initiated by the DON on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property. · On 05/12/22 at 3:00 P.M., 22 direct care staff were surveyed to see if any of them were aware of residents stating staff were not responsive to their needs or were not answering call lights. All 22 reported not having any knowledge of those concerns. The 22 direct care staff were also asked if they were aware of any issues with the residents in room [ROOM NUMBER] (Residents #11 and #45). All 22 reported they were not aware of any issues. · On 05/16/22 at 10:00 A.M., STNA #200 was terminated as an employee of the facility for not following facility rules and federal/state rules and regulations regarding the allegation of neglect of Resident #11. · On 05/18/22 at 7:00 P.M., LPN #130 received a coaching education by the DON regarding the untimely reporting of suspected neglect to the Administrator/designee per the facility's policy. · On 05/24/22 at 3:24 P.M., all staff were educated by Human Resource Manager #220 on the facility's Abuse and Neglect Policy, reporting of abuse, passing ice water and snacks, and answering call lights. This was transmitted via the company Paycom Notification Center to each individual staff members' cell phone. · On 05/24/22 at 3:35 P.M., Admissions Director #330 met with Resident #11. Resident #11 voiced no concerns with her current care and felt safe in the facility. · On 05/24/22 at 4:30 P.M., the Ad hoc Quality Assurance Performance Improvement (QAPI) committee met to review the Immediate Jeopardy deficient practice. Medical Director #599 was notified of the Immediate Jeopardy situation. · On 05/24/22 at 5:00 P.M., five different staff members from admissions, housekeeping, human resources, nursing, and social services were interviewed by the DON/designee using an Abuse Quiz. All five employees passed the quiz. · On 05/24/22 at 6:06 P.M., a call light audit was completed by Medical Records Manager #610. All call lights were answered under five minutes. · On 05/24/22 at 6:08 P.M., 38 residents who were cognitively intact were interviewed by members of the Interdisciplinary Team (IDT) about feeling safe and cared for at the facility, if they received water and snacks, and staff assistance when needed. Thirty-three (33) of the 38 residents revealed they had no concerns with the questions. Five (5) of the 38 residents provided comments which were going to be further reviewed as to the reasons for their reply. · On 05/24/22 at 6:30 P.M., 23 residents with moderate to severe cognitive impairment received a skin assessment by the DON/designee. No concerns were identified of any injuries that were suspect of potential abuse/neglect. · Beginning on 05/24/22 (no time specified), a member of the IDT will conduct audits of three to five residents per day for five days, then five residents per week for 30 days, then five residents two times per month for 30 days to identify any concerns with abuse, neglect, exploitation, or misappropriation of resident property. Any positive responses would open a new investigation. · Beginning on 05/24/22 (no time identified), a member of the IDT will conduct audits with three to five staff member per day for five days, then five staff members per week for 30 days, then five staff members two times per month for 30 days to assess the staff's knowledge of the facility's abuse policy, passing snacks and ice water and answering call lights. An Abuse Quiz will be used. Any incorrect answers will require the staff member to re-read company policies and retake the quiz. · Beginning 05/24/22 (no time specified), a member of the IDT will complete three random call light audits per day for five days, then three audits per week for 60 days to assess staff response to call lights and ensure residents' needs are being met. Audits will be completed on both day and night shifts. · Beginning 05/24/22 (no time specified), the second shift nurse working on the Green Unit will verify snacks and ice water were passed each night for 30 days. Documentation will be noted on a calendar posted on the unit for this purpose. · Beginning 05/24/22 (no time specified), all new hires will be educated by Human Resource Manager #220 on the facility's Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy, passing snacks and ice water, and answering call lights. · Beginning 05/24/22 (no time specified), the findings of all audits will be reviewed during the weekly QAPI meetings for 60 days. Results will determine if ongoing audits continue. · On 05/26/22 from 10:03 A.M. to 10:09 A.M., interviews with LPN #130, LPN #425, STNA #400, and Housekeeper #413 revealed all staff confirmed they received education and knew they needed to report allegations of abuse/neglect immediately, had to pass ice water and snacks to all residents and could not pick and choose who they provided care too. Although the Immediate Jeopardy was removed on 05/24/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the facility submitted SRI revealed an allegation of neglect was made known on 05/10/22. The initial source of the allegation was a resident victim, and the alleged perpetrator was a facility staff member. The involved resident was identified as Resident #11, and the alleged perpetrator was STNA #200. The date of discovery was indicated to be 05/10/22 and the SRI's initial report was noted to have been submitted on 05/11/22. Information included under the involved resident section of the SRI revealed Resident #11 was able to provide meaningful information when interviewed. The effects the incident had on the resident initially was a concern of lack of care and feeling like she was not safe. The SRI's summary of the incident revealed the date, time, and location of the occurrence was on 05/09/22 at 7:30 P.M. outside the resident's room. LPN #130 informed the DON she was walking past Resident #11's room, when the resident called her into the room to talk to her. Resident #11 reported STNA #200 would not go into their (her and her roommate's) room. Resident #11 stated STNA #200 passed snacks and ice water and did not give them anything. Resident #11 also stated she turned her call light on because she needed to be changed, but STNA #200 never stopped in their room. LPN #130 asked Resident #11 if she felt safe in the facility and the resident indicated she did not. She was asked why and replied, if she or her roommate had a fall, she would feel unsafe because she knew STNA #200 would not come in the room to help them. The SRI revealed LPN #130 talked to STNA #200 about Resident #11's concerns and explained to her that there was no reason for her not to give care to those residents. STNA #200 was asked to provide a statement. She was also asked by the Administrator to provide a statement prior to the start of her shift on the following evening. It was then that STNA #200 was asked to leave until the investigation of the alleged incident was completed. The SRI revealed Resident #11 and her roommate (Resident #45) were both interviewed by the DON. When Resident #11 was asked to explain what happened with STNA #200 the other day, she stated that STNA #200 insisted on not doing her job. She was then asked why she did not feel safe, and she replied she did not feel safe because several weeks ago she asked STNA #200 to do something for Resident #45 and she just walked out of the room. She did not feel safe because, if there was an emergency, that could be dangerous. She then stated she felt safe now as STNA #200 was not in the building. A review of the written witness statements obtained during the facility's investigation of the allegation of neglect revealed written witness statements were obtained from STNA #200 and Resident #45's family member. There was a copy of an email that was sent from LPN #130 to the DON dated 05/11/22 at 1:44 P.M. A written statement from Resident #11 or LPN #130 was not included as part of the facility's investigation packet. On 05/24/22 at 9:56 A.M. during an interview with the Administrator, he indicated LPN #130's statement was what was included in the SRI from her conversations she had with the DON. The Administrator verified Resident #11 did not write down a statement but had been interviewed by the DON as part of the facility's investigation. Review of the SRI revealed STNA #200 provided two written statements regarding the incident. One was undated but referenced the events that occurred on Monday evening 05/09/22. The statement provided addressed questions on ignoring any call lights or not passing water and snacks. STNA #200 indicated she worked on 05/09/22 from 7:00 P.M. to 7:00 A.M. She reported her hall partner was running late so she decided to pass snacks and ice. She passed all the snacks and ice except to the residents in room [ROOM NUMBER] (Resident #11 and #45) because she does not go in that room any more due to the residents talking lies on her. So, to keep herself safe, she just did not go into that room. STNA #200 identified her co-workers understood and they assisted with that room. STNA #200 denied the call light was ever on as indicated by Resident #11. STNA #200 reported she asked the nurse if she could please give the residents in room [ROOM NUMBER] snacks and water because she did not feel safe going in that room. The nurse informed her that she would. STNA #200 then proceeded to say in her statement that she had no problem doing her job but, to keep herself from getting in trouble she just did not go into Resident #11's and #45's room. The second written statement from STNA #200 that was dated 05/10/22 revealed the same information as in her other statement but it also included additional information as to why she did not go into the room. She alleged both residents (Resident #11 and #45) told a lie on her. To keep her job, she preferred not to go in that room. A written statement from Resident #45's family member dated 05/10/22 revealed she was there visiting her mom when Resident #11 called for STNA #200 to change her. STNA #200 kept walking so she ended up changing Resident #11 and got her ready for bed as she did for her mom (Resident #45). Resident #11 told her that STNA #200 never walked into their room, and they never got changed. STNA #200 reportedly told Resident #11 she was not allowed in their room. Review of a copy of the email sent from LPN #130 to the facility's DON on 05/11/22 at 1:44 P.M. revealed she informed the DON that she was walking past Resident #11's room and was called into the room by the resident. Resident #11 informed her that STNA #200 would not come in her room. Resident #11 also informed her that STNA #200 passed snacks and ice water last night and did not give them (her and her roommate) anything. Resident #11 reported she called out to STNA #200 as she walked past but she just kept walking. She turned her call light on because she needed to be changed but STNA #200 never stopped in their room. Resident #45's daughter was indicated to have changed Resident #11. Resident #11 informed her that she did not feel safe having STNA #200 as her aide. Her concerns were what would happen if she or her roommate fell . She knew STNA #200 would not go in their room to help them. She did not feel it was fair for her to have to feel that way and was not sure what they ever did to her (STNA #200). LPN #130 informed Resident #11 that she would report the issue and would see it through to be resolved. The email indicated the nurse had STNA #200 and Resident #45's family member, write statements of their own. She did not leave the statements in the building due to the night shift aides going into mailboxes looking at other people's paperwork as far as bonuses. She knew they would go in and read the statements. A review of a disciplinary action form included as part of the facility's investigation revealed STNA #200 was given a written warning on 05/10/22. The reason for the disciplinary action was indicated due to the employee refusing to give care to the residents in room [ROOM NUMBER]. There was no reason indicated as to why STNA #200 should not provide care to those residents. There were no reported problems with the employee or the residents in that room. Improvement needed included teaching of job description needed to be implemented. As a result of the facility's investigation into the allegation of neglect, they unsubstantiated the allegation. Their investigation determined the incident did occur; however, the facility did not feel they could identify the intent to cause harm. A review of Resident #11's electronic health record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's quarterly MDS assessment dated [DATE] revealed she did not have any problems with her speech, vision, or hearing. She was able to make herself understood and was able to understand others. She was also cognitively intact and not known to display any behaviors or reject care. She required an extensive assist of one for bed mobility, locomotion, dressing, personal hygiene and toilet use. She was dependent on two for transfers. On 05/24/22 at 9:56 A.M., an interview with the facility's Administrator revealed the facility did not substantiate Resident #11's allegation of neglect as there was no willful intent to cause any harm. He acknowledged there does not have to be a willful intent to inflict injury or harm. The definition of willful was that the individual acted deliberately. The act of the employee walking past the resident's room disregarding her call for assistance and refusing to provide care to the residents in that room was a deliberate act. The Administrator acknowledged the family member of Resident #45 (who did not work in the facility) ended up providing incontinent care and assisting with getting Residents #11 and #45 ready for bed. The Administrator stated the other factor in not substantiating the allegation of neglect was that the employee and resident had different stories. The Administrator acknowledged Resident #11 was cognitively intact and they also had a written statement from Resident #45's family member who supported Resident #11's facts she gave of the alleged incident. The Administrator then agreed the facility should have substantiated the allegation of neglect based on those facts. The Administrator confirmed the allegation of neglect was not reported to him immediately as per their abuse/neglect policy. The DON had not been made aware of the allegation of neglect by Resident #11 until 05/10/22, the day after it had been made known to LPN #130. The Administrator was not informed about the allegation of neglect until the following day, 05/11/22. That was when the initial SRI was submitted. On 05/24/22 at 10:20 A.M., an interview with Resident #11 revealed STNA #200 did refuse to assist her with care the evening of 05/09/22. Resident #11 reported she had her call light on and needed to be changed and assisted with getting ready for bed. Resident #11 confirmed she was already incontinent when she put her call light on and wanted the aide to change her incontinent brief. Resident #11 also called out to STNA #200 when she walked past her room, but the aide ignored her and kept walking by. Resident #11 stated there had been a pattern with her (STNA #200). Before it was just her roommate (Resident #45) that she refused to assist care with but eventually it included her too. Resident #11 confirmed her roommate's daughter, who was visiting, ended up providing her with the care she needed. Resident #11 stated it was upsetting to her and she did not feel it was her roommate's daughter's responsibility to provide her with care when visiting. Resident #45's daughter used to work at the facility as an aide but did not currently work there. Resident #11 stated she was worried something would happen that they needed emergent care, such as chest pain from a [CONDITION(S)], and the aide would not respond to their call for help. Resident #11 stated she was not sure why she refused to take care of her but was aware the aide thought her roommate said some lies about her. Some nights, STNA #200 was the only one on the hall. STNA #200 refusing to come into their room had been going on for the past three or four weeks before the incident on 05/09/22 but, that was the only time someone else was not there to assist them with their care. On 05/24/22 at 10:37 A.M., an interview with LPN #130 revealed she was the nurse that Resident #11 called into her room to report concerns she had with STNA #200. LPN #130 was a little unclear with her recollection of when the incident occurred and when she was notified of it. LPN #130 denied she was assigned to work the resident's hall but was just passing by when Resident #11 called for her to come into her room. It was then that Resident #11 told her what took place with STNA #200. LPN #130 was told STNA #200 walked past her room when the resident had her call light on and when calling out to her as she passed by. LPN #130 confirmed Resident #11 told her she did not feel safe and was concerned something may happen. LPN #130 reported she got statements from Resident #11, STNA #200, and Resident #45's daughter as she was a witness to the alleged incident. LPN #130 notified the DON of the incident on 05/10/22. LPN #130 was given a verbal warning for not timely reporting it to the DON or Administrator. LPN #130 stated she had informed the nurse assigned to that unit what was going on when it happened on 05/09/22 and claimed everyone knew. LPN #130 stated she was going to put the witness statements she obtained on 05/10/22 in the DON's mailbox but, was worried some of the staff may read them as they tended to go through other people's mailboxes. LPN #130 decided to pull them out and send an email instead, which she did on 05/11/22. LPN #130 was asked if she considered what happened to Resident #11 as neglect and she stated she did. On 05/26/22 at 10:33 A.M., an interview with LPN #130 revealed Resident #45's daughter did not typically assist the resident with personal care when visiting. LPN #130 stated it was because the daughter observed STNA #200 to pass by the room and ignore Resident #11's request for assistance that Resident #45's daughter decided to go ahead and change the residents in that room and get them ready for bed. LPN #130 also stated Resident #45's daughter had to come out and request ice water and a snack for Resident #45 since STNA #200 did not pass them to that room on 05/09/22. A review of STNA #200's employee file revealed her employment at the facility had been terminated. The reason for the termination was marked as other with the explanation referring to an SRI. The employee was not eligible for re-hire. A review of LPN #130's employee file revealed she received a disciplinary action on 05/18/22. The type of warning given was indicated to be a coaching warning. The reason for the disciplinary action was not reporting immediately to her supervisor/DON any resident concerns/ complaints. The coaching warning was given over the phone by Human Resource Manager #220. A review of the staffing schedule for the nurses and aides for 05/09/22 through 05/11/22 revealed LPN #130 and STNA #200 both were assigned to work on 05/09/22 and 05/10/22. LPN #130 worked from 7:00 A.M. to 11:00 P.M. on 05/09/22. She was not assigned to work on Resident #11's unit that night. LPN #130 was scheduled to work the following day on 05/10/22 but again, not on Resident #11's unit. STNA #200 was scheduled to work night shift from 7:00 P.M. to 7:00 A.M. on 05/09/22. STNA #200 was assigned as one of two aides that were supposed to work Resident #11's unit that night. STNA #200 was scheduled to work again on 05/10/22 from 7:00 P.M. to 7:00 A.M. but on that night it was on a different unit. A review of the time reports for LPN #130 and STNA #200 confirmed they clocked in and out at the times consistent with the schedule. STNA #200 worked on 05/10/22 from 6:54 P.M. to 8:46 A.M., despite an allegation of neglect being made known about her by Resident #11 on 05/09/22. A review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised October 2020 revealed the facility would not tolerate abuse, neglect, and exploitation of its' residents or the misappropriation of resident property. It was the facility's policy to investigate all alleged violations involving abuse and neglect of a resident. The facility staff should immediately report all such violations to the Administrator and the Ohio Department of Health in accordance with procedures in the policy. 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. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. If a staff member was accused or suspected of abuse or neglect, the facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation. All incidents and allegations of abuse or neglect must be reported immediately to the Administrator or designee. This deficiency substantiates Complaint Number OH 852.

Based on closed record review, facility policy and procedure review and interview the facility failed to ensure Resident #66 received non-invasive ventilator (NIV) support in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Actual harm occurred on 05/19/22 when Resident #66 was transferred to the hospital and admitted for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to the hospitalization , on 04/18/22 results of a sleep study recommended the use of an automatic adjusting continuous positive airway pressure ([CONDITION(S)]) machine for the resident. The machine was not ordered until 05/03/22 and then not provided as ordered for the resident between 05/03/22 and 05/19/22 resulting in an acute change in condition, development of shortness of breath, abnormal lung sounds and lung infiltrates (indicative of pneumonia) first identified by the resident's family. The resident did not return to the facility following the hospitalization . This affected one resident (#66) of three residents reviewed for NIV use. Findings include: A review of Resident #66's closed electronic health record (EHR) revealed the resident was admitted to the facility on [DATE]. The resident was hospitalized on [DATE] and readmitted to the facility on [DATE], where she remained in the facility until being transferred to the hospital again on 05/19/22. Resident #66 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #66's nursing progress notes revealed a nurse's note, dated 04/12/22 at 7:46 P.M. that indicated the resident's daughter notified the nurse the resident had been previously using a continuous positive airway pressure ([CONDITION(S)]) machine until it was recalled. A certified nurse practitioner was in to see the resident and gave a new order to obtain a sleep study. A review of Resident #66's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #66's nurses' progress notes revealed a nurse's note, dated 04/15/22 revealed the sleep study equipment was to be delivered on 04/18/22. Resident #66's family was to bring her [CONDITION(S)] machine she had at home that had never been used. The note indicated the resident had been admitted to a different nursing facility and never had orders to utilize a [CONDITION(S)] machine. A physician was to review the sleep study results for potential sleep study orders. The sleep study was completed on 04/18/22 as ordered. A review of Resident #66's sleep study report, dated 04/18/22 revealed the sleep study started at 11:08 P.M. and ran through 7:58 A.M. on 04/19/22. The total recording time was eight hours and 50 minutes. Her total sleep time during the study was 4 hours and 43 minutes. The summary and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had significant oxyhemoglobin desaturation during the study, with lowest saturation of 81%. Recommendations made as a result of the sleep study was a trial of an automatic adjusting [CONDITION(S)] 5-20 cm water with heated humidification for comfort. On 05/03/22 (15 days after the sleep study was completed) a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the resident was to receive 5-20 cm/H2O per the resident's home machine and was to be worn during sleeping hours and as needed (PRN). A review of Resident #66's progress notes revealed a respiratory note by Respiratory Therapist (RT) #255. The note indicated the AutoPAP set up was completed with the resident's home machine on 05/03/22. A review of Resident #66's treatment administration record (TAR's) for May 2022 revealed the use of AutoPAP 5-20 cm/H2O per resident home machine to be worn during the night and PRN was being initialed to show the order was implemented. Staff noted on the TAR for 05/04/22 and 05/07/22 the resident refused the APAP machine. A review of Resident #66's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. that indicated the resident refused the APAP machine on that night and also indicated it was broke and/or missing a piece. An eMAR note, dated 05/08/22 at 1:54 A.M. revealed the resident had again refused the APAP machine. Neither eMAR note was specific to what was exactly refused or what was broke/missing a piece but coordinated with the dates the resident was indicated to have refused the APAP machine during those nights. There was not a nurse's initial for 05/15/22 to provide documented evidence of the resident wearing or having been offered her APAP on that night shift. A review of Resident #66's nurses progress notes revealed a nurse's note, dated 05/18/22 at 7:44 P.M. indicating the resident's family was concerned about the resident sounding short of breath. She was also assessed to have bilateral expiratory wheezes in her lungs. The certified nurse practitioner (CNP) was notified of the resident's family's request to obtain a chest x-ray. A new order was given to obtain a stat chest x-ray as requested by the family. The x-ray results showed bilateral pulmonary (lung) infiltrates (evident of pneumonia) and were received by the facility on 05/19/22 at 3:13 A.M. The on call nurse practitioner was notified but no additional orders were received other than to continue to monitor the resident for respiratory symptoms. The next relevant note was a nurse's note dated 05/20/22 at 11:32 A.M. that indicated the resident was hospitalized and not expected to return at that time. There were no progress notes in between or a change in condition note that explained what transpired that resulted in the resident being sent to the hospital. A review of Resident #66's hospital records for her admitted d, 05/19/22 revealed a hospital history and physical (H&P) that indicated the resident had acute on chronic [CONDITION(S)] with hypoxemia/ hypercapnea suspect due to decompensated OSA/ [NAME] (Obesity Hypoventilation Syndrome) in setting of polypharmacy. Per the husband's report, the nursing facility was not placing her on her [CONDITION(S)] machine at night. She arrived drowsy but did awaken periodically. She was given [MEDICATION(S)] for reported opioid use she took for left hip pain. She improved thereafter, but still required non-invasive pulmonary ventilation (NIPV). She arrived to the Medical Intensive Care Unit (MICU) off bilevel positive airway pressure ([CONDITION(S)]), awake and alert/ oriented. She was saturating at 100% on four liters of oxygen per nasal cannula. The hospital planned to wean her down with a plan for the [CONDITION(S)] to be worn during the night and PRN. She historically had OSA and nocturnal [CONDITION(S)] for now, but would eventually use a [CONDITION(S)] at night. A review of Resident #66's Pulmonary and Critical Care H&P, dated 05/19/22 revealed the resident's husband stated she had not been wearing her NIV at night at the nursing facility. Apparently, they had not been placing it on the resident. The resident required NIV nightly and as needed with naps especially in light of her use of [MEDICATION(S)]. She was also diagnosed with [CONDITION(S)] toxic/metabolic which had improved after [MEDICATION(S)] was administered in the emergency room . It was likely due to untreated OSA/[NAME] combined with the use of [MEDICATION(S)]. On 05/23/22 at 3:15 P.M. an interview with Physical Therapy Assistant (PTA) #23 revealed she was the daughter of Resident #66. She confirmed the resident had a sleep study done on 04/18/22 that recommended the trial use of an automatic adjusting [CONDITION(S)] machine nightly when the resident slept. She was not sure why the use of the APAP machine was not ordered until 05/04/22. She stated her father had brought the resident's machine in from home around the time of her sleep study for her to use. She reported the resident had the use of a [CONDITION(S)] machine when she was at home. She denied the resident had the use of the [CONDITION(S)]/ APAP machine while at the facility. She denied it was used between 05/03/22 and 05/19/22 even after it had been ordered. She was not sure why it was not being used and denied it was broken or missing a piece. She stated the machine was brand new out of the box as the resident had received a new one when her prior machine was recalled. She stated the only thing it needed was distilled water and she was under the impression the facility would supply that. She had contacted the home medical supply company that provided the APAP machine the resident used. There was no data available to pull up a report after 05/03/22 to show it was being used nightly as ordered. She stated the home medical equipment company told her when the machine was on it connected automatically and provided them with that data regarding the usage. They informed her they did not have data on or after 05/03/22 because the modem stopped sending data. They informed her the most likely reason for that was the modem was shut off. On 05/24/22 at 6:13 A.M. an interview with State tested Nursing Assistant (STNA) #26 revealed she had worked at the facility for four months and was on the night shift working from 7:00 P.M. to 7:00 A.M. She was familiar with Resident #66 as she worked on her unit when she was there. She stated Resident #66 was supposed to have oxygen on and that was all that she knew of. She denied the resident had the use of any other respiratory appliances to include an APAP machine. The STNA revealed oxygen was the only thing she ever saw the resident have on. She reported she took care of the resident the night before she went to the hospital. She stated she saw the APAP machine sitting on the resident's nightstand in front of her cabinet but did not know what that was and never saw it connected to her. The STNA denied she had ever seen the resident wearing a mask of any kind that would have been connected to the APAP machine by a corrugated hose if used. She thought she would have seen it on the resident if used as she took care of her often. On 05/24/22 at 7:07 A.M. an interview with STNA #39 revealed she had worked at the facility for a year. The STNA revealed she worked night shift and was assigned to work both sides of the facility and was familiar with Resident #66. She recalled the resident had the use of oxygen per nasal cannula on a continuous basis. The STNA revealed the resident also had a breathing machine in her room but it was never put on her at night and stated she was not sure the reason why it was not being applied. STNA #39 revealed the nurse just never came in to put it on. She reported between 05/03/22 and 05/19/22 she did not observe Resident #66 to be wearing a respiratory mask of any kind that was connected to that breathing machine by a hose. The only thing she saw the resident have on was her oxygen that was administered through tubing (a nasal cannula) that went into her nose. On 05/24/22 at 8:45 A.M. an interview with Licensed Practical Nurse (LPN) #42 revealed he had worked at the facility for about 15 months. LPN #42 revealed he was a day shift nurse working between 7:00 A.M. and 7:00 P.M., had worked on all units and was familiar with Resident #66 as he took care of her a lot. LPN #42 indicated he felt he a good relationship with both the resident and her family. He confirmed the resident used oxygen on a continuous basis by a nasal cannula. The LPN was asked if the resident had the use of any other respiratory appliances and stated there was a prescription for a [CONDITION(S)] machine and he had been informed by the family the resident used one while at home but did not have it as it had previously been recalled. LPN #42 recalled the resident had a sleep study done in April 2022 and they had not been informed there was a recommendation for her to use a [CONDITION(S)] again. The respiratory therapist made the recommendation but they did not get the order until 05/03/22 to use the [CONDITION(S)]. The LPN revealed they were going through a transition period with a lot of changeover with both the respiratory therapists (RT) they were using and the facility Director of Nursing (DON). The previous RT had given the previous interim DON the order for [CONDITION(S)] and during that time the RT left. A new RT then took over the position. RT #255 informed him she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated it had been difficult staying up on things due to the facility transitioning between RT and DON staff. LPN #42 revealed he was not sure what [CONDITION(S)] machine was provided to the resident, if it came from the family or one that was provided by the facility. He stated he never saw it on the resident and then indicated since he worked during the day, it would not have been in place. LPN #42 reported he was aware of one of the resident's daughters voicing concerns with it not being on the resident as reported by the resident. On 05/24/22 at 11:01 A.M. an interview with RT #255 revealed she was the facility's contracted respiratory therapist and had been providing services at the facility for four weeks now. She confirmed Resident #66 had her own APAP machine. She stated she was the RT who looked at the machine and made sure the settings were based on the recommendations from the sleep study the resident had done recently. She recalled the resident had a Respiratory Stream station (one of the newer ones) and confirmed it was an AutoPAP machine. Her settings was 5-20 cm/H2O. She confirmed it was all the resident's own equipment but was not aware of when it was made available to them. All she knew was it was there on 05/03/22 when she set it up. She was not sure why there was a delay between the time the sleep study was done and recommendations were made to when the APAP was ordered by the physician. She denied it was missing any pieces or had any broken parts that she was aware of. She could not recall if it had humidification for the resident's comfort or not. She stated with that equipment it would have been a slide in and something the home medical supply company would have provided if heated humidification was ordered. A review of the facility undated policy titled Noninvasive Ventilation ([CONDITION(S)], [CONDITION(S)], AVAP Trilogy) revealed it was the policy of the facility to provide noninvasive ventilation as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Common equipment included the machine, tubing, mask, headgear/ straps, disposable/ non-disposable filters and humidifier chamber. The facility would obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)], [CONDITION(S)], Trilogy must be set up. A personal [CONDITION(S)]/ [CONDITION(S)]/ Trilogy device may/ may not be brought into the facility for the resident's use. If brought in, the nurse/ respiratory therapist would verify the settings on the machine prior to use. The facility would follow the manufacturer's instructions for use of the machine. This deficiency substantiates Complaint Number OH 852.

Based on record review, review of facility medication error reports, review of the facility policy and procedure related to Medication Administration and Documentation, and interviews with facility staff including Corporate Registered Nurse (RN) #205, the Director of Nursing (DON), Nurse Practitioner (NP) #210 and Registered Nurse (RN) #121, the facility failed to provide quality care and treatment by ensuring an effective system was in place to properly identify residents on admission to ensure appropriate care and services were provided and all physician orders were delivered as prescribed to meet the total care needs of Resident #46 and Resident #04. This resulted in Immediate Jeopardy when Resident #46 and Resident #04 were admitted to the facility on [DATE] from another long-term care facility for COVID-19 care. Following admission, staff failed to correctly identify the resident's name/identity resulting in the residents being mixed up with one another. From 01/23/21 until 01/26/21, the residents received each other's medications, treatments, and care orders. The lack of an effective system and procedures to accurately identify residents, placed two (#04 and #46) of five sampled residents at risk for serious life-threatening harm, impairment or death when staff provided care, treatment and physician's orders incorrectly to the wrong resident over a three day time period. The facility census was 62. On 02/04/21 at 2:45 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 01/23/21 when Resident #04 and #46 were admitted to the facility for COVID-19 care from another facility and for three days (01/23/21 to 01/26/21) received physician ordered medications, treatments and care under the other resident's identity, without staff knowledge or proper identification. This was identified by Resident #46's family and brought to the attention of the facility on 01/26/21 when they (family) were asked to participate in a care conference and Resident #04, who was incorrectly identified to be their father (Resident #46), was present for the conference. The Immediate Jeopardy was removed on 01/26/21 at 11:30 P.M., when the facility implemented the following corrective actions: · On 01/26/21 at 10:50 A.M., the DON, Social Service Director (SSD) #117 and Agency Licensed Practical Nurse (ALPN) #185 were made aware the facility had incorrectly identified Resident #46, who was hospitalized at the time as Resident #04, and Resident #04 who was incorrectly identified as Resident #46 by Resident #46's family during a scheduled facility family/resident care conference. · On 01/26/21 at 10:52 A.M., Resident #46's family was notified Resident #46 had been transferred to an acute care hospital (on 01/25/21) for respiratory distress secondary to COVID-19 during the care conference by the DON. · On 01/26/21 at 10:55 A.M., Resident #04 was immediately assessed with [REDACTED]. · On 01/26/21 at 11:00 A.M., the DON notified Physician #200 of medication errors that had occurred related to Resident #04 receiving Resident #46's medications and vice versa from 01/23/21 to 01/26/21. The DON also reviewed the medications, allergies and side effects of the medications with Physician #200. Physician #200 did not implement any new orders at that time. · On 01/26/21 at 11:00 A.M., Corporate Registered Nurse (CRN) #205 reviewed Resident #04's medical record and initiated a mood and pain assessment. · On 01/26/21 at 11:05 A.M., the DON verified the identity of all residents on the COVID-19 unit. Identification bracelets were placed on the four residents, Residents #01, #02, #03 and #04, remaining on the COVID-19 unit as well as identifiers being placed on the nameplates outside the four resident's doors. · On 01/26/21 at 11:30 A.M., CRN #205 notified the corporate regional team of the medication errors involving the mistaken identities of Resident #04 and Resident #46. · On 01/26/21 at 11:33 A.M., CRN #205 notified the pharmacy and Pharmacy Consultant #202 completed a review of Resident #04 and #46's medications, demographics and medication interactions. · On 01/26/21 at 11:35 A.M., CRN #205 and the DON verified the identity of all residents residing on the COVID-19 unit. Photograph verification was then completed for all resident's residing in the facility. Identification bracelets were placed on the residents on the COVID-19 unit as well as all residents residing in the facility who could not self-identify. · On 01/26/21 at 11:40 A.M., the DON completed an audit on all residents to confirm their identification and to ensure proper identification on doors and in the electronic medical record were in place. · On 01/26/21 at 11:40 A.M., the DON initiated education for all nurses regarding resident identifiers, admission process and the five rights of medication administration. Education for all facility nursing staff was completed by 01/26/21 at 11:30 P.M. · On 01/26/21 at 12:00 P.M., the DON reviewed all residents admitted since 01/23/21 and reviewed each resident to ensure identifiers were in place and medication orders were correct. · On 01/26/21 at 12:00 P.M., the DON initiated an audit for all admissions for the past 30 days to review for proper identification with no negative findings. · On 01/26/21 at 4:45 P.M., a Quality Assessment Performance Improvement (QAPI) meeting was held to review the action items taken and to provide recommendations for additional items. Team members present at the meeting included the Administrator, DON, CRN #205, Nurse Practitioner #206, Registered Nurse (RN) #121, SSD #117 and Assistant Administrator #130. · On 01/26/21 at 11:30 P.M., the facility determined the corrective action implemented was completed. · On 01/27/21 at 7:30 A.M., the DON/designee(s) began audits to ensure wrist bands were on residents, resident photographs were in the electronic medical record and door identifications were in place. · On 01/28/21 at 8:00 A.M., Chief Nursing Officer (CNO) #201 reviewed and revised the emergency nursing preparedness plan to address the facility process for confirming resident transfers as a result of an emergency. The process was revised to address a hand-off procedure from the transferring facility and a double check system for the receiving facility to ensure proper resident identification. · On 01/28/21 at 8:00 A.M., CNO #201 reviewed the admitting process and revised the process to have two staff members confirm the identity of all new admissions and the need to ensure identification bands were on new admissions for a period of at least the first 14 days. · On 01/29/21 at 8:00 A.M., the DON/designee began random staff interviews regarding the new admission policy and procedure. All new admissions would be audited to ensure that identity verification was completed. Audits would continue daily for at least two weeks and then three times a week. · On 01/29/21 at 3:00 P.M., an additional QAPI meeting was held to review implemented action items with the above team members present. Although the Immediate Jeopardy was removed on 01/26/21, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings Include: Review of Resident #46's medical record revealed an admission date of [DATE]. The resident was discharged to an acute care hospital on [DATE] for respiratory distress secondary to COVID-19. The resident did not return to the facility. Resident #46 had [DIAGNOSES REDACTED]. Review of Resident #46's electronic medical record revealed the following assessments were crossed out with a notation of wrong resident: A 01/23/21 pain assessment, smoking assessment, oral assessment, abnormal involuntary movement scale (AIMS) assessment, pressure ulcer prevention/treatment, admission assessment with baseline plan of care, admission/readmission screener, bowel and bladder assessment, Braden scale assessment and a fall risk evaluation. Additionally, there was a 01/24/21 assessment for COVID-19 and nurse's note and a 01/25/21 assessment for COVID-19 and nurse's notes. Review of Resident #46's medication orders from admission revealed the following orders: [MEDICATION NAME] 5 milligrams (mg) by mouth daily, Aspirin 81 mg by mouth daily, Vitamin B12 1000 micrograms (mcg) by mouth daily, [MEDICATION NAME] 10 mg by mouth daily, [MEDICATION NAME] 5 mg by mouth daily, [MEDICATION NAME] 25 mg by mouth daily, Latanoprost [MEDICATION NAME] 0.005% with the special instructions to instill one drop in both eyes at bedtime, [MEDICATION NAME] 5 mg by mouth daily at bedtime, [MEDICATION NAME] 500 mg by mouth daily, [MEDICATION NAME] 25 mg by mouth twice daily, [MEDICATION NAME] 25 mg by mouth daily, [MEDICATION NAME] 40 mg by mouth daily at bedtime and [MEDICATION NAME] 0.4 mg by mouth daily at bedtime. The resident also had orders for occupational therapy (OT)/Certified Occupational Therapy Assistant (COTA) to treat five times a week for 30 days with interventions to include activities of daily living (ADL), therapeutic exercise/activities, re-education, resident/caregiver instructions to maximize safety and independence and an order dated, 01/25/21 for physical therapy (PT) to treat at least five times a week for 30 days for gait training, therapeutic activity, therapeutic exercise and neuromuscular re-education. Review of Resident #04's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #04 was discharged from the facility on 02/04/21 to the previous long-term care facility he resided in. Review of Resident #04's electronic medical record revealed Resident #04 had the following assessments in his record crossed out with a notation of wrong resident: A 01/23/21 pain assessment, smoking assessment, oral assessment, abnormal involuntary movement scale (AIMS) assessment, pressure ulcer prevention/treatment, admission assessment with baseline plan of care, admission/readmission screener, bowel and bladder assessment, Braden scale assessment and a fall risk evaluation. Additionally, there was a 01/24/21 assessment for COVID-19 and nurse's note and a 01/25/21 assessment for COVID-19 and nurse's notes. Review of Resident #04's admission medication orders revealed orders for [MEDICATION NAME] 0.5 mg by mouth three times a day, [MEDICATION NAME] 25 mg by mouth twice a day, [MEDICATION NAME] 300 mg by mouth two times a day, [MEDICATION NAME] 30 mg by mouth daily, [MEDICATION NAME] 10 mg by mouth daily, Trazadone 50 mg by mouth daily at bedtime, Sennosides 8.6 mg with the special instructions to administer two tablets by mouth daily, [MEDICATION NAME] 5 mg by mouth twice daily and [MEDICATION NAME] 100 mg by mouth daily. The resident also had orders, dated 01/24/21 for OT/COTA to treat five times a week for 30 days with interventions to include activities of daily living (ADL), therapeutic exercise/activities, re-education, resident/caregiver instructions to maximize safety and independence and for physical therapy, dated 01/25/21 to treat at least five times a week for 30 days for gait training, therapeutic activity, therapeutic exercise and neuromuscular re-education. Review of a facility medication error report for Resident #46, dated 01/26/21 at 11:45 A.M. revealed Resident #46 had been admitted to the facility within the past 72 hours and the resident had received the wrong medications. Review of a medication error report for Resident #04, dated 01/26/21 at 11:46 A.M. revealed Resident #04 had been admitted to the facility within the past 72 hours and the resident had received the wrong medications. On 02/03/2021 at 11:42 A.M., interview with CRN #205 and the DON revealed Resident #04 and Resident #46 were admitted on [DATE] to the facility COVID-19 unit from another skilled nursing facility for COVID-19 care. At the time of the interview, CRN #205 and the DON verified the resident's identities had been mixed up after their admission resulting in Resident #04 receiving Resident #46' medications, treatments and care orders and Resident #46 receiving Resident #04's medications, treatments and care orders from 01/23/21 to 01/26/21. CRN #205 confirmed Resident #46's documentation, including admitting assessments from 01/23/21 to 01/25/21 (when the resident was hospitalized ) were documented in Resident #04's medical record and Resident #04's documentation, including admitting assessments from 01/23/21 to 01/26/21 were documented in Resident #46's medical record. The DON confirmed Resident #46 had a change in condition, on 01/25/21, including transfer to an acute care hospital for respiratory distress secondary to COVID-19 which was documented in Resident #04's medical record. The DON also confirmed Resident #04's family was notified of the transfer to the acute care hospital instead of Resident #46's family. The DON revealed the facility was unaware of the resident's identities being mixed up until Resident #46's family alerted them during a care conference (on 01/26/21) that Resident #04 was attending as Resident #46. On 02/04/21 at 11:21 A.M., interview with Nurse Practitioner (NP) #210 revealed he had examined both Resident #04 and Resident #46 during their stay in the facility. The NP revealed one resident was non-verbal (unable to remember which resident specifically) and the other resident was demented (unable to remember which resident specifically). The NP revealed he had been notified (date/time not provided) by the facility after they confirmed Resident #46 and Resident #04's identities had been mixed up following their admission to the facility. The NP revealed after that, he completed a medication review and corrected the assessments he completed for Resident #04 and #46. On 02/04/21 at 3:07 P.M., interview with Registered Nurse (RN) #121 revealed the facility had no photo identification in the electronic medical record, name band or identification on the name plate (of the residents' rooms) when she came on duty on 01/25/21 and the off-going nurse, RN #129 had identified Resident #04 as Resident #46 and Resident #46 as Resident #04. The RN confirmed she had administered Resident #46's medications, treatments and care to Resident #04 and Resident #04's medications, treatments and care were administered to Resident #46 on this date. RN #121 verified the electronic medical record did not contain a photograph of Resident #04 or #46 until after the issue was brought to the facility's attention (on 01/26/21) and the medication errors had occurred. Review of the facility's undated policy titled, Medication Administration and Documentation revealed medications may only be administered to the resident for whom they were prescribed. Prior to and during administration, the nurse must observe the five rights of medication, right patient, right dose, right time, right route, right drug and right documentation. Record review revealed following the incident (on 01/26/21), the facility revised their admission policy related to the proper and accurate identification of all residents. The policy and procedure in place prior to the incident was not provided to review during the survey. This deficiency substantiates Complaint Number OH 700 and Complaint Number OH 673.

Based on medical record review, observation, staff interviews, and review of the facility's policy on nutrition, the facility failed to accurately assess a resident's nutritional status with significant weight loss, failed to ensure weights were performed as recommended and per facility policy, and failed to meet the resident's estimated energy needs. Actual harm occurred to Resident #228 when the weight scales were questionably inaccurate, the facility was providing less calories then the resident's estimated energy needs, and no new nutritional interventions were attempted resulting in the resident losing 35 pounds with an avoidable 17.5 percent significant weight loss during a two month time period. This affected one (#228) of three residents reviewed for weight loss. The facility identified seven current residents with significant weight loss. The facility census was 74. Findings include: Medical record review for Resident #228 revealed an admission of 05/08/18. Medical [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 05/08/18, identified Resident #228 was admitted with a weight of 199 pounds (lbs.). Review of physician orders, dated 05/10/18, revealed the resident was on a low concentrated sweets, pureed diet with nectar thick consistency. Review of the admission Minimum Data Set (MDS) assessment, dated 05/16/18, revealed the resident was cognitively impaired, he was a totally dependent on staff for all activities of daily living, including eating. He was on a mechanically altered diet, holding food in his cheeks or mouth, and had complaints of difficulty or pain with swallowing. He was coded as a risk for malnutrition. The assessment indicated he had no significant weight loss, his current body weight was 199 lbs. and his height was 73 inches. Review of nutritional risk assessment, dated 05/16/18, revealed he was at risk for nutritional deficits due to dysphasia. Registered Dietitian (RD) #162 estimated the resident's nutritional needs were 2700 calories, 90 grams of protein and 2700 milliliters (ml.) of fluids. The document indicated there were no skin or [MEDICAL CONDITION] issues. Current body weight was 199 lbs. The assessment did not address the resident's usual body weight or the hospital weight. The dietary progress notes, dated 05/16/18, by RD #162, revealed the resident was admitted to facility after an extensive stay in the hospital following a [MEDICAL CONDITION]. Resident was non-English speaking and was relatively new to United States of America. Beef was restricted entirely and meat was restricted to three days a week. Family was reportedly providing food from the outside of the facility. Diet level, cultural differences, language barrier, and cognition may compromise nutritional status. There were no skin issues on admission. Weight was appropriate for stature and serum protein levels. Review of care plan, dated 05/21/18, for Resident #228 revealed he had potential nutritional problem related to dysphasia. The interventions were to observe for, document, and report any signs and symptoms of dysphasia, obtain and monitor laboratory work as ordered, provide and serve diet as ordered, and provide one-to-one assistance with eating. The RD was to evaluate and make diet change recommendation as needed. Further review of dietary notes, dated 06/15/18, revealed there was a noted weight record discrepancy. The resident's current weight for two days was 173.5 lbs. on 06/01/18 and 06/02/18, but review of hospital records revealed hospital weight of 181 lbs., making the admission weight of 199 lbs. likely inaccurate. The resident's intake records were quite good, 50-75-100 percent (%). The plan was to monitor baseline weights. This body weight vs. hospital weight indicated a 7.5 pound weight loss, a 4.3 % weight loss and there were no new nutrition interventions implemented at this time. Review of dietary notes, dated 07/02/18, revealed the weight was recorded at 164 lbs. on 07/02/18. It was noted a Moderate [MEDICATION NAME] Swallow was completed and the diet continued as ordered except for low concentrated sweets was discontinued from the diet order. The resident continued to receive outside foods that were neither pureed or nectar thickened liquids despite counsel to the family. Physician was notified via communication book. Fluids were well received and additional fluids were added to the diet. The RD questioned weight accuracy again. There was no additional nutrition interventions implemented at this time to address the resident's 9.5 pound weight loss since a month ago, a 5.5 significant weight loss in one month. Overall, it was a 35 lbs. and a 17.6% significant weight loss in two months. Review of meal intakes from 06/01/18 through 07/12/18 revealed the resident's food intake was approximately 50-75%. Review of weights for Resident #228 revealed the resident weighed: on 05/08/18 at 199 lbs., 06/01/18 at 173.5 lbs., 06/02/18 at 173.5 lbs., and 07/02/18 at 164 lbs. Those weights were obtained with the same method, a Hoyer lift scale. There were no recorded weights in the resident's medical record between 05/09/18 to 06/01/18. In addition, there were no weights from 06/02/18 to 07/02/18, indicating the resident was not weighed weekly. Observation on 07/11/18 at 12:42 P.M. revealed Resident #228 was lying in bed with head of the bed up and STNA #128 was assisting with feeding the resident. The tray consisted of pureed teriyaki chicken, fried rice, oriental blend vegetables, wheat bread and applesauce. The plate was full and the resident ate 75% of the food and drank all of the thickened milk and orange juice. Subsequent observation on 07/12/18 at 8:12 A.M. revealed the resident was lying in bed with the head of the bed up and STNA #128 was feeding the resident. She encouraged him to eat his food on the plate then the drinking. The plate was full of pureed Danish, scrambled eggs, sausage, orange juice and milk. Observation and interview with Maintenance Supervisor (MS) #134 on 07/11/18 at 12:47 P.M. revealed the Hoyer lift scales have not been calibrated by the weight company since (YEAR). MS #134 took 20 lbs. of weights in a .50 lb. bag and put them on the scales for the Hoyer and it weighed 4.5 lbs. MS #134 stated the scales for the Hoyer lift had not been calibrated since she arrived at the facility nine months ago and verified the scales were off by 4.5 lbs. She stated she would call the company to come out and calibrate the scales as soon as possible. Interview with the Director of Nursing (DON) on 07/11/18 at 12:20 P.M. revealed she felt the RD was not communicating to the facility of her concerns. She verified the facility was not holding weekly nutrition meetings and they should be. She verified the resident should have been weighed weekly at least the first four weeks, and stated it should be the RD's determination to discontinue or continue weekly weights after the initial four weeks. The DON felt the RD should have communicated to her about the resident's questionable weight accuracy, because she would have had the scales calibrated at the time of question and felt the RD should have notified her weekly weights were not being completed per policy. She felt the RD had a poor work performance at the facility with the lack of communication and not leading the nutritional meetings on a weekly basis. She stated she notified the corporate nurse and Administrator recently because she was questioning if the RD had poor work performance in other sister facility's or just her facility. Interview with RD #162 on 07/12/18 at 10:41 A.M. revealed Resident #228 came into the facility after a severe [MEDICAL CONDITION]. She stated he required some assistance with a low functioning level with eating and drinking. She stated he was on a pureed diet with nectar thickened liquids. She stated in (MONTH) (YEAR), the resident flagged for weight loss and something was amiss with the weights. She stated he had no skin issues, was eating with times of self-feeding, lab results and blood sugars were within normal limits, and he was eating food the family brought into the facility. She stated with everything looking good she believed the weights were inaccurate. She stated she informed the physician about the weight loss and more fluids were added to diet. She further revealed the resident was not sick and was gaining strength. She stated the weight record was not a reflection of what she was observing. She revealed she did not let anyone know, at the facility, about the inaccuracies of the weights for the resident and did not realize the resident was not weighed every week for the first four weeks of arriving in the facility. Subsequent interview with RD #162 on 07/12/18 at 1:55 P.M. revealed the menus for the facility provided 1800-2200 calories and the corporate dietitian designed the menus. She stated this was a starting point for the residents and some residents would be ok with the recommended diet, but others may need more or less calories. She confirmed Resident #228 was recommended 2700 calories a day, as this was 500 calories more than the facility's menus provided. Subsequent interview with RD #162 revealed stated she didn't feel the resident needed a supplement, and that was not always the answer. Review of policy titled Nutritional Monitoring, dated 01/01/17, revealed residents with a history of weight loss or at nutritional risk as determined by further criteria shall be followed utilizing Nutritional Monitoring. Residents on the Nutritional Monitoring will be, but not limited to those: with a significant unplanned weight loss, hospitalization and chronic weight loss. The nutrition alert team should consist of Dietary Manager, DON, Restorative Aide, and Therapy coordinator. All residents on the nutrition alert program shall be weighed weekly per facility weighing procedure. If weight gain has not occurred in the two-week period, the house supplement shall be initiated three times a day between meals. If weight gain has not occurred within another two-weeks, the medication pass program shall be initiated, which would give the resident 60 ml's of two calorie supplement up to four times a day. If weight gain has still not occurred within another two weeks, contact the physician for additional orders. This deficiency substantiated Complaint Number OH 821.

Based on closed medical record review, staff interview, review of facility policy, and review of the National Pressure Ulcer Advisory Panel (NPUAP) information on pressure ulcers, the facility failed to implement preventative measures to ensure a resident did not develop pressure ulcers. Actual harm occurred to Resident #163 when the resident developed one stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) to the coccyx and one deep tissue injury (purple or maroon localized area or discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to his heel. This affected one (#163) of two residents reviewed for in-house acquired pressure ulcers. The facility identified two residents currently residing in the facility who had in-house acquired pressure ulcers. The facility census was 74. Findings include: Closed medical record review for Resident #163 revealed an admission date of [DATE] and was discharged to the hospital for a chronic hemoglobin of 5.5 on 07/10/18. Medical [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/18, revealed the resident had intact cognition. The resident was an extensive assistance for bed mobility, transfers and was a limited assistance for ambulating. The resident was coded for a stage four pressure ulcer and an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar), and were not present upon admission. The resident was occasionally incontinent of bladder and did not have any refusal of care. Review of nursing admission skin assessment, dated 05/02/18, revealed the resident had an abrasion on the right buttock and surgical incision on the left trochanter. There was no pressure ulcers present upon admission. Review of pressure ulcer risk assessment, dated 05/02/18, revealed the resident was a moderate risk for skin breakdown. Review of intermediate care plan, dated 05/02/18, revealed to turn and reposition the resident every three to four hours as needed and add pressure reducing devices as needed. Review of physician orders, dated 05/02/18, revealed there was not any physician order [REDACTED].>Review of plan of care, dated 05/21/18, revealed an infection of the coccyx wound with interventions to administer antibiotic and follow facility policy and procedures for infections. Further review of plan of care, dated 05/21/18, revealed the resident had a pressure ulcer to coccyx and deep tissue injury to the left heel. The interventions were to administer treatments as ordered, turn and reposition every two hours, monitor the skin and report any signs of infection wound size and stage to the physician and pressure reducing mattress to the bed and chair. Review of the medical record, dated 05/02/18 through 07/10/18, for Resident #163 revealed there was no documented evidence wound prevention interventions were implemented or if the resident refused for wound prevention interventions. Review of wound monitoring sheets, dated 05/18/18, for Resident #163 revealed a new stage four pressure ulcer to the coccyx was discovered. The wound measured 3.5 centimeters (cm.) in length, 2.8 cm. in width, and 2.0 cm in depth and was described to have 25 percent (%) granulation, 75% slough and there was undermining at 12 o'clock at 1.1 cm., at 3 o'clock at 1.1 cm., at 6: o'clock at 0.2 cm. and 9 o'clock at 6.0 cm. The wound was serous with odorous exudate. Review of wound monitoring sheets, dated 05/25/18, revealed a suspected deep tissue injury (SDTI) to the resident's left heel was found, measuring 3.5 cm. in length, 5.5 cm. in width, and 0.0 depth. There was no exudate or odor. Interview with the Director of Nursing (DON) on 07/10/18 at 2:35 P.M. revealed Resident #163 was found in the facility with the pressure ulcers to the coccyx and left heel. She stated she looked at the hospital records, admission notes, skin sweeps and could not find anything indicating the resident was admitted with the wounds. She stated she spoke to the Resident #163 about the wounds and she said she had them before on her sacrum and heel and said they were healed, but could not remember when she had the wounds. The DON reported the resident sat in her wheelchair for hours at a time, but did not have any documentation to prove it. She stated she remembered the resident had a cushion in her chair, but did not know when it was. She revealed the only intervention in place at the time of admission was every three to four-hour repositioning, as needed for the sacrum and heel and interventions were not implemented until 05/21/18. The DON stated the interventions included for the resident's bed lay as flat as possible to reduce shear, to reposition the resident with two staff assistance, required a lifting device or draw sheet to reduce friction, a pressure reducing device to bed and to wheelchair, and every two hours to turn and reposition the resident and assess, record, monitor wound healing weekly. The DON verified the interventions were not documented in the resident's medical record as being completed. Review of information from the National Pressure Ulcer Advisory Panel (NPUAP), 2014 defined pressure ulcers as a localized injury to the skin and/or underlying tissue over a bony prominence, as a result of pressure, or pressure in combination with shear. The NPUAP indicated that early assessment of risk factors and the implementation of preventative measures were key. The NPUAP further instructed to offload the pressure injury and to turn and reposition the individual. Review of the facility's policy and procedure on wound care, dated 01/01/14, identified factors that placed the residents at risk for the development of pressure ulcers and to implement appropriate intervention to prevent the development of clinically avoidable wounds. This violation substantiated Complaint Number OH 821.

Based on closed medical record review, staff interviews and facility policy review, the facility failed to provide care and services to prevent a pressure ulcer from developing and then failed to prevent the decline to an acquired pressure ulcer for a resident. This resulted in harm when the resident (Resident #2) developed a pressure ulcer at the facility and then when the ulcer progressed to having necrotic tissue without physician intervention. This affected one resident of three reviewed for pressure ulcers. The facility census was 78. Findings include: Closed medical record review revealed Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly comprehensive assessment dated [DATE] revealed the resident was moderately cognitive impaired. The assessment further revealed the resident required an extensive assist with bed mobility, personal hygiene and was dependent for transfers and toilet use. Review of the pressure sore risk dated 09/11/15 revealed Resident #2 was at high risk for pressure ulcers. Review of Resident #2's weekly pressure ulcer condition report revealed Resident #2 had a history of [REDACTED]. Review of the January 2016 Treatment Administration Record (TAR) revealed an order to turn the resident from side to side three times a day. This order was not completed for 18 days. On day shift 01/01/16-01/15/16, evening shift 01/03/16, 01/07/16, 01/10/16 and night shift 01/01/16) for a total of 43 shifts. An additional order was noted for house barrier cream to be applied twice a day. This order was not completed for 17 days on day shift 01/01/16-01/09/16, 01/12/16-01/15/16, evening on 01/03/16, 01/07/16 and 01/09/16) for a total of 29 shifts. Review of the impaired skin integrity pressure ulcer care plan dated 01/04/16 revealed to assess areas, initiate treatments, perform treatments to wound per current treatment order, monitor for pain and medicate as needed. Review of the shower sheet dated 01/04/16 revealed a decubitus pressure ulcer was found to Resident #2's coccyx. There was no formal assessment, additional interventions, or orders initiated for this wound. Review of weekly pressure ulcer condition report dated 01/06/16 (two days later) revealed Resident #2 had a pressure ulcer to the coccyx, including slough, measuring 2.0 centimeters (cm) x 2.5 cm x 1 cm in depth. Telephone order dated 01/06/16 revealed an order to clean the wound at the top of buttocks with saline, pat dry, apply foam dressing, change daily and as needed. Review of the January 2016's TAR revealed no transcription of the order. There was no evidence the treatment was implemented or completed as ordered. Review of the weekly skin check sheet dated 01/11/16 revealed the pressure ulcer now measured 2.0 cm x 1.5 cm x 0.5 cm in depth, with black eschar area to the wound bed. No additional interventions or orders were initiated at this time. On 01/13/16 the weekly pressure ulcer condition record revealed the coccyx wound measured 2.5 cm x 2.5 cm x 0.8 cm. in depth. Physician's order dated 01/13/16 revealed an order to cleanse area to coccyx with normal saline, pack with silver alginate, cover with dressing, change daily and as needed. Review of the physician's progress note dated 01/14/16 revealed the resident was in pain and had shearing to the coccyx, with deepening ulcer and necrotic tissue. Physician order dated 01/14/16 revealed a treatment change for the coccyx wound to apply Santyl (ointment) in the necrotic wound with wet to dry dressing change every day. The order further revealed to apply a thin layer of hydrogel to the sheared area before covering entire area with border gauze. Telephone interview with Certified Nurse Practitioner (CNP) #20 on 02/29/16 at 9:40 A.M. revealed she was not notified of the order that was written on 01/06/16 or that Resident #2 had a pressure ulcer until 01/14/16. The CNP #20 further revealed when she seen the pressure ulcer on 01/14/16 she indicated it was an unstageable pressure ulcer and the resident had pain when the area was assessed. Interview with Director of Nursing (DON) on 02/29/16 at 10:00 A.M. revealed she was not notified of Resident #2's pressure ulcer until 01/06/16 and the physician was never notified. The DON confirmed interventions of turning side to side three times daily and house barrier cream twice daily were not completed as ordered. The DON further confirmed the treatment that was ordered on [DATE] was not transcribed, implemented and completed. The DON revealed her expectations of the staff after they find a pressure ulcer would be to notify the physician and the family. The DON further stated the physician should be notified in the event of a decline in the pressure ulcer. The DON confirmed Resident #2 was sent out to the hospital after the family insisted due to the resident's unrelieved pain as a result of her wound. The DON stated the resident had not returned to the facility. Interview with Registered Nurse (RN) #38 on 02/29/16 at 11:40 A.M. revealed most of the treatments are scheduled to be completed on first shift and they do not always have time to complete the treatments as ordered. Interview with RN #37 on 02/29/16 at 12:15 P.M. revealed she was not always able to get her treatments completed. Review of the facility policy titled Wound Care Policy dated 01/01/14 revealed that any skin impairments, including pressure ulcers should be assessed and documented weekly by the wound nurse or designee on the wound evaluation flow sheet or the point click care weekly wound assessment. It revealed that the goals of wound treatment are to promote healing. Residents should be assessed for pain, related to the pressure ulcer or its treatment, per policy. Nursing staff should keep the attending physician aware of the progress of all ulcers. This deficiency substantiates Complaint Number OH 688.

Based on closed medical record review, open medical review, staff interviews, observations and pain management policy review, the facility failed to provide a resident (Resident #2) with an unstageable pressure ulcer with adequate pain relief. This resulted in harm when Resident #2 was transported to the hospital due to the pain from the pressure ulcer. This affected one resident (#2) of three reviewed for pain. The facility further failed to provide timely [MEDICAL CONDITION] care to a resident (Resident #4). This affected one resident of one resident with an [MEDICAL CONDITION]. The facility census was 78. Findings include: 1. Closed record review revealed Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] revealed a moderate cognitive impairment. The assessment further revealed the resident was an extensive assist with bed mobility, personal hygiene and dependent for transfers and toilet use. Review of the pain care plan dated 02/23/13 revealed to administer pain medications as ordered and monitor for effectiveness and side effects. The care plan further revealed to update the physician as needed regarding effectiveness or the need for medication change. Review of the weekly skin sheets revealed on 01/04/16 Resident #2 developed an unstageable pressure ulcer to her coccyx. Review of the Certified Nurse Practitioner's (CNP's) #20 progress note dated 01/14/16 revealed the resident was in pain. The note further revealed the resident had shearing to the coccyx with deepening ulcer and necrotic tissue. Review of the physicians order dated 01/14/16 revealed [MEDICATION NAME] (pain reliever) 50 mg, one tablet, every eight hours for pain. Review of the January 2016 medication administration record (MAR) revealed an order for [REDACTED]. Further review of the MAR and January 2016 pain monitoring flowsheet revealed Resident #2 received Tylenol a total of 17 times; (01/02/16 at 10:00 A.M., 01/04/16 at 8:00 A.M. and 1:15 P.M., 01/05/16 at 8:00 A.M., 01/06/16 at 9:10 A.M. and 1:20 P.M., 01/10/16 at 7:40 A.M. and 1:30 P.M., 01/11/16 at 4:00 P.M., 01/12/16 at 7:30 A.M.,8:30 A.M. and 2:10 P.M., 01/13/16 at 8:00 A.M. and 8:00 P.M. On 01/14/16 at 8:10 A.M. and 2:00 P.M., 01/15/16 at 4:30 A.M.) for complaints of pain in her lower back and buttocks. Resident #2's pain was noticed to range from an eight to a nine, on a scale of 0-10 (with 10 being the worse pain) prior to receiving Tylenol. There was no documentation the resident was given the [MEDICATION NAME] which was ordered on [DATE]. Review of nurse's note dated 01/14/16 (no time indicated) revealed the resident complained of pain on the coccyx area when repositioned in bed and had no relief from Tylenol. There was no evidence the resident was given the [MEDICATION NAME] which was ordered on [DATE]. Review of nurse's note dated 01/15/16 at 1:45 P.M. revealed Resident #2's family member phoned the facility and stated the resident needed to be sent to the hospital due to the pain from the wound of her coccyx. The note further revealed the resident's family member was very upset of the pain the resident was in. Telephone interview with CNP #20 on 02/29/16 at 9:40 A.M. revealed she ordered the [MEDICATION NAME], 50 mg, for Resident #2 due to the resident expressing pain when the wound was assessed. The CNP further revealed she was concerned Resident #2 was not always able to tell staff when she was in pain. The CNP revealed she would have expected the first dose of [MEDICATION NAME] to be given at least by the scheduled dose on 01/15/16 at 6:00 A.M. The CNP further revealed she would have expected the staff to call and let her know if the medication was not available to be given. Interview with Director of Nursing (DON) on 02/29/16 at 10:00 A.M. and 12:44 P.M. revealed if a resident was receiving Tylenol on a daily basis and it was not controlling the pain then she would expect the nurse to notify the physician for a new order. The DON confirmed Resident #2 was ordered [MEDICATION NAME] on 01/14/16 late in the evening and this medication was available at the facility in the emergency medication box, however was not administered to the resident when she was in pain. The DON revealed she would have expected the staff to at least start the resident's [MEDICATION NAME] administration by the scheduled 6:00 A.M. dose on 01/15/16. The DON confirmed the [MEDICATION NAME] was delivered to the facility on [DATE] at 10:54 A.M. However, the resident did not receive a scheduled dose of [MEDICATION NAME], 50 mg, until 01/15/16 at 2:00 P.M. She revealed she would have expected her staff to have called to get an authorization from pharmacy to pull from the emergency box to administer the 6:00 A.M. dose on 01/15/16. The DON confirmed on 01/15/16 Resident #2 was sent out to the hospital, after her daughter insisted due to the resident's unrelieved pain as a result of her wound, and the resident has not returned. Interview with Registered Nurse (RN) #37 on 02/29/16 at 12:15 P.M. revealed Resident #2 was a total care and she seemed to be in pain when she was turned from side to side. Interview with State tested Nurses Assistant (STNA) #49 on 02/29/16 at 12:55 P.M. revealed Resident #2 was noticed to have pain when care was provided. Review of the facility policy titled Pain Management and Assessment dated 01/01/14 revealed to assess and document pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. If pain is not relieved, give further medication as the physician ordered, if there are no orders, notify the physician of assessment results and obtain an order. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission comprehensive assessment dated [DATE] included the resident was cognitively intact, needed extensive assistance for all activities of daily living, required limited assistance for hygiene and required supervision for eating. The medical record further revealed the resident had an [MEDICAL CONDITION] with a [MEDICAL CONDITION] bag. Review of the [MEDICAL CONDITION] care plan dated 02/08/16 included to provide ostomy care per policy, every shift and as needed. Goals included to maintain skin integrity. Review of nursing note dated 02/16/16 revealed the resident's [MEDICAL CONDITION] bag was leaking. The entire area around the stoma was reddened and excoriated. Telephone order dated 02/16/16 included to apply a thin layer of zinc oxide ointment to reddened area around the stoma. Allow to dry. Apply stoma adhesive on top of dry zinc oxide. Apply wafer, cut just to size of stoma and then apply the bag. Change every three days and as needed. Review of the treatment record revealed the treatment was completed on 02/24/16 only. Observation and interview on 02/25/16 at 10:27 A.M. revealed Resident #4 reported her [MEDICAL CONDITION] bag had leaked and she reported it to State tested Nursing Assistant (STNA) #33 at 9:30 A.M. that the bag needed changed. The resident revealed she was waiting on Licensed Practical Nurse (LPN) #35 to change it. The Resident stated the STNA had given her towels because of the bag leaking. Observation at this time revealed the [MEDICAL CONDITION] bag was leaking a yellow, brown substance. Interview at 11:08 A.M. revealed the resident was still waiting on the nurse to change the bag. Interview on 02/25/16 at 11:09 A.M. with STNA #33 confirmed she told LPN#35 at approximately 9:15 A.M. the resident's bag was leaking and needed changed. Observation with LPN #35 at 11:35 A.M. revealed the LPN changed the bag. The LPN confirmed the resident's skin around the ostomy was red and irritated and the [MEDICAL CONDITION] bag had leaked onto the towels. The LPN confirmed STNA #33 had reported Resident #4's ostomy bag was leaking, however had been busy passing medications and had not had the opportunity to change it. This deficiency substantiates Complaint Number OH 664.

Based on observation, medical record review, review of facility investigation and staff interview, the facility failed to implement fall prevention devices for one (#19) of three residents reviewed for accidents/falls. This resulted in actual harm when Resident #19 had two separate falls resulting in fractures. This had the potential to affect 62 current residents identified by the facility as being assessed as a high fall risk. The facility census was 87. Findings include: Review of Resident #19's medical record revealed an admission date of [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], documented the resident understood others, made herself understood, but was moderately impaired for daily decision making skills. She was assessed as having signs of delirium such as disorganized thinking that comes and goes and changes in severity. She did not exhibit signs of psychosis, did not have any negative behaviors, and did not reject any care. Resident #19 was assessed as needing the assistance of one staff with physical assistance for toileting, transfers, and bed mobility. She needed set up only for locomotion on and off the unit. The MDS documented Resident #19 was not steady and only able to stabilize with human assistance for walking, moving from seated to standing position, moving on and off the toilet, and turning around and facing the opposite direction while walking. Resident #19 had impairment to one side in range of motion to both the upper and lower extremity. She was not on a toileting program and was occasionally incontinent of bladder and always continent of bowel. The MDS assessment documented one fall resulting in a major injury since her last assessment. The MDS [DIAGNOSES REDACTED]. Review of Resident #19's fall care plan dated 05/14/13 , prior to the 02/09/14 and the 06/10/14 falls, had interventions of low bed, non-skid footwear, clutter free room, well lit room, bed and chair alarm, and toilet before and after meals. Review of Resident #19's nurses' notes dated 02/09/14 revealed at 6:00 P.M., she was found on the floor between the bed and entrance door. She was yelling for help. She stated she lost her balance coming from the bathroom. Resident #19 stated she could not move her right arm and it felt numb. Review of nurses notes at 8:30 P.M., documented the hospital called and Resident #19 had a right humorous fracture. At 9:45 P.M., nurses' notes documented the resident complained of arm pain, rating an 8 on a scale of 1 to 10 (with 10 being the highest amount of pain). Review of nurses notes dated 02/10/14 at 6:00 A.M., documented the resident complained of arm pain, rating an 8 on a scale of 1 to 10. Review of Resident # 19's Fall Incident Report dated 02/09/14, revealed the report did not document if the alarm was sounding. Observation on 07/31/14 with 8:38 A.M., with Licensed Practical Nurse (LPN) #57 revealed the occupied bed with Resident #19, was not in the lowest position. When asked if it was, the nurse went over to the bed and pushed the button and lowered the bed to the lowest position stating no it wasn't. He said it should have been. He stated Resident #19 disconnects the alarms, hides them, and or muzzles the sound so you can't hear it. Interview with the Fall Incident reporter LPN #74 on 07/31/14 at 11:58 A.M. revealed the alarm was not sounding in the resident's room when she fell on [DATE]. She stated she heard the resident yelling for help and responded. Review of Resident #19's orthopedic consult form dated 02/14/14, documented the resident had a non-displaced proximal humorous fracture on the right upper extremity. She was ordered Percocet for pain. Review of Resident # 19's nurses' notes dated 06/10/14 at 2:45 P.M., documented Resident #19 was in her room trying to walk out the door. LPN #57 saw the resident standing from the nurses' station and went to get the resident. The resident fell on her left side before the nurse reached her. Resident #19 was sent to the local hospital after the x-ray was taken. The note documented the resident complained of hurt to touch to the left hip and femur areas. The nurses' note documented the nurse checked to see why the alarm did not sound and discovered the alarm was unplugged. LPN #57 charted the resident had unplugged the alarm. Interview with LPN #57 on 07/31/14 at 9:43 A.M., denied after the fall on 06/10/14, that he asked the resident if she had unplugged the alarm. He stated it was possible that staff had unplugged it or had not turned it on. He felt that the resident had unplugged it because she had unplugged it in the past. Review of Resident #19's Fall Incident Report dated 06/10/14; revealed Resident #19 was in her room trying to walk out the door. LPN #57 saw the resident from the nurses station and went to get the resident but the resident fell on her left side before the nurse reached her. The form documented the resident complained of a little pain, was oriented to place and person, and no injuries were observed. The form had no documentation to indicate if the alarm was sounding. Review of Resident #19's radiology report dated 06/10/14, documented left hip fracture involving the left femoral neck with modest displacement, acute left hip fracture and a proximal femoral neck fracture with moderate displacement. Review of Resident #19's nurses notes from 06/16/14 through 06/26/14, document the resident was being medicated for pain. Review of nurses' note dated 06/23/14, as a late entry documented the resident stated she was still hurting from time to time but the pain medication helped. Review of Resident #19's Fall Incident Report dated 06/27/14 at 11:15 A.M., documented the resident was found on her right side on the bathroom floor. The report documented the alarm apparently was turned off and pad was disconnected from the alarm. No injury observed. Resident denied pain. She stated she was just going to the bathroom. Interventions put into place: scheduled toileting before meals and before bed, not to be left in room unsupervised, and stat x-ray of left anterior and upper thigh. Interview with the Director of Nursing (DON) on 07/31/14 at 10:15 A.M., revealed on 06/27/14, therapy staff brought Resident #19 back to her room and left her in the wheelchair. They didn't notify the nurses that the resident had returned and did not hook up the chair alarm. The resident fell shortly after that. The DON verified Resident # 19's fall care plan that was in place before the 02/09/14 fall, documented interventions as bed in low position, bed and chair alarm, non-skid foot wear, and room well lit and clutter free. She stated the resident had basically been on alarms since admission. She stated the resident periodically turns off alarm or hides them. She stated they keep the bed and chair alarms because it works sometimes.

Based on record review, observation and staff interview the facility failed to assure residents received adequate assistance with transfers and devices as per the plan of care. This affected two (#35 and #87) of 11 residents reviewed for falls. The lack of adequate assistance resulted in harm for one resident #35 as a result of an improper transfer by one staff which resulted in a fracture leg. The facility census was 91. Findings include: 1. Record review revealed Resident #35 was initially admitted to the facility on [DATE]. Pertinent [DIAGNOSES REDACTED]. An undated intervention on an initial 12/03/04 care plan stated transfer with Hoyer lift (a mechanical lift) using assist of two. A 03/18/08 care plan for physical mobility stated Resident #35 had a history of [REDACTED]. The 12/16/09 Minimum Data Set (MDS) assessment identified Resident #35 as having short term memory impairment, long term memory intact and poor decision making. The resident was easily distracted and mental function varied over the course of the day. The resident exhibited repetitive verbalizations, persistent anger with self or others, repetitive health complaints and sad pained worried facial expressions. Resident #35 required extensive assistance of one staff with bed mobility and extensive of two staff with transfers. The resident was not able to attempt the test for standing balance without physical support and was unsteady but able to re-balance for sitting balance. A 03/04/10 quarterly Nursing Assessment stated Resident #35's functional status for transfers was total dependence and two or more person assist. The equipment required was a "sling lifter." She was assessed as a high risk for falls. A 03/08/10 Resident Progress Notes timed 10:10 P.M. stated Resident #35 complained of her right lower extremity hurting. Resident #35 stated when being transferred into her bed her leg twisted and started hurting. Her complaint of pain was eight on a scale of ten. A new order was obtained for a STAT x-ray of the right knee, tibia, fibula, and ankle. The pain medicine administered was not effective. The 03/08/10 x-ray of the right knee revealed proximal fibular and mid shaft tibia fractures. A 03/09/10 Resident Progress Note timed 4:30 P.M. stated Resident #35 returned from the hospital with a full leg cast extending from mid calf to her toes. A 03/08/10 care plan was developed for physical mobility impaired due to right tibia and fibula fracture. The 03/08/10 Resident Event Report Worksheet stated Resident #35 was injured during a transfer. The injury occurred during a technique or policy variance. The severity of the outcome was moderate to serious. A 03/08/10 statement by State tested Nurse Aide (STNA) #4 who was transferring Resident #35 revealed the resident was being transferred from the wheelchair to the bed. STNA #4 was attempting to transfer Resident #35 by herself. As STNA #4 was pivoting the resident , the resident started to yell out stating her leg was hurting real bad. Resident #35 stated her leg got caught under the bed. STNA #4 verbalized she did not see the leg get caught but felt more realistically it got tangled in the wheelchair as opposed to the bed. A 03/08/10 statement by Licensed Practical Nurse(LPN) #5 revealed when Resident #35 was being transferred from the wheelchair to her bed, her leg got twisted and the resident complained of right leg pain. Resident #35's leg was swollen and red and the physician was notified and x-ray was obtained. LPN #5 did not witness the event but verified Resident #35 was transferred by only one STNA #4. A 03/09/10 statement by Resident #35 revealed when she was being transferred on 03/08/10 to bed, as turning her leg got stuck under the bed and she heard a "pop." Resident #35 was unable to state the aides name but described the STNA consistent with STNA #4. Interview and observation of Resident #35 on 11/16/10 at 12:00 P.M. revealed a nurse aide tried to put her in bed and "broke my leg". Resident #35 stated her foot got caught under her wheelchair and broke her foot and leg. This happened eight months ago. Resident #35 was observed with a cast on her lower right leg which extended above her knee. Interview with Corporate Registered Nurse(CRN) #6 and review of the facility investigation on 11/16/10 at 2:55 P.M. revealed Resident #35 was transferred by STNA #4 at the time of her fracture. CRN #6 verified only one STNA, STNA #4, completed the transfer. CRN #6 stated the fracture of Resident #35's leg has been very slow in healing. Two unsuccessful attempts were made to reach STNA #4 via telephone on 11/19/10 at 9:08 A.M. 2. Record review revealed Resident #87 had pertinent [DIAGNOSES REDACTED]. The 08/28/08 care plan for at risk for injury from falls included a 10/02/06 intervention for Dycem (an anti- slip material) over and under the wheelchair cushion. The 07/14/10, the most recent Minimum Data Set(MDS) assessment, on the resident's medical chart identified the resident as having short and long term memory impairment and poor decision making. Resident #87 required extensive assistance of one staff with all activities of daily living except eating. The resident was unable to maintain standing balance and was unsteady but able to rebalance self while sitting. Observation on 11/17/10 at 12:10 P.M. revealed STNA #6 transferred Resident #87 from bed to the wheelchair. The cushion was on the seat of the wheelchair but no Dycem was under or over the cushion. Interview with STNA #6 following the transfer verified the there was no Dycem under or over the wheelchair cushion. Interview with STNA #7 on 11/17/10 at 3:35 P.M. verified Resident #87 should have had Dycem on top and under the wheelchair.