Every finding on record at First Community Village Healthcare CTR

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility incident report and investigative documents, resident and staff interview, and facility policy review, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 01/30/25 when staff attempted to transfer Resident #16 from the bed to his wheelchair with the mechanical lift and due to poor staff transferring techniques, Resident #16 was dropped to the floor. Resident #16 was sent to the hospital and returned to the facility with the following injuries: right knee posterior cruciate ligament (PCL) avulsion fracture, right Lateral Compression (LC) 1 pelvic ring injury, sacrum fracture, and Thoracic (T)9 distraction fracture (a fracture caused by a flexion-distraction injury during a rapid deceleration event). This affected one resident (#16) of three residents reviewed for accidents/falls. The facility census was 31. Findings Include: Resident #16 was admitted to the facility on [DATE] with diagnoses including, but were not limited to, osteoporosis, spastic hemiplegia, morbid obesity, type II diabetes, pneumonia, spinal stenosis, coronary atherosclerosis, chronic embolism and thrombosis, chronic kidney disease, cerebral infarction, mood disorder, peripheral vascular disease, anemia, nicotine dependence, acute kidney failure, epilepsy, insomnia, hyperlipidemia, and anxiety disorder. Review of the resident's Minimum Data Set (MDS) assessment, dated 02/06/25, revealed the resident was cognitively intact and dependent on staff for transfers. Review of Resident #16's care plan, dated 01/30/25, revealed Resident #16 had an activity of daily living (ADL) deficit. An intervention, within this care plan, revealed the resident needed two-person total assistance for all transfers due to having to use a mechanical lift. Review of Resident #16's Incident Report and Progress Notes, dated 01/30/25 to 02/03/25, confirmed Resident #16 was being transferred from his bed to his wheelchair via mechanical lift on 01/30/25 by Certified Nursing Assistant (CNA) #127 and CNA #400. During the transfer, CNA #400 adjusted the resident's feet and the lift pad, while the resident was suspended in the air. CNA #400 lifted one side of the lift pad while Resident #16 was in it, the pad/resident became unbalanced, and one hook of the pad came loose from the mechanical lift. The mechanical lift became unbalanced and tipped forward, which caused Resident #16 to fall out of the lift to the ground. Nursing staff were immediately called to his room to assess him for injuries; Emergency Medical Services (EMS) were called, and Resident #16 was sent to the hospital. In review of the findings, the facility confirmed CNA #400 should not have lifted Resident #16 mechanical lift pad while the resident was suspended in the air. The facility further confirmed this action contributed to the lift being unbalanced and tipping over, which caused Resident #16 to fall. Interview with the Administrator on 06/17/25 at 11:06 A.M. confirmed Resident #16 fell while he was being transferred by staff in his mechanical lift. She stated, based on the investigation that was completed, CNA #127 and CNA #400 put Resident #16's lift pad in place to prepare him for transfer. She stated one CNA was maneuvering his pad/body from the front of him (by his feet/legs), and the other CNA was on the back, maneuvering the actual lift. She stated CNA #400 lifted Resident #16's lift pad to assist him in his wheelchair. She confirmed the mechanical lift pad came unhooked from the machine, the machine became unbalanced, and it tipped over, causing an injury to Resident #16 when he fell out of the lift to the floor. She confirmed the facility completed the investigation, and started a plan of correction for this situation, which included educational training to all nursing staff, auditing all resident medical records of those that used mechanical lifts, and on-going monitoring. Interview with Resident #16 on 06/18/25 at 9:59 A.M. stated the aides who were transferring him were moving too fast when moving him from his bed to his wheelchair in the mechanical lift. He stated he was off-center in the lift/pad, and the CNAs tried to adjust him while he was suspended in the air, and the machine started to tip. One of the CNAs tried to hold him up, but one side of the pad came off the machine, and he fell to the ground. He confirmed it was very painful, and after going to the hospital, it was confirmed he had fractures. Review of facility's mechanical lift manual, undated, revealed the facility is to follow all the procedures to ensure a resident transfer is completed safely. After the resident has been safely placed in the mechanical lift pad and raised from the bed, staff is to stand behind the resident and hold onto the center handle located on the back of the sling. When the resident is nearly seated, gently pull up on the center handle to ensure the resident will be seated in an upright position. The deficient practice was corrected on 02/12/25, when the facility implemented the following corrective actions: On 01/30/25, Director of Nursing (DON) or designee assessed all residents who use a mechanical lift for injuries, no injuries were identified. On 01/30/25, DON or designee audited all mechanical lift pads for safety and functionality. None had to be discarded. The facility also had enough lift pads in varying sizes to meet the needs of each resident who utilized a mechanical lift. On 01/30/25, DON or designee audited all residents who utilize a mechanical lift. Mechanical lift assessments and care plans were reviewed, and updates were made as necessary. On 01/30/25, the Administrator completed a Quality Assurance Performance Improvement (QAPI) meeting to review the fall, determine the root cause, and develop a plan of action to reduce the likelihood of an accident similar to this occurring again. From 01/30/25 to 02/10/25, DON or designee educated all nursing staff. The education included operating a mechanical lift with two staff at all times, proper use of mechanical lifts, and the overall lateral transfer system usage. The following nursing staff were interviewed on 06/17/25 and 06/18/25, and confirmed they received education and were aware of the proper procedures to follow regarding mechanical lifts: DON, ADON #120, CNA #117, CNA #142, and CNA #153. From 02/03/25 to 02/12/25, DON ensured all nursing staff received and passed competency training regarding the proper assessment of mechanical lift pads and properly transferring a resident with the mechanical lift. Starting 01/31/25, nursing managers/designees assessed mechanical lift pads to ensure the correct size was being used and monitored/observed actual resident transfers via mechanical lift at least three times weekly for four weeks through March 2025 and then discussed at the June 2025 QAPI meeting. Audits were completed on the following dates: 01/31/25, 02/03/25, 02/05/25, 02/07/25, 02/10/25, 02/12/25, 02/14/25, 02/17/25, 02/19/25, 02/21/25, 02/24/25, 02/26/25, 02/28/25, 03/03/25, and 03/10/25 with no negative findings.

Based on record review and interview the facility failed to ensure dressing changes were completed as ordered by the physician. This affected one (Resident #22) out of two residents reviewed for pressure ulcers. The facility census was 31. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/14/22 with diagnoses including dementia, adult failure to thrive, protein-calorie malnutrition, stage three pressure ulcer of the sacral region, bed confinement status, full incontinence of urine and feces, and muscle contractures. Review of the care plan dated 07/25/22 indicated Resident #22 has a pressure injury of the sacrum related to terminal diagnoses, bed confinement, impaired cognition, and decreased functional mobility. Interventions included administering and completing preventative treatments and dressing changes as ordered, assessing and monitoring wound healing weekly and as needed, following facility policies for skin breakdown prevention and treatment, and hospice nurse oversight of routine dressing changes and wound care orders. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 11/18/24 showed Resident #22 was severely cognitively impaired, required substantial to maximal assistance with bed mobility, was always incontinent of urine and bowel, and had one stage III pressure ulcer (full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, underlying fascia). Review of the Braden Scale for predicting pressure ulcer risk, dated 12/13/24, revealed Resident #22 was completely limited, very moist, bedfast, immobile, poorly nourished, and at very high risk of pressure ulcers due to friction and shearing. Review of physician orders dated 09/07/24 revealed staff were required to cleanse sacral pressure ulcer with wound cleanser, pat dry, apply calcium alginate to pack the entire wound bed, followed by application of a sacral Allevyn dressing. Review of the Treatment Administration Record (TAR) from 02/01/25 through 02/28/25 revealed missed treatments on 02/02/25 and 02/08/25. Review of skin and wound evaluation dated 02/06/25 noted Resident #22 had a stage III pressure ulcer on the sacrum measuring 0.6 cm by 2.1 cm, with a depth of 2.0 cm by 0.2 cm undermining and 1.2 cm tunneling. The wound showed 100% granulation, no signs of infection or odor, moderate bloody drainage, and was noted as stable. Review of skin and wound evaluation dated 02/13/25 showed the same ulcer measuring 1.6 cm by 3.7 cm, with a depth of 1.2 cm. There was no undermining or tunneling. The wound was 100% granulated, free of infection or odor, had moderate bloody drainage, and was noted as improving. Interview on 06/17/25 at 11:20 A.M. with the Assistant Director of Nursing (#120) confirmed Resident #22 had missed treatments on 02/02/25 and 02/08/25, and no documentation supported completion of these treatments by nursing staff or hospice providers. Review of skin care and wound management policy dated 01/2024 revealed residents with pressure injuries will receive necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new injuries from developing.

Based on medical record review and staff interview, the facility failed to provide parameters for as needed pain medication. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The census was 31. Findings Include: Resident #16 was admitted to the facility on [DATE]. His diagnoses included but were not limited to osteoporosis, spastic hemiplegia, morbid obesity, Type II diabetes, pneumonia, spinal stenosis, coronary atherosclerosis, chronic embolism and thrombosis, chronic kidney disease, cerebral infarction, mood disorder, peripheral vascular disease, anemia, nicotine dependence, acute kidney failure, epilepsy, insomnia, hyperlipidemia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 02/06/25, revealed he was cognitively intact and dependent on staff for transfers. Review of Resident #16's physician orders, dated September 2024 to June 2025, revealed an order for Acetaminophen (analgesic) 325 milligrams (mg), two tablets every four hours as needed for pain. Also, there was an order for Oxycodone (opioid) five mg every four hours as needed for pain. Neither the Acetaminophen or the Oxycodone medications had parameters as to which pain medication should be given and what pain level each medication should be given at. Review of Resident #16 medication administration record (MAR), dated January 2025 to June 2025, revealed the following as needed pain medications were administered: in February 2025, Acetaminophen was administered zero times and Oxycodone was administered a total of 10 times for pain levels between two to nine. In March 2025, Acetaminophen was administered one time for pain level five and Oxycodone was administered a total of 31 times for pain levels between zero and eight. In April 2025, Acetaminophen was administered zero times and Oxycodone was administered 23 times for pain levels between four and eight. In May 2025, Acetaminophen was administered zero times and Oxycodone was administered 36 times for pain levels between three and eight. For June 2025, Acetaminophen was administered two times for pain levels four and five, and Oxycodone was administered 18 times for pain levels between four and eight. Interview with Registered Nurse (RN) #141 on 06/17/25 at 3:59 P.M. stated he will judge a residents pain level based on what they state their level of pain is, and why the resident is in the facility (surgery, chronic pain, etc.) as to which pain medication he will administer. He will verify with physician or Director of Nursing (DON) if a resident has two as needed pain medications, to ensure the resident is supposed to have them. Once verified, he will use his nursing judgement as to which pain medication to offer/administer. He confirmed there are not always parameters for the as needed pain medications, which is why he will use nursing judgement on which pain medication to administer. Interview with Director of Nursing (DON) and Administrator on 06/18/25 at 9:06 A.M. confirmed there should be parameters on the as needed pain medication orders. They stated Resident #16 is able to tell the nurse which medication he would want, but they confirmed as needed pain medications should be given at certain pain levels. They confirmed the pain levels for Resident #16, and the medications administered, were inconsistent. Review of facility Pain Management policy, dated April 2025, revealed the facility is committed to recognizing, assessing, treating, and documenting pain management to promote the comfort and quality of life for all residents. Pain will be addressed through evidenced based practices, resident centered care, and interdisciplinary care. For pain management, the facility will following physician orders for pain medications and administered PRN medications as indicated.

3. Review of the medical record for Resident #54 revealed an admission date of 04/16/25 with no cognitive deficits. Diagnoses included aftercare following surgery on the digestive system, malignant neoplasm colon, and intestinal obstruction, unspecified as to partial versus complete obstruction. Resident #54 discharged from the facility to home on on 04/25/25. Review of Resident #54's Minimum Data Set, dated [DATE] indicated Resident #54 was transferred to the hospital. After surveyor intervention it was modified on 06/17/25 to indicate Resident #54 was discharged home. Interview on 6/17/25 at 10:14 A.M. with the Director of Nursing (DON) confirmed a corrected MDS for Resident #54 was submitted after surveyor intervention on 06/17/25 indicating Resident #54 was not discharged to the hospital as previously recorded, but was discharged home. Based on medical record review and staff interview, the facility failed to complete and maintain accurate resident assessments when significant changes occurred. This affected three (Residents #16, #24, and #54) of 15 resident assessments reviewed. The census was 31. Findings Include: 1. Resident #16 was admitted to the facility on [DATE]. His diagnoses included but were not limited to osteoporosis, spastic hemiplegia, morbid obesity, Type II diabetes, pneumonia, spinal stenosis, coronary atherosclerosis, chronic embolism and thrombosis, chronic kidney disease, cerebral infarction, mood disorder, peripheral vascular disease, anemia, nicotine dependence, acute kidney failure, epilepsy, insomnia, hyperlipidemia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 02/06/25, revealed he was cognitively intact and dependent on staff for transfers. Review of Resident #16's MDS assessments revealed his most recent resident assessment was completed on 02/06/25. A quarterly resident assessment was started on 05/09/25, but it had not been completed as of 06/18/25, confirming it was not completed in a timely manner. 2. Resident #24 was admitted to the facility on [DATE]. Her diagnoses were cachexia, unspecified protein calorie malnutrition, encephalopathy, chronic kidney disease, Alzheimer's disease, dementia, chronic respiratory failure, osteoporosis, restlessness and agitation, disorder of thyroid, osteoarthritis, hypo-osmolality and hyponatremia, acute kidney failure, depression, sleep disorder, atherosclerotic heart disease, anxiety disorder, hypertension, muscle weakness, hyperlipidemia, vitamin D deficiency, spinal stenosis, and hypothyroidism. Review of her MDS assessment, dated 02/01/25, revealed she had a significant cognitive impairment. Review of Resident #24's MDS assessments revealed the most recent resident assessment was completed on 02/01/25. A quarterly resident assessment was started on 05/02/25, but it had not been completed as of 06/18/25, confirming it was not completed in a timely manner. Interview with Administrator on 06/18/25 at 2:53 P.M. confirmed the MDS assessments were not done in a timely manner; she confirmed they should have been completed already.

Based on interview, record review, and review of facility policy, the facility failed to provide proper behavior monitoring and documented discussion of the need for psychotropic's and causes of anxiety. This affected two residents (#10 and #11) of five residents reviewed for unnecessary medications. The facility census was 31. Findings include: Review of Resident #11's medical record revealed an admission date of 05/01/25 with diagnoses including chronic obstructive pulmonary disease, severe protein-calorie malnutrition, dysphagia, systemic sclerosis, depression, osteoarthritis, chronic heart failure, and hypertension. Review of Resident #11's comprehensive Minimum Data Set (MDS) 3.0 dated 05/03/25 revealed he had intact cognition. Review of Resident #11's plan of care on 06/16/25 revealed it did not address his anxiety medication use. Review of Resident #11's mini mental score on 05/05/25 revealed no mention of anxiety concerns and no behaviors. Review of Resident #11's physician order dated 05/08/25 to 05/09/25 revealed an order for Hydroxyzine (used to help control anxiety) 25 milligrams (mg) one tablet by mouth one time only for anxiety or shortness of breath. Review of Resident #11's progress note dated 05/08/25 revealed the resident had high anxiety. The certified nurse practitioner (CNP) gave an order for one time dose of Hydroxyzine. Review of Resident #11's physician order dated 05/09/25 to 05/13/25 revealed an order for Hydroxyzine Pamoate one capsule by mouth every eight hours as needed for shortness of breath or anxiety. Review of Resident #11's progress note dated 05/09/25 revealed the resident had anxiety and shortness of breath. The CNP provided an order for as needed Hydroxyzine 25 mg. Review of Resident #11's progress note dated 05/11/25 revealed Hydroxyzine was administered, there was no indication as to why the resident required the medication. Review of Resident #11's CNP note dated 05/12/25 revealed his anxiety was not addressed. Review of Resident #11's physician order dated 05/13/25 to 05/27/25 revealed an order for Hydroxyzine Pamoate one capsule by mouth ever eight hours as needed for anxiety. Review of Resident #11's physician order dated 05/13/25 to 06/05/25 revealed an order to monitor for anxiety related behaviors and document if behaviors were present. Review of Resident #11's CNP note dated 05/12/25 revealed his anxiety was noted, however there was no discussion of cause. Review of Resident #11's progress note dated 05/17/25 revealed Hydroxyzine was administered, there was no indication as to why. Review of Resident #11's progress note dated 05/19/25 revealed Hydroxyzine was administered due to the residents request. Review of Resident #11's CNP note dated 05/19/25 revealed his anxiety was noted, however there was no discussion of cause. Review of Resident #11's progress note dated 05/21/25 revealed Hydroxyzine was administered due to the resident being anxious and decreased stimulation. Review of Resident #11's May 2025 Medication Administration Record (MAR) revealed Hydroxyzine was administered on 05/08/25 as scheduled. It was administered as needed on 05/17/25, 05/18/25, 05/19/25, and 05/21/25. Resident #11's anxiety monitoring indicated no anxiety occurred. Review of Resident #11's progress note dated 06/12/25 revealed an order from the CNP to start the resident on Hydroxyzine 25 mg every eight hours as needed. Review of Resident #11's progress note dated 06/12/25 revealed Hydroxyzine was administered due to increased anxiety. Review of Resident #11's physician order dated 06/12/25 to 06/16/25 revealed an order for Hydroxyzine 25 mg one tablet by mouth every eight hours as needed for anxiety. Review of Resident #11's physician order dated 06/16/25 revealed an order for Hydroxyzine Pamoate one capsule by mouth three times a day for anxiety. Review of Resident #11's physician order dated 06/16/25 revealed an order to monitor for anxiety related behaviors and document if behaviors were present. Review of Resident #11's mini mental score dated 06/02/25 revealed the resident had increased anxiety with shortness of breath. He reported as needed Hydroxyzine was effective when he was anxious. Review of Resident #11's CNP note dated 06/16/25 revealed his anxiety was noted, however there was no discussion of cause. Review of Resident #11's 06/01/25 to 06/17/25 MAR revealed as needed Hydroxyzine was only provided on 06/12/25. Scheduled Hydroxyzine was provided twice on 06/16/25 and three times on 06/17/25. Resident #11's anxiety monitoring indicated no anxiety occurred. Interview on 06/17/25 at 11:00 A.M. and 06/18/25 at 1:17 P.M. with the Director of Nursing (DON) verified the reasoning for Resident #11's anxiety had not been documented until 06/16/25. She reported the anxiety was new to him due to a change in his condition. Resident #11 was anxious due to his shortness of breath; however, she was unable to provide evidence, this or alternate interventions had been discussed with the resident. She additionally verified the nurses were not always documenting the reason for administration of Hydroxyzine. Resident #11's Hydroxyzine was increased to scheduled three times a day despite the fact that he had only used the as needed medication once since 05/20/25. Review of the facility policy 'Psychotropic Medications Policy' dated April 2025, revealed the facility was to ensure residents have not used psychotropic medications unless necessary to treat a specific condition. Efforts were to be made to utilize psychotropic medications at the lowest possible dose to achieve therapeutic dose. 2. Review of the medical record for Resident #10 revealed an admission date of 03/04/24 with diagnoses of altered mental status, anxiety, major depressive disorder, and vascular dementia. Review of the care plan dated 03/04/24 revealed Resident #10 is prescribed anti-anxiety medications related to anxiety and vascular dementia. Interventions include administering non-pharmacological interventions prior to as needed (PRN) medications; nurse practitioner/medical director to perform routine gradual dose reductions (GDR); pharmacy to routinely evaluate medications per policy; and staff to follow up on pharmacy recommendations accordingly. Review of physician orders dated 06/20/24 revealed an order for Buspirone HCl (antianxiety) oral tablet 15 milligrams (mg) three times daily for anxiety, which was an increase from the initial dosage started on 11/27/23. Review of the medication administration record (MAR) from 11/01/24 through 04/30/25 revealed anxiety-related behaviors such as pacing, wandering, disrobing, inappropriate responses to verbal communication, and aggression toward staff or others were not observed or documented during this period. Review of the medication regimen review dated 12/05/24 revealed Resident #10 had been prescribed Buspirone 15 mg since 06/20/24. The pharmacist recommended evaluating the current dose and considering a gradual dose reduction to ensure use of the lowest effective dose. The prescriber selected the option indicating the resident had a good response to treatment and required the current dose for condition stability. It was documented that dose reduction was contraindicated as the benefits outweighed the risks, and reduction could impair the resident ' s function and/or cause psychiatric instability. A request for patient-specific justification was made; however, the prescriber ' s response was disagree, with no further explanation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 12/17/24 revealed Resident #10 is cognitively intact and exhibits no behavioral symptoms. Review of psychiatric evaluation dated 01/03/25 revealed Resident #10's mood was documented as good. The resident reported feeling anxious and depressed daily, while staff reported her anxiety was at baseline and she exhibited no behavioral concerns. Review of psychiatric evaluation dated 02/07/25 revealed the resident was re-evaluated for depression, anxiety, insomnia, and dementia with behavioral disturbance. The resident reported her mood was very good, denied depression and anxiety, and was at baseline with no new or worsening symptoms. The resident was observed to have no aggression, irritability, or mania. The resident tolerated an increase in Zoloft (antidepressant medication) with improvement in mood. The note indicated a diagnosis of chronic anxiety disorder with baseline symptoms requiring ongoing monitoring. Review of behavior monitoring and interventions from 02/16/25 through 06/06/25 revealed the following documented behaviors: on 02/17/25, Resident #10 was physically aggressive toward others and made threats; on 02/27/25, she was physically aggressive again, accusatory, cursing at others, and agitated; on 06/06/25, she was making disruptive sounds, agitated, refusing care, and screaming; on 06/08/25, she was accusatory toward others, making disruptive sounds, exit-seeking, pacing, and verbalizing persistent false beliefs. Review of the medication regimen review dated 03/05/25 again recommended considering a gradual dose reduction. The same rationale for continuation of the current dose was selected by the prescriber, citing the need for stability and risks associated with dose reduction. No patient-specific justification was provided, and the prescriber again selected disagree without further comment. Interview on 06/17/25 at 2:33 P.M. with the Director of Nursing confirmed the medication regimen reviews did not contain specific rationale explaining why gradual dose reduction was declined on 12/05/24 and 03/05/25. The Director of Nursing also confirmed that the medication administration records used to document anxiety-related behaviors lacked sufficient supporting details to justify refusal of a gradual dose reduction and was inconsistent in documentation. Review of facility policy dated 04/2025 revealed residents receiving psychotropic medications will receive gradual dose reductions and behavioral interventions in an effort to discontinue these drugs. Staff will evaluate the use and effectiveness of any psychotropic medication administered to assist the resident in achieving or maintaining their highest level of overall functioning. Efforts will be made to utilize psychotropic medications at the lowest possible dose to achieve a therapeutic effect.

Based on record review, review of the facility policy, and physician and staff interview, the facility failed to monitor the effectiveness of the pain interventions for a resident per the resident's plan of care and professional standards of practice. This affected one (Resident #35) of three residents reviewed for pain management. The facility census was 33. Findings include: Review of the medical record for Resident #35 revealed an admitted [DATE] and discharge date [DATE]. Diagnoses included spinal cerebrospinal fluid leak, spinal fusion, and spondylolisthesis lumbosacral region. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact. Review of the hospital records prior to admission revealed the resident was admitted to the hospital on 11/01/23 and had spinal surgery 11/01/23. Review of the hospital after visit summary (AVS) dated 11/07/23 revealed the discharge recommendation was to start taking Oxycodone (narcotic pain medication) one tablet by mouth every six hours as needed (PRN) for pain for up to three days and take acetaminophen 325 milligram (mg) tablet to take two tablets by mouth every six hours for mild pain. The AVS instructed to use muscle relaxants to help with muscle spasms and pain. Review of the physician orders dated 11/07/23 revealed an order for acetaminophen tablet 325 mg with instructions to give two tablets by mouth every six hours PRN for mild pain (pain level of one to four on a pain scale from zero (no pain) to 10 (most severe pain). An order dated 11/07/23 to 11/08/23 for Oxycodone HCL oral tablet five mg with instructions to provide one tablet by mouth every six hours as needed for moderate pain (pain level from five to seven). An order dated 11/08/23 to 11/14/23 was for Oxycodone HCL oral tablet five mg with instructions to give one tablet by mouth every six hours for pain. The order dated 11/14/23 to 11/21/23 revealed an order for Oxycodone five mg with instructions to give one tablet by mouth every four hours for pain. Review of the plan of care dated 11/08/23 revealed Resident #35 had acute pain related to a postoperative discomfort with interventions to administer analgesia as per orders, anticipate residents need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of the pain including dosing schedules and resident satisfaction with results, monitor and record side effects of pain medication and notify the physician if interventions were unsuccessful or if current complaint was significant change from past reports of pain, provide the resident and family with information about pain and options available for pain management. Review of the Nurse Practitioner (NP) note dated 11/08/23 revealed Resident #35 was on Oxycodone five mg every six hours as needed for pain but also stated Oxycodone five mg was scheduled every six hours. The note stated the resident's pain was unstable, but the resident was responding well to current regimen. The note was not clear if the Oxycodone was scheduled or PRN at the time of the assessment as both were listed. This date the Oxycodone medication changed from every six hours as needed to scheduled medication. The NP did mention in the note that the muscle relaxant dose was adjusted as well. Review of the progress notes dated 11/10/23 at 12:17 P.M. revealed Resident #35 had pain with protective body movements, facial expressions stabbing and burning that was worse with movement with interventions of changed position, cool compress applied, and PRN medications administered. The progress notes dated 11/11/23 at 6:06 P.M. revealed the resident had pain level of 10 with vocal complaints of pain, generalized pain, lumbar back pain, The resident was on scheduled Oxycodone and other interventions included a changed in position, cool compress applied, and scheduled PRN pain medication given. The progress notes dated 11/12/23 at 1:32 P.M. revealed the resident had pain level of 10 with sharp, burning numbing stabbing pain worse with movement with interventions of changed position, cool compress applied, and scheduled PRN pain medication given. The progress notes dated 11/13/23 at 12:54 P.M. revealed the resident had pain level of 10 with sharp, burning numbing stabbing pain worse with movement with interventions of changed position, cool compress applied, and scheduled PRN pain medication given. The progress notes dated 11/14/23 at 10:54 P.M. revealed the resident had pain level of 10 with sharp, burning numbing stabbing pain worse with movement with interventions of changed position, cool compress applied, and scheduled PRN pain medication given. The progress notes did not include a follow up pain assessment to indicate if the interventions aided in the resident's pain management and there was no indication if the physician was notified due to the resident's severe pain daily on three days from 11/10/23 to 11/12/23. Review of the Medication Administration Record (MAR) dated 11/2023 revealed Resident #35 was administered Oxycodone every six hours (scheduled) for pain from 11/08/23 at 6:00 P.M. to 11/14/23 at 2:27 P.M. The resident's pain was documented in the MAR and the pain tasks report as follows: On 11/10/23 at 12:00 P.M., the resident's pain level was five, and her pain level was not rechecked until 5:11 P.M. and was at five. On 11/10/23 at 6:00 P.M., the resident's pain level was five, and her pain level was not rechecked the rest of the day. On 11/11/23 at 12:00 P.M., the resident's pain level was nine, and her pain level was not rechecked until 3:23 P.M. and it was 10. On 11/11/23 at 6:00 P.M., the resident's pain level was 10, and her pain level was not rechecked until 11:45 P.M. and it was eight. On 11/12/23 at 12:00 A.M., the resident's pain level was eight, and her pain level was not rechecked until 5:14 A.M. and the pain level was at five. On 11/12/23 at 6:00 A.M., the resident's pain level was five and her pain level was not rechecked. On 11/12/23 at 12:00 P.M., the resident's pain level was five, and her pain level was documented again at 12:11 A.M. and was at pain level was five. It was not documented if this was a recheck or if it was when the resident was assessed, and medication was provided at 12:00 A.M. medication pass. On 11/12/23 at 6:00 P.M., the resident's pain level was five, and her pain level was not rechecked until 11:28 P.M. and her pain level was four. On 11/13/23 at 12:00 A.M., the resident's pain level was four, and her pain level was not rechecked until 5:06 A.M. and her pain level was six. On 11/13/23 at 6:00 A.M., the resident's pain level was six, and her pain level was not rechecked until 5:06 A.M. and her pain level was six. On 11/13/23 at 12:00 P.M., the resident's pain level was eight, and her pain level was documented again at 12:04 A.M. and her pain level was eight. It was not documented if this was a recheck or if it was when the resident was assessed, and the medication was provided at 12:00 P.M. medication pass. Review of the NP note dated 11/13/23 revealed Resident #35 was on Oxycodone five mg every six hours scheduled for pain but also stated Oxycodone five mg scheduled every six hours as needed was ordered (this was discontinued on 11/08/24). The note stated the pain was unstable but also stated the resident was responding well to current regimen. The NP mentioned in the note a discussion of using Oxycodone extended release or scheduling it every four hours. The resident was to let nursing know how it was working and staff shall reach out to provider. Review of the pain assessment dated [DATE] revealed Resident #35 occasionally had pain, and the pain occasionally affected therapy and day-to-day activities. The resident rated her worst pain in the last week was an eight out of ten. The pain assessment indicated the resident had scheduled and PRN pain medication ordered. Review of the physician note dated 11/14/23 revealed Resident #35 complained of pain and discussed with residents' spouse about pain. The Oxycodone was increased from every six hours PRN to every six hours scheduled and then to every four hours scheduled. The resident was also noted on Flexeril for muscle spasms which could be increased and Lyrica which could help with pain. Review of the NP note dated 11/14/23 revealed Resident #35's pain was not well managed. The resident was working with therapy at times but was limited due to pain. The NP discussed with family at bedside about pain control concerns. During the evaluation, the resident had muscle spasm attack causing pain all over and discussed Oxycodone medication effects last about four hours. The Oxycodone was changed to every four hours and muscle spasm medication was scheduled twice daily. If spasms continued, NP planned to increase Flexeril or switch to Robaxin. Interview on 02/05/24 at 11:28 A.M. with NP #200 revealed her expectations for staff would include giving pain medications or interventions and checking back with the resident in about 45 minutes to see the effectiveness of the interventions. If the interventions were not effective, NP revealed they could make changes to medications or would possibly request staff to reach out to the surgeon's office for recommendations or get a follow up appointment. NP revealed she would expect staff to complete rechecks and if pain control was not maintained, the staff should reach out to the medical team for next steps. The NP reviewed Resident #35's pain levels and confirmed the resident had several pain levels at eight, nine and 10 without documented timely rechecks. The NP stated the medical team did not just want to increase pain medications and were trying to make small adjustments at a time. NP #200 confirmed the facility had difficulty in managing residents' pain level which was confirmed in her notes. Interview on 02/05/24 at 12:49 P.M. with Physician #250 revealed Resident #35's pain was difficult to manage. The physician revealed he had spoken with the resident's family about concerns that staff were not offering pain medications timely and discussed options for pain control. The physician stated he wanted to slowly adjust medications due to side effects in the elderly population. The physician revealed his expectations that staff offer medication timely and check back to ensure the interventions were effective. Interviews on 04/08/24 from 1:30 P.M. to 2:30 P.M. with the Administrator and Director of Nursing stated the MAR included documentation of the pain medication effectiveness. The DON confirmed the scheduled medications dated 11/08/23 to 11/15/23 had no notation in the MAR if the medication was effective for Resident #35. The DON stated the facility identified an issue with order transcription and found orders were being put in without having the effectiveness notation. The DON and Administration acknowledged the importance for staff to check back in after giving pain medication. The DON stated I don't have the staffing to do that but at the same time acknowledged if the orders were transcribed incorrectly, the expectation was that staff should verify if pain levels had improved after interventions or medications were given. The DON and Administrator confirmed Resident #35 was hospitalized from complications with pain during a follow up visit with the surgery team on 11/15/23. Review of the facility policy titled Pain Management Program, dated 01/2016, revealed each resident's response to pain is different and resident should be monitored for pain. The facility shall use a pain scale to determine the effectiveness of intervention. The facility shall address goals and reduce pain through assessment, implementation of interventions and through monitoring the resident's response to interventions. This deficiency represents non-compliance investigated under Complaint Number OH00152034.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, staff interview, review of the fall investigation and witness statements, review of the hospital records, and review of the manufacturer recommendations for use, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 03/28/23 when Resident #07 was transferred from the bed to the wheelchair with the mechanical lift when the straps to the lift pad tore and Resident #07 dropped to the floor approximately two to three feet. Resident #07 complained of coccyx and buttock pain. Subsequently, Resident #07 was sent to the local hospital where he was diagnosed with a sacral fracture. This affected one resident (#07) of one resident reviewed for accident hazards. The facility census was 34. Findings include: Review of the medical record for Resident #07 revealed an admitted [DATE]. Diagnoses included osteomyelitis, chronic obstructive pulmonary disease, and a fracture of the sacrum 03/28/23. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #07 had mild cognitive impairment, required extensive assistance of two persons for bed mobility, and total dependence of two persons for transfer. Review of the progress note dated 03/28/23 at 11:00 A.M., revealed Resident #07 was being transferred from the bed to the wheelchair by the mechanical lift when the straps of the lift pad tore and the resident dropped two to three feet to the floor. Resident #07 complained of coccyx and buttocks pain at a 10 out of 10 on the scale of one to 10 with 10 being the worst pain. Resident #07 was transferred to the local hospital for evaluation. Review of the care plan dated 03/28/23 revealed to check Resident #07's lift pad prior to each use. Review of the hospital notes dated 03/28/23 revealed Resident #07 had a closed fracture of the sacrum status post a fall from a mechanical lift. Review of the fall investigation revealed Resident #07 required the use of an EZ Way Smart lift to transfer from the bed to the wheelchair. The straps on the mesh lift pad tore due to the resident being a large sized man. Registered Nurse (RN) #83 was called to the resident's room and found Resident #07 on the bars of the mechanical lift while also still on the lift pad. State tested Nurse Aides (STNA) #84 and #43 were witnesses and who also transferred Resident #07. Review of the witness statement of RN #83 dated 03/28/23 revealed when she entered the room two STNAs #84 and #43 were in the room. Resident #07 had fallen from the lift due to the straps of the mechanical lift tore. Review of the witness statement of STNA #84 dated 03/28/23 revealed STNAs #84 and #43 transferred Resident #07 with the mechanical lift and the lift pad broke in half and Resident #07 dropped to the floor. Review of the witness statement of STNA #43 dated 03/28/23 revealed STNAs #43 and #84 were transferring Resident #07 from the bed to the wheelchair when the mechanical lift pad broke in two different parts causing Resident #07 to drop to the floor. Interview on 07/20/23 at 1:34 P.M., with the Director of Nursing (DON) revealed she was not the DON at the time of the fall. The DON was able to produce the investigation for the fall where it documented the mechanical lift pad tore while using it and the corrective action taken. Interview on 07/20/23 at 1:54 P.M., with Medical Records Coordinator #49 revealed she now inspects the pads every week after the slings/lift pads were washed and completed the audit for the pads. Verified the facility used the regular basic sling and the deluxe sling at the facility from the EZ Way Inc. website. Medical Records Coordinator #49 said the audits were put in place after Resident #07 had the fall from the mechanical lift back in March 2023. Attempted interviews with RN #83 and State tested Nursing Aide #84 during the survey period. Both staff no longer worked at the facility at the time of the survey. Attempted interview with STNA #43 during the survey period and no return call was received. Review of the manufacturer's washable slings and harnesses important notice revised date 05/18/20 revealedthe following: This product is designed and manufactured to the highest possible performance specifications. It is constructed of high quality, durable, 100 percent synthetic fabrics. It has been individually inspected before shipping to ensure the safety of the product. However, water washing temperature, detergents and disinfectants, patient incontinence, frequency of use, types, and weights of patients, etc., all have an impact on the life expectancy of each product. Because of these factors, the continued integrity of the product is not guaranteed. The institution or private user must therefore examine the product to ensure its integrity before each use. EZ Way offers a 6-month warranty on slings and harnesses and recommends replacement after one year or if the sling or harness shows any sign of damage or wear. All slings and harnesses can bear a 1,000-pound weight load but must only be used to hold the amount of weight dictated by the lift or stand capacity. Accordingly, the PURCHASER hereby accepts full responsibility for checking the condition of all slings and harnesses before each use on a patient or client. As a result of the incident, the facility took the following actions to correct the deficient practice as of 03/29/23: On 03/28/23, Medical Records Coordinator #49 audited mechanical lift pads and removed five additional lift pads from use. On 03/28/23, the Interdisciplinary Team (IDT) comprehensive review was completed by the Administrator, the former DON #100, and Occupational Therapist (OT) #74 to put a plan in place to inspect all lift pads prior to use and remove from service if they were worn or frayed. New canvass lift pads were purchased. On 03/28/23 and 03/29/23, Staff Development Coordinator RN #29 provided all direct care staff education on the mechanical lift pads, the lifts, and inspection of the pad prior to each use. On 03/28/23, the DON/designee updated the care plan of Resident #07 to include inspection of the lift pad prior to use. On 03/28/23, the DON/designee audited all residents who required a mechanical lift and updated the care plan with interventions to inspect the lift pad prior to each use. On 03/28/23, Medical Records Coordinator #49 began audits to ensure the lift pads were in good repair after washing, and prior to use. Five lift pads were removed from service. Audits continued weekly and on 04/04/23 one additional lift pad was removed. Audits were presented and completed weekly and continue as of the annual survey. On 04/18/23, 10 additional new mechanical lift pads were put in service. .

Based on record reviews, staff interview, and policy review, the facility failed to monitor antibiotic use appropriately as part of an antibiotic stewardship plan. This had the potential to affect all 34 residents. The facility census was 34. Findings Include: Review of documents dated April, May, and June 2023, provided by the Director of Nursing (DON), revealed there was no documentation and analysis of appropriate indications for the use of antibiotics. Interview on 07/20/23 at 2:45 P.M. with the DON confirmed the facility used McGreer's criteria for the antibiotic stewardship program. The DON had no evidence how the facility was monitoring antibiotic medications using the McGreer criteria. The DON verified there was no documentation of an antibiotic stewardship program. The DON stated she had only been in the position for approximately three weeks and had identified antibiotic stewardship as an area of improvement for the facility. Review of the facility policy, Antibiotic Stewardship Program Policies and Procedures Annual Authorization, dated 01/20/23, revealed the policy stated, facility leadership commits to executing the Centers for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes. Antibiotic Stewardship can be defined as any interdisciplinary activity that supports appropriate drug selection, dose, and duration of antibiotic use while reducing adverse events associated with antibiotic use. The DON duties included: oversee adherence to and enforcement of antibiotic prescribing practices and ensure proper communication templates are being used to document antibiotic use upon admission to the facility and during stay.

Based on observation, interview, review of the tray line temperature log, and policy review, the facility failed to serve foods at the appropriate temperature. This had the potential to affect all residents who ate food in the facility. The census was 34. Findings included: Observation on 07/19/23 at 11:33 A.M. revealed Diet Tech (DT) #90 taking the temperature of foods prior to meal service. DT #90 pulled a hot dog that was ready to serve from the tray line and its temperature was 150 degrees Fahrenheit (F). DT #90 tested two other hot dogs with temperatures of 140 degrees F and 120 degrees F. After reheating the hot dogs for eight minutes, the temperature was 168 degrees F. DT #90 taking the temperature of a hamburger patty from the tray line that was ready to serve and the temperature was 158 degrees F. DT #90 took the temperature of the coleslaw which was 53 F degrees and the fruit cocktail was 57 degrees F. Interview on 07/19/23 at 11:33 A.M. with DT #90 confirmed the hotdog temperature were 120 to 160 degrees F, the hamburger was 158 degrees F, the coleslaw was 53 degrees F, and the fruit cocktail was 57 degrees F. Review of Trayline Taste and Temperature Log revealed hot entrees should be served at 165 degrees F and cold items should be served between 36 and 38 degrees F. Review of a policy titled Recording Final Cooking Food Temperatures, dated 01/2016 revealed if the food item tested does not meet acceptable temperatures, the item shall continue to be cooked to the proper cooking temperature. If the food item does not meet acceptable temperatures and cannot be corrected prior to meal service, an appropriate menu substitution shall be assigned and served.

Based on resident record review, observation, staff interviews, review of the infection control logs, and policy review, the facility failed to ensure infection control logs were completed for tracking trends and patterns. This had the potential to affect all 34 residents who reside in the facility. In addition, the facility failed to follow proper infection control policies and procedures during catheter care. This affected one resident (#24) of one resident reviewed for catheter care. The facility census was 34. Findings include: 1. Review of the Infection Control Logs dated April, May, and June 2023 revealed the logs lacked tracking of the disease organism, isolation type identification, and culture dates. For months May and June 2023, there was no mapping of the house-acquired infections (HAI) or mapping of the organism in the facility. For all three months, the logs did not indicate which infections were in-house acquired infections, did not include culture dates or isolation types, and were inconsistent with documenting signs and symptoms that appeared. Interview on 07/20/23 at 2:45 P.M. with the Director of Nursing (DON) confirmed the infection control logs were missing identification of HAI, tracking disease organisms, culture dates, and isolation types. The DON confirmed there was no mapping of infections or organisms for the months of May and June 2023. The DON had only been in the position for three weeks and had identified the infection control logs as an area of improvement and had already began revisions of the logs. Review of the facility policy, Infection Control-Monthly Infection Control Log-Guidelines, dated 10/2006, revealed the policy stated, the facility will ensure infections meet the approved criteria and gather the following information on all infections (community acquired and nosocomial (HAI): resident name, admitted , room number, unit or hall, type and/or site of infection, date of onset, date and results of culture, type of antibiotic therapy and date started, place a checkmark in the appropriate column indicating if the infection met the Centers for Disease Control (CDC) definition, state type of organism identified, and classification of infection (infectious, community acquired, nosocomial). 2 Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnosis included urinary tract infection, obstructive and reflux uropathy, retention of urine, and benign prostatic hyperplasia. Review of Resident #24's physician orders for July 2023 revealed a order to maintain a indwelling Foley catheter 16 French size 10 cubic centimeters (cc) balloon size to straight drain for diagnosis of urinary retention related to obstructive uropathy, and to provide catheter care daily and as needed. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicated a moderately impaired cognition for daily decision making abilities. Resident #24 required extensive assistance from two staff members for toilet use, and required an indwelling catheter for urine elimination. Review of the plan of care dated 01/11/23 and revised 01/23/23 revealed Resident #24 had an indwelling urinary Foley catheter, 16 french 10 cc balloon for the diagnosis of obstructive uropathy, and urinary retention Interventions include to provide catheter care and to monitor for signs and symptoms of discomfort and infection. Observation on 07/19/23 at 2:34 P.M. of State tested Nursing Assistant (STNA) #32 completing catheter care for Resident #24 revealed infection control was not maintained during catheter care. STNA #32 was observed using the wet and soapy wash cloth to complete catheter care where after this was completed she placed the dirty wash cloth on the stand next to the residents bed. The STNA #32 then used the wet wash cloth to rinse off any soap followed by placing that dirty wash cloth on the stand beside the residents bed. The STNA #32 then used the dry hand towel to dry up any water and then used that hand towel to grab up the two wet and used wash cloths. Interview on 07/20/23 at 12:30 P.M. with the Director of Nursing (DON) revealed when catheter care or incontinence care is completed, the dirty or used wash cloth should have been placed in a bag and not on the bedside table. Review of the facility policy titled Catheter-Urinary-Care and Maintenance-Nurse Aide, dated 03/2019 revealed under Daily Indwelling Catheter Care, 6) Gently cleanse about three inches of the catheter from the urethra outward avoiding traction. 7) Rinse thoroughly and gently dry. 8) Check drainage bag and tubing for proper placement. 9) Remove gloves and place gloves and other used supplies in plastic bag. Wash hands.

Based on observation, interview, and policy review, the facility failed to store and serve food in a sanitary manner to prevent potential contamination. This had the potential to affect all 34 residents who eat in the facility. Findings included: 1. Observation on [DATE] at 9:56 A.M. revealed an undated tub of coleslaw and an uncovered and undated container of fruit in the tray line refrigerator. Interview on [DATE] at 9:56 A.M. with Director of Dietary Services (DDS) #87 confirmed the coleslaw and fruit were not dated and the fruit was uncovered. 2. Observation on [DATE] at 9:58 A.M. revealed a large tub of flour which was undated. Interview on [DATE] at 9:58 A.M. with DDS #87 confirmed the tub of flour was undated. 3. Observation on [DATE] at 10:05 A.M. revealed a tray of bread and a box of freezer burnt chicken uncovered in the walk-in freezer. Interview on [DATE] at 10:05 A.M. with DDS #87 confirmed the tray of bread and box of freezer burnt chicken were uncovered. 4. Observation on [DATE] at 10:09 A.M. revealed one full half-gallon of buttermilk and one half-gallon of buttermilk with approximately 50 percent left had expired on [DATE], two five-pound containers of cottage cheese expired on [DATE], two two-pound blocks of goat cheese expired on [DATE], one box containing 20 32-ounce cartons of egg whites expired on [DATE], four four-pound bags of yogurt expired on [DATE], and two three-pound blocks of cream cheese expired in June of 2023. Interview on [DATE] at 10:15 A.M. with DDS #87 confirmed the buttermilk, cottage cheese, goat cheese, egg whites, yogurt, and cream cheese had expired. 5. Observation and interview on [DATE] at 10:25 A.M. revealed the ceiling in the dish area was leaking into clean dish water. DDS #87 confirmed the ceiling was leaking into clean dish water. 6. Observation on [DATE] at 11:40 A.M. revealed Dietary Aid (DA) #89 walking through tray line area without a hairnet. Interview on [DATE] at 11:40 A.M. with Dietetic #90 confirmed DA #89 did not have a hairnet on. 7. Observation on [DATE] at 11:46 A.M. revealed Cook #86 wearing gloves during tray line. Cook #86 used tongs to handle the hamburger patties, but used her gloved hands to handle the buns, lettuce, tomatoes, and pickles. Cook #86 walked to a refrigerator with her gloves still on, opened the refrigerator, came back to the tray line and proceeded to handle the food without changing gloves or washing hands. Interview on [DATE] at 12:15 P.M. with DDS #87 confirmed Cook #86 did not change her gloves or wash her hands after touching the refrigerator. 8. Observation on [DATE] at 11:52 A.M. revealed Cook #88 coughing into her left elbow while her left hand touched her right shoulder as she was standing in front of the stove cooking hamburger patties. Cook #88 continued to work without changing gloves or washing hands. Cook #88 was standing next to the stove with her left hand on her hip while still wearing gloves. At 11:53 A.M. Cook #88 used her left hand, still gloved, to push her glasses up on her nose and continued cooking. At 12:05 P.M. Cook #88 did get new gloves and proceeded to cook while her left hand rested on her hip. Interview on [DATE] at 12:15 P.M. with DDS #87 confirmed Cook #88 had coughed into her left elbow and touched her right shoulder, nose, and hip while cooking and did not change gloves or wash her hands. DDS #87 stated, we will have in-services immediately after this. Review of the policy titled Dry Storage and Supplied, dated ,d+[DATE] revealed working containers holding food/ingredients that are removed from their original package for use shall be identified by the common name of the food and opened boxes or cans shall be stored in resealed containers/food bags that are labeled/dated. Review of the policy titled Storage of Potentially Hazardous Foods, dated ,d+[DATE] revealed meats and other potentially hazardous foods shall be dated, labeled, and properly covered or wrapped tightly. Review of the policy titled Refrigerated Storage revealed refrigerated items shall bear a label indicating product name and date product was received or first opened. Review of the policy titled Hand Hygiene Procedures revealed staff should wash hands before and after handling contaminated items, eating, sneezing, coughing, blowing, or wiping nose. Instructions for hand hygiene include rub hands together vigorously with soap, apply friction to all surfaces of the hands for at least 20 seconds, use moderate amount of water for rinse, dry hands thoroughly with paper towels, use a dry paper towel to turn off the faucet.

Based on observation, resident and staff interviews, review of the meal times, and policy review, the facility failed to ensure meals were provided timely. This affected all 34 residents who ate meals in the facility. The facility census was 34. Findings include: Observation on 07/17/23 at 12:00 P.M. revealed a sign posted by dining room revealed lunch was to be served at 11:45 A.M. There were seven residents sitting in the dining room waiting for the meal service. Observation 07/17/23 at 12:20 P.M. no residents had received lunch meal trays in the dining room or room trays. Observation on 07/17/23 at 12:24 P.M. revealed the first of four meal carts was delivered to dining room. No drinks had been served prior to the meal tray arrival. Observation on 07/17/23 at 12:34 P.M. revealed staff started serving lunch trays to the residents. Observation on 07/17/23 at 12:34 P.M. revealed Residents #09 was sitting at the dining room table and had not received a lunch tray with all the other residents. Resident #27 was sitting at a separate table and also had not received his lunch tray. Interview on 07/17/23 at 12:36 P.M., with State tested Nursing Aide (STNA) #32 reported the kitchen had not sent a tray for Resident #09. STNA contacted the kitchen and had a tray brought brought for Resident #09. Resident #27's tray was in the warming cart. STNA #32 reported Resident #27 required assistance with eating and she would get his tray out when she was done feeding another resident. Observation on 07/17/23 at 12:42 P.M. revealed Resident #09 was served his lunch tray. Observation and interview on 07/17/23 at 12:45 P.M. revealed STNA #23 was passing out meal trays to resident rooms in the skilled unit and revealed the second to last tray had been passed out and only one remained. STNA #23 reported the final resident required some set up assistance. STNA #23 was observed to check on several lights and pass coffee and water refills to residents. At 12:58 P.M. Resident #244 was provided the meal tray STNA #23 confirmed lunch trays frequently came out late. Observation on 07/17/23 at 12:46 P.M. with STNA #32 revealed the STNA brought Resident #27's tray to him. At 12:53 P.M. a staff member came on unit and took Resident #27 away from table. Resident had not eaten anything yet, and had not had anyone assisting with eating yet. Observation on 07/20/23 at 12:22 P.M. revealed the first lunch cart arrived to the unit on 12:22 P.M. Prior to the arrival five residents were in the dining room waiting on their meals. At 12:25 P.M. staff began passing trays on the skilled unit and finished with the trays at 12:40 P.M. Observation on 07/20/23 at 12:34 P.M. revealed the first tray arrived to the long term care (LTC) unit. Staff dropped off the cart and walked away without informing staff. The first tray was passed to a resident at 12:39 P.M. The second food cart was brought to the unit on 12:40 P.M. and was fully passed out at 12:49 P.M. Observation on 02/20/23 at 12:43 P.M. Resident #14 was brought out to the dining room in her geri chair. Resident #14 was reclined back around a 45 degree angle and was unable to reach her tray and and take the lids and covers off the food. Resident #14 was calling out for assistance with no staff in the near vicinity. At 12:50 P.M. Resident #14 received assistance from staff to get adjusted to a proper position and to have food uncovered. Resident #14 was able to feed herself once she received the set up assistance. Interview on 07/20/23 at 12:50 P.M. Resident #14 said she was hungry while waiting for the food to come and reported the food had a cold temperature. Review of the meal schedule revealed breakfast was scheduled for 7:45 A.M. lunch was scheduled for 11:45 A.M. and dinner was scheduled for 5:45 P.M. Review of facility policy titled Meal Tray Service,dated 01/2016 revealed once the cart arrives, the trays must be passed out timely. The policy does not include verbiage related to the timeliness of carts being delivered to the units. This deficiency represents non-compliance investigated under Complaint Number OH00144055.

Based on medical record review, staff interview, review of the self reported incidents, and policy review, the facility failed to ensure resident abuse, neglect and misappropriation allegations were thoroughly investigated. This affected four residents (#138, #142, #141, and #143) of six residents reviewed for abuse. The facility census was 34. Findings include: 1. Record review revealed Resident #143 admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery, stress fracture right ankle, alcohol abuse with alcohol-induced anxiety disorder, depression, atrial fibrillation, type 1 diabetes, and conductive bilateral hearing loss. Review of a self-reported incident (SRI) for an allegation of misappropriation revealed Resident #143 reported she had an iPad charger when she admitted to the facility but was no longer able to locate it. Resident #143's room was searched, as were surrounding rooms and the laundry room. The facility interviewed staff which lead to no reports of the missing iPad charger being seen. The facility stated the allegation of misappropriation was unsubstantiated after also interviewing six other residents with no concerns of missing property. Review of General Incident Investigation Packet revealed Resident #143 was agitated at the time of the incident. Investigation report also stated Resident #143 was alert and oriented when the incident occurred. Due to the allegation of misappropriation the facility staff received re-education on missing personal property, abuse, and completing a personal inventory sheet. The policy for Care of Resident Personal Items stated staff should attempt to place the resident's name on all items if possible. Then, the resident's personal items should be logged on the Inventory of Personal Effects sheet. Review of Resident #143's chart revealed no Inventory of Personal Effects sheet. Interview on 07/18/23 at 3:14 P.M. with Director of Nursing (DON) #10 revealed the facility did not replace Resident #143's iPad charger because her son had replaced it before they had a chance to. Facility did not reimburse resident's son for the new iPad charger. DON #10 also confirmed the facility did not complete an Inventory of Personal Effects sheet upon Resident #143's admission or after the allegation of misappropriate occurred and she became aware of the missing inventory form. Interview on 07/18/23 at 4:23 P.M. with Resident #143 revealed since her iPad charger had gone missing there has been no effort from the facility to reimburse her for the new one her family purchased. Resident #143 stated since the incident occurred, she had lost a blouse and reported it to therapy and housekeeping. Resident #143 stated the home supervisor came into her room to search for the missing blouse but it was never found and was not replaced. 44070 2. Review of the medical record for the Resident #138 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included epileptic seizures, respiratory failure with hypoxia, embolism, hemiplegia, metabolic encephalopathy and vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #138 was cognitively intact with a BIMS of 15 and required extensive assistance of two staff members for transfers and mobility. Review of the plan of care dated 06/22/23 revealed Resident #138 had an activity of daily living (adl) self-care deficit with interventions of provide assistance with bathing including a sponge bath when a full bath was not tolerated, resident requires oral inspection, and to allow sufficient time for dressing. Review of the progress notes dated 03/27/23 revealed a progress note stating residents daughter spoke with staff about concerns including lack of care her mom received over the weekend and since admission. Family stated Resident #138 had not received a bath, have linens changed, oral care and changed clothes since admission. Progress note also stated these concerns were investigated and determined resident had worked with therapy and received a bath for admission and had linens changed after concern was reported. Review of the self-reported incident investigation number 233422 dated 03/27/23 revealed Resident #138's family reported concerns related to bathing, changing clothes, oral hygiene, and changing linens (ie: crumbs found in bed). The investigation summary stated the facility completed a record review and reported adls were provided. The investigation report included no evidence of the chart review or the reported findings. The investigation contained no evidence of staff interviews and resident interviews, resident skin assessments. The report documented staff were educated, but no evidence of education sign in sheets were provided. Interview on 07/19/23 at 4:55 P.M., with DON and Administrator acknowledged facilities lack of self-reported incident investigations and confirmed missing elements included staff and resident interviews and signed statements, skin and body assessments, interviews of other witnesses, evidence of chart reviews, education and review of the supporting evidence and documentation. 3. Review of the medical record for the Resident #141 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included fracture of left femur, kidney disease, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated ,d+[DATE] revealed Resident #141 was cognitively intact with a BIMS of 15 and required extensive assist of one to two staff for mobility and transfers. Review of the plan of care dated 05/17/23 revealed Resident #141 had a self care deficits. Review of the progress notes revealed no information related to neglect allegations. Review of the self-reported incident investigation number 235323 dated 05/22/23 revealed Resident #141's family reported concerns of resident being afraid at night and reported a long call light wait time of 50 minutes. The investigation summary stated the facility spoke with the resident and she did not like the dark but was not fearful of staff and facility provided a night light for resident use. The investigation summary also reported a call light audit was completed and found a 50 minute call light was confirmed to have occurred on 05/20/23. The investigation report included no evidence of staff interviews and resident interviews, and resident skin assessments. The report staff was educated, but no evidence of education sign in sheets was provided. The report documented call light were audited but provided no evidence of the audits or findings. Interview on 07/19/23 at 4:55 P.M. with DON and Administrator acknowledged facilities lack of self-reported incident investigation and confirmed missing elements included staff and resident interviews and signed statements, skin and body assessments, interviews of other witnesses, education and review of the supporting evidence and documentation. 4. Review of the medical record for the Resident #142 revealed an admitted [DATE] and discharge 05/03/23. Diagnoses included osteomyelitis of right food and ankle, orthopedic joint implant, seizures, migraines, anxiety and weakness. Review of the Minimum Data Set (MDS) assessment dated ,d+[DATE] revealed Resident #142 was cognitively intact with a BIMS of 15 and required limited one person assist. Review of the plan of care dated 06/19/23 revealed Resident #142 had an activity of living self care self deficit requiring assist of two staff for activities of daily living. Review of the progress notes revealed no information related to neglect allegations. Review of the self-reported incident investigation number 235407 dated 05/25/23 revealed Resident #142 reported concerns of neglect of care. Concerns included showers, hydration, medications and treatments as ordered, oral care and accurate meals. The investigation summary stated the facility completed a chart review that disproved the concerns but provided no evidence of this information. The shower schedule was not marked off as completed or refused but as not applicable. For hydration, the Dietitic reported resident was provided with 60-72 ounces of fluids and required a minimum of 75 ounces. The investigation summary reported a record review was completed but provided no evidence or documentation from the record review to show evidence of the resident's claims/concerns being reviewed and discounted. The investigation report included no evidence of staff interviews and resident interviews, and resident skin assessments. The report stated staff was educated, but provided evidence of less than half of the staff completing any education sign in sheets. Interview on 07/19/23 at 4:55 P.M. with DON and Administrator acknowledged facilities lack of self reported incident investigations and provided understanding of missing elements including staff and resident interviews and signed statements, skin and body assessments, interviews of other witnesses, chart reviews, education and assessment and review of the supporting evidence and documentation. Review of the facility policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, dated 10/2016. The policy revealed the investigation would be completed within five working days. This shall include interview with the involved resident, the accused, and all witness. Witnesses generally included anyone who was involved or who heard of the incident, came in close contact with the involved resident including other residents, family, and staff working. If no direct witnesses were indicated, interviews should be expanded to cover employees working on the unit for shifts around when the incident occurred. The interviews shall be documented and the interviewee shall review and sign the statement. Obtain medical records including hospital records if indicated. The investigation and all evidence should be reviewed and maintained for the investigation.

Based on observation, staff interview and menu review, the facility failed to follow the menu. This affected four residents (#07, #10, #13, and #22) out of four residents on a mechanical altered diet. The facility census was 34. Findings included: Review of the menu for lunch on 07/19/23 revealed the facility planned to serve grilled cheeseburgers, grilled hot dog on a bun, Boston baked beans, soft potato salad, creamy coleslaw, and fresh fruit salad. Observation of the tray line on 07/19/23 at 12:00 P.M. revealed residents receiving a pureed diet were receiving pureed hamburger, with no cheese or bun, served with 3.25-ounce scoop, two ounces of baked beans, and a container of apple sauce. Resident with a mechanical soft diet were served a chopped cheeseburger with no bun. Interview on 07/19/23 at 12:15 P.M., with the Director of Dietary Services (DDS) #87 confirmed residents with a pureed diet did not receive a bun, coleslaw, sweet potato salad, or fruit cocktail and that residents receiving mechanical soft texture did not receive a bun with their chopped cheeseburger.

Based on observation, staff interview and menu review, the facility failed to ensure diets met the needs of residents. This had the potential to affect four residents (#07, #10, #13, and #22) who received a mechanically altered diet in the facility. The facility census was 34. Findings included: Review of the menu for lunch on 07/19/23 revealed the facility planned to serve grilled cheeseburgers, grilled hot dogs on a bun, Boston baked beans, soft potato salad, creamy coleslaw, and fresh fruit salad. Observation of the tray line on 07/19/23 at 12:00 P.M. revealed residents receiving a pureed diet were receiving pureed hamburger, with no cheese or bun, served with one 3.25-ounce scoop, two ounces of baked beans, and a container of apple sauce. Residents' with a mechanical soft diet were served a chopped cheeseburger with no bun. Interview on 07/19/23 at 12:15 P.M. with Director of Dietary Services (DDS) #87 confirmed residents with a pureed diet did not receive a bun, coleslaw, sweet potato salad, or fruit cocktail and that residents receiving mechanical soft texture did not receive a bun with their chopped cheeseburger. Review of the spreadsheet for 07/19/23 revealed a resident receiving a regular diet with pureed texture were to be served a pureed cheeseburger or pureed hot dog on bun at six ounces, pureed baked beans at four ounces, pureed sweet potato salad, pureed creamy coleslaw, and pureed fruit cocktail. Resident on a regular diet with mechanical soft texture were to receive a cheeseburger cut up or a hotdog on bun at six ounces, three ounces of baked beans, four ounces of creamy coleslaw, and four ounces of fresh fruit. Review of recipes revealed a pureed diet should receive an eight-ounce scoop of cheeseburger or a four-ounce scoop of hotdog, four ounces of baked beans, four ounces of potato salad, four ounces of creamy coleslaw, and four ounces of fruit cocktail. Review of a policy titled Portion Control Guidelines dated 01/16 revealed portion sizes shall be denoted on standardized recipes, therapeutic diet spreadsheets, and production sheets.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents fluid intake was adequate to meet their nutritional needs. This affected one resident (#13) out of two residents reviewed for nutritional support. The facility census was 34. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnosis included fracture of the right acetabulum sequela, difficulty walking, moderate protein-calorie malnutrition, and adult failure to thrive. Review of Resident #13's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognition for daily decision making abilities. Resident #13 required extensive assistance from one staff member for bed mobility and transfers. No impairments noted to residents bilateral upper or lower extremities. Resident #13 was frequently incontinent of bowel and bladder function. Resident #13 had one stage one pressure ulcer which was present upon admission. Pressure wound interventions include turning and repositioning program, nutrition and hydration intervention and pressure ulcer injury care. Review of the care plan dated 06/16/23 and revised 06/29/23 revealed Resident #13 had a nutritional problem or potential nutritional problem related to advanced geriatric age, right hip fracture, heart disease, congestive heart failure (CHF), anxiety, history of transient ischemic attach (TIA), abdominal aortic aneurysm, needing a mechanically altered diet, poor appetite, significant weigh loss, and varied intake. Interventions included to administer medication as ordered, honor food preferences as able, monitor, record, and report to physician any symptoms or signs of malnutrition, obtain and monitor lab values, and monitor and document intakes. Review of Resident #13's admission Skilled Nursing Facility (SNF) Nutritional assessment dated [DATE] revealed the resident was ordered a regular diet, mechanical soft texture, with nectar thin liquids. The residents current weight was 127 pounds and was 73 inches tall. Estimated needs with ideal body weight of 172 pounds due to underweight status. Daily recommended fluid intake was between 1955 ml to 2346 ml daily. Review of Resident #13's physician diet order revealed a order for a regular diet with mechanical soft texture food and thin consistency fluids ordered 06/28/23. Also noted an order dated 06/22/23 for Enlive (a nutritional support drink), give eight ounces with each meal for nutritional support and to promote weight gain. Review of Resident #13's fluid intake and nutritional supplement intake dated from 06/21/23 through 07/19/23 revealed the total daily intake was less than the required 1955 to 2346 ml required for the resident to maintain adequate fluid intake. Review of Resident #13's progress notes from 06/21/23 through 07/19/23 revealed no evidence of communication to the physician regarding the residents poor fluid intake. Interview on 07/20/23 at 2:30 P.M., with the Director of Nursing (DON) confirmed Resident #13's fluid intake along with supplement intake was under the recommended amount and fluid intake was something the nursing staff should be monitoring to ensure each resident received and consumed their needed daily intake. If a resident was not getting the required fluids, then the physician would be contacted for recommendations and interventions. Review of the policy titled Evaluation of Hydration Needs, dated 01/2016 revealed 4) An interdisciplinary care plan shall be developed utilizing the clinical conditions and risk factors identified, taking into consideration the amount of fluid that the resident requires. The care plan shall be maintained to be a current reflection of status for each resident. 5) The interdisciplinary team shall work together to determine the resident's response to nutrition interventions. Revised nutrition interventions shall be implemented as needed to facilitate adequate hydration and health.

Based on medical record review, staff interview, and facility document review, the facility failed to provide a bed hold notice to resident or resident representative. This affected one resident (#27) of three residents reviewed for hospitalization s. The facility census was 34. Findings include: Review of the medical record for Resident #27, revealed an admitted [DATE]. Diagnoses included: chronic kidney disease, stage 4, metabolic encephalopathy, chronic respiratory failure with hypoxia, dependence on renal dialysis, hypertension chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease and type 2 diabetes mellitus with hyperglycemia with a code status of FULL CODE and no known allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a BIMS score of 05, special treatments, procedures, and programs with dialysis triggered, bed mobility/toileting is extensive assistance with two+ persons physical assist, transfer is total dependence with two+ persons physical assist, eating is extensive assistance with one-person physical assist, and personal hygiene extensive assistance with one-person physical assist. Review of the nurse progress note dated 07/10/23 at 4:05 P.M. revealed Resident #27 went for dialysis appointment this morning and has not returned this nurse called the dialysis center to ask for patient this nurse was told that patient was admitted to ohio state university teaching hospital. family notified. Review of Resident #27's paper and electronic medical records revealed no evidence of documentation for a bed hold for the hospitalization on [DATE]. Interview on 07/18/23 at 5:10 P.M. with Business Office Associate #52 and the Administrator #46 revealed the facility did not have evidence of transfer or discharge notices being provided or bed hold notices being provided to resident or representative upon discharge. They revealed Resident #27 went to the hospital from the dialysis clinic and not from the facility and acknowledged therefore he was discharged from the facility for the time being and should have been given a transfer/discharge notice as well as bed hold notice. Review of the facility policy titled, Bed Holds, Room Changes, Transfers and Discharges dated March 19 with no year, revealed admissions staff will provide the resident with a bed hold policy form as follows: a bed hold letter will be mailed by certified mail on the day of transfer from the facility to the appropriate responsible party.

Based on medical record review, staff interview, and policy review, the facility failed to develop comprehensive care plans for resident specific care needs. This affected three residents (#13, #08, and #20) out of thirteen residents reviewed for comprehensive care plans. The facility census was 34. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnosis included fracture of the right acetabulum sequela, difficulty walking, moderate protein-calorie malnutrition, and adult failure to thrive. Review of Resident #13's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognition for daily decision making abilities. Resident #13 required extensive assistance from one staff member for bed mobility and transfers. No impairments noted to residents bilateral upper or lower extremities. Resident #13 is noted to be frequently incontinent of bowel and bladder function. Resident #13 noted to have one stage one pressure ulcer which was present upon admission. Pressure wound interventions include turning and repositioning program, nutrition and hydration intervention and pressure ulcer injury care. Review of the plan of care dated 06/22/23 revealed Resident #13 had a stage one pressure ulcer to the coccyx. Interventions included applying barrier cream to the coccyx every shift and administer treatments as ordered along with weekly treatment documentation including measurement of each area of skin breakdown width, length, depth, type of tissue and exudate. Review of Resident #13's skin/pressure assessment dated [DATE] revealed resident had a stage three (a pressure wound with full thickness skin loss) pressure ulcer to the coccyx which was noted to be present upon admission. Measurements included 1.7 centimeter (cm) by 2.6 cm by 0.9 cm. Moderate amount of serous exudate noted and wound noted to be deteriorating. Review of Resident #13's physician orders revealed an order dated 06/27/23 for daily wound care for pressure to the coccyx. Order included to clean the wound with wound cleanser, apply Medihoney (a medical honey used to hasten the healing or wounds through its anti-inflammatory effects) and Calcium Alginate (used to keep the wound site moist enough for proper healing) to the wound bed, cover with a foam dressing daily and as needed. Interview on 07/20/23 at 1:20 P.M. with the Director of Nursing (DON) confirmed Resident #13's care plan related to pressure wounds and injures was not accurate and did not appropriately reflect the residents current pressure wound condition. 2. Record review revealed Resident #20 admitted to the facility on [DATE] with diagnoses including meningitis, acute diastolic congestive heart failure, hypertensive heart disease with heart failure, chronic respiratory failure, gastro-esophageal reflux disorder, obstructive sleep apnea, hypothyroidism, hyperlipidemia, unspecified dementia without behavioral disturbance, and osteoarthritis. Review of Resident #20's orders revealed an order for oxygen two liters via nasal cannula continuous and an order to apply continuous positive airway pressure (CPAP) machine every evening at bedtime. Review of Resident #20's respiratory care plan revealed the resident has oxygen therapy. Resident #20's care plan stated she receives oxygen via nasal cannula at two liters as needed. There were no indications Resident #20 wears a CPAP at bedtime. Interview on 07/17/23 at 11:46 A.M. with Resident #20 revealed staff have forgotten to apply her CPAP at bedtime which makes her weak. Interview on 07/20/23 with Director of Nursing (DON) #10 revealed 2:30 P.M. confirmed Resident #20 has an order for oxygen at two liters via nasal cannula continuously and the care plan states Resident #20 has oxygen at liters via nasal cannula as needed. DON #10 also confirmed Resident #20 has an order for her CPAP to be applied every evening at bedtime but there is no care plan to indicate she has a CPAP. 44070 3. Review of the medical record for the Resident #08 revealed an admitted [DATE]. Diagnoses included wedge fracture of lumbar vertebra, heart failure, chronic kidney disease, and fibromyalgia. Review of physician orders for 05/27/23 revealed oxygen tubing to be changed weekly on Saturday. Resident also had orders dated 05/27/23 for oxygen at two liters via nasal cannula to be provided. Review of the plan of care dated 07/03/23 revealed Resident #08 did not have a care plan for oxygen. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 was cognitively intact with a BIMS of 13 and required extensive assistance of two staff members for mobility and transfers. Observation on 07/17/23 at 12:03 P.M. revealed Resident #08's door did not have a Oxygen in use no smoking sign. STNA #23 confirmed Resident #08 did not have a no smoking sign, oxygen in use on the door. Interview on 07/19/23 at 3:06 P.M., with the Director of Nursing (DON) revealed oxygen was not care planned for Resident #08. The facility was unable to find a policy for resident care plans.

Based on medical record review, review of the beneficiary notices, staff interview, review of the State Operations Manual, and policy review, the facility failed to ensure residents were provided appropriate beneficiary notices when Medicare part A services were reduced or discontinued and the residents remained in the facility. This affected two residents (#24 and #30) out of three residents reviewed for beneficiary notices. The facility census was 34. Findings Include: 1. Review of the medical record for Resident #24 revealed an admitted on 01/10/23. Diagnoses included type II diabetes, Parkinson's, dementia, muscle weakness, and a history of falling. Review of Resident #24's census revealed the resident had a Medicare part A payer source from 01/10/23 until 03/13/23. Effective 03/13/23, Resident #24 changed to a private pay payer source and remained in the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 had impaired cognition and scored a ten out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #24 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the Notice of Medicare Non-Coverage for Resident #24 revealed the residents' skilled services would end on 03/12/23. The notice was signed and dated 03/08/23. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review for Resident #24 revealed the resident had a Medicare part A skilled services episode with a start date on 01/10/23 and the last covered day of part A services was 03/12/23. The facility initiated the discharge from Medicare part A services when benefit days were not exhausted. Resident #24 did not receive an Advanced Beneficiary Notice (ABN) and remained in the facility. Review of the discharge summaries for physical and occupational therapies dated 03/10/23 revealed Resident #24 was discharged from therapies due to reaching the highest practical level. Interview on 07/20/23 at 12:36 P.M., with the Rehabilitation Manager (RM) #74 confirmed Resident #24 was discharged from skilled services in March due to reaching maximum rehabilitation potential. Resident #24 had not exhausted all of his benefits when he was discharged from the services. RM #74 confirmed Resident #24 remained in the facility. 2. Review of the closed medical record for Resident #30 revealed an initial admitted on 04/12/23, a readmitted on 05/08/23, and a discharge date on 07/04/23. Diagnoses included osteomyelitis of the left shoulder, type II diabetes, arthritis in the left shoulder, fibromyalgia, difficulty in walking, muscle weakness, and chronic pain. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 was independent to requiring supervision from staff to complete Activities of Daily Living (ADLs). Resident #30 received daily antibiotic medication. Resident #30 received intravenous (IV) medications. Resident #30 received occupational therapy and physical therapy with a start date on 05/09/23. Review of the census for Resident #30 revealed the resident had a Medicare part A payer source throughout her stay at the facility. Review of the physician orders dated June 2023 revealed Resident #30 had the following order: Cefazolin Sodium Injection Solution Reconstituted two grams (gm) with instructions to inject two gram via IV three times daily for infection until 06/29/23. Resident #30 had a peripherally inserted central catheter (PICC) line in place until 07/04/23 that was flushed once daily. Resident #30 had the following discharge order: may discharge to home with physical therapy, occupational therapy, home health aide, and nursing services on 07/04/23. Review of the discharge summaries for physical therapy and occupational therapy dated 06/30/23 revealed Resident #30 was discharged from physical therapy due to highest practical level being achieved on 06/30/23. Resident #30 was discharged from occupational therapy due to all goals were met on 06/30/23. Review of the Notice of Medicare Non-Coverage (NOMNC) for Resident #30 revealed the notice was signed and dated on 06/30/23 (the same day skilled therapies ended). Resident #30 was not provided with an Advanced Beneficiary Notice (ABN) notice and remained in the facility until 07/04/23. Interview on 07/20/23 at 12:55 P.M., with Rehabilitation Manager (RM) #74 confirmed Resident #30's IV antibiotics were discontinued effective 06/29/23 and the resident's physical and occupational therapies were discontinued on 06/30/23. RM #74 confirmed Resident #30 remained in the facility until 07/04/23. RM #74 stated Resident #30 remained a skilled resident until discharge on [DATE] due to having a PICC line in place that needed flushed once daily. RM #74 confirmed Resident #30 received a NOMNC on 06/30/23, the same day skilled therapies ended and did not receive a SNF ABN. Review of the State Operations Manual, Appendix PP, revised 02/03/23, revealed, the NOMNC is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. Furthermore, the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) must be given to a beneficiary for the following triggering event: in the situation in which a SNF proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNFABN to the beneficiary before it reduces items or services to the beneficiary. In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services. Review of the policy titled Notice of Medicare Provider Non-Coverage Policy, updated 04/2018 revealed the policy stated, A Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) will be issued to beneficiaries no later than two days before the termination or reduction of Medicare covered services and prior to the initiation of non-covered Medicare service.

Based on record review, staff interview and facility document review, the facility failed to notify the ombudsmen of a resident's discharge from the facility. This affected two residents (#05 and #27) out of two residents reviewed for hospitalization . The facility census was 34. Findings include: 1. Review of the medical record for Resident #27, revealed an admitted [DATE]. Diagnoses included: chronic kidney disease, stage four, metabolic encephalopathy, chronic respiratory failure with hypoxia, and dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had impaired cognition. Review of the nurse progress note dated 07/10/23 at 4:05 P.M. revealed Resident #27 went for dialysis appointment this morning and has not returned this nurse called the dialysis center to ask for patient this nurse was told that patient was admitted to ohio state university teaching hospital. family notified. Review of Resident #27's paper and electronic medical records revealed no evidence of the ombudsmen being notified of the hospitalization on [DATE]. Interview on 07/18/23 at 5:10 P.M. with Business Office Associate #52 and the Administrator revealed the facility did not have evidence of transfer or discharge notices being provided or bed hold notices being provided to resident or representative upon discharge. They revealed Resident #27 went to the hospital from the dialysis clinic and not from the facility and acknowledged therefore he was discharged from the facility for the time being and should have been given a transfer/discharge notice as well as bed hold notice. 44070 2. Review of the medical record for the Resident #05 revealed an admitted [DATE] and discharge on 07/20/23. Diagnoses included encephalopathy, urinary tract infection, weakness, diabetes, and parkinson's. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 was cognitively intact and required extensive assistance of one to two staff. Review of the progress notes dated 06/29/23 revealed, Resident #05 demanding to be sent out to hospital. States that he had a stroke. Upon assessment everything appears to be within normal limits. vital signs were stable. Resident able to move all extremities. Face and smile are equal. Resident began yelling out and trying to get out of bed. 911 called. Physician notified and family notified and was sent to a local hospital Interview on 07/18/23 at 5:10 P.M. with Business Office Associate (BOA) #52 and the Administrator revealed facility did not have bed hold notices for the Ombudsman available. A follow-up interview on 07/19/23 at 2:37 P.M. with Administrator revealed the previous Director of Nursing (DON) completed Ombudsman notifications until 03/2023. Administrator revealed no notification had been sent since then. Facility reported they did not have any evidence of Ombudsman notifications being provided for any of the discharges and requested previous staff (DON) to provide evidence of emails that were sent. The Administrator reported being unaware of discharges being sent to the Ombudsman on a routine basis. Review of facility policy titled, Bed holds, room changes, transfers and discharges, dated 03/2019 revealed Facility would provide a list of emergency discharges to the Ombudsman.

Based on record review, review of facility investigation, staff interview, and review of fall policy, the facility failed to follow physician's orders for two staff to provide care. This resulted in actual harm when a staff member provided care for Resident #2 without a second staff member present and the resident fell from the bed and sustained a fractured clavicle. This affected one (#2) out of three residents reviewed for falls. The facility census was 70. Findings included: Review of the medical record revealed Resident #2 was admitted on [DATE] with re-entry on 03/24/18 [DIAGNOSES REDACTED]. Review of care plan dated 11/27/17 included the resident required total assistance from staff for activities of daily living due to confusion, requires a tube feeding, contractures, [MEDICAL CONDITION], and being non-ambulatory. Review of care plan dated 02/05/18 included the resident yells out in pain due to [MEDICAL CONDITION]'s disease, spasms, and bilateral upper extremity contractures. Review of care plan dated 02/16/18 revealed the resident will scream,Oh my God, No, No! Review of physician orders dated 03/24/18 noted an order for [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/14/18, identified Resident #2 to have memory problems and to be severely impaired for decision making. The resident was dependent for all activities of daily living, and had limited range of motion to her upper extremities. The resident did not walk and had no falls since the previous assessment. The resident received anti-anxiety, anti-depressant, and anti-coagulant medications seven of seven days during the prior seven days. Review of care plan dated 05/22/18 included the resident was at risk for falls due to non-ambulatory, confusion and a mechanical lift for transfers. Interventions included floor mats beside bed when the resident was in bed. Review of care plan dated 05/24/18 included the resident will display increased crying, sadness, and depression symptoms. Review of nursing note on 06/01/18 at 6:00 A.M., indicated the State tested Nursing Aide (STNA) was changing the resident when the resident slid to the mat on the floor. The resident's range of motion was within normal and no apparent injuries were noted. At 9:17 A.M. Resident #2 was noted to be in no pain. At 8:05 A.M. the resident had a sudden onset of generalized pain. The resident was medicated with relief documented at 9:17 A.M. Review of nursing note dated 06/01/18 at 2:56 P.M. documented the resident was yelling out and crying. Staff was unable to understand what was wrong and the resident was unable to relax. Review of nursing note dated 06/02/18 at 8:34 P.M. included the resident was alert upon entry into the room at the time of medication pass. The resident communicated in a non-distressed fashion, but talked about an x-ray. The nurse assessed the resident with light touch for fracture and the resident started yelling out. The resident yelled out for five-minute intervals. No other pain indicators were present. The nurse was informed that the resident was up all night demanding an x-ray. Her behaviors escalate when staff leave the room. Review of nursing note dated 06/05/18 at 12:31 P.M. included two x-ray views were added to the right shoulder due to resident expressing pain and pointing to shoulder. The x-ray staff were unable to get a right hand x-ray due to contractures. Review of x-ray dated 06/05/18 noted Resident #2 had a nondisplaced distal clavicle fracture. Review of Incident and Accident Investigation dated 06/01/18 at 6:00 A.M. noted STNA #101 was in the resident's room changing the resident and the resident rolled onto mat on the floor. The resident was unable to communicate what happened. The resident has [MEDICAL CONDITION] status [REDACTED]. The investigation revealed safety intervention were not in use at the time of fall as the resident was receiving one person versus two-person assistance. Immediate action taken was assessment, re-education, and formal discipline for not following the task list which included order for two-person assistance for Resident #2. Review of the investigation revealed a statement by Nurse #343 which indicated STNA #101 reported the resident had rolled from the bed to the floor while she was being changed. It was noted the resident typically fights caregivers and yells out all of the time. Nurse #343's statement indicated the STNA was not using two staff for care of Resident #2 as required. STNA #101's statement documented she was changing the resident by rolling her on her left side. As she was turning her, she rolled far and rolled off the side of the bed onto the mat. The resident landed on her back and did not hit her head. The Interdisciplinary team (IDT) review form included the task list identified Resident #2 was to have two-person assistance which was not followed by STNA #101. The IDT review indicated the resident had a nondisplaced clavicle fracture and the facility would check on different style mattresses. Final conclusion inn the investigation revealed the temporary agency was notified the STNA was not to return, staff were educated on the task list focus and two-person transfers to task list. Interview with the Director of Nursing (DON) on 06/25/18 at 9:26 A.M. confirmed Resident #2 had always required two staff assistance for care. She confirmed STNA #101 should have not went into the room to give care by herself. The DON explained it was difficult to really assess Resident #2 for any injuries because at baseline the resident hollers out, and she cannot always make her need known. Interview with the DON and Administrator on 06/25/18 at 10:44 A.M. confirmed they had concerns with the incident and started a review prior to the confirmation of the fracture. The Administrator explained when she was interviewing STNA #101, the aide confirmed she was aware Resident #2 required more assistance than just one person, however the aide felt like she could handle giving care to the resident by herself. Review of the facility policy titled Fall, dated 11/2015, included the resident upon admission will be assessed for risk factors of falls. The nurse will enter safety orders and nurse aide tasks in the electronic medical record. The resident will be assessed for risk of falls on readmission, new changes in health conditions and at least quarterly. Rounding will be completed throughout each shift to observe residents and ensure safety and fall prevention interventions in place. This deficiency substantiates complaint number OH 485

Based on medical record review and staff interviews, the facility failed to ensure a resident was safely transferred with the assistance of two people when utilizing a mechanical lift. This resulted in actual harm when the resident fell from the mechanical lift and suffered a neck fracture of her left Cervical -Vertebra (C1). This affect one (#1) of three residents reviewed for safe transfers. The facility census was 83. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE], with a [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS) assessment dated [DATE], revealed Resident #1 has extreme cognitive impairment. Her functional status is listed as extensive assist of two people for all transfers. Review of the Care Plan revealed a plan for the resident requiring assistance with activities of daily living (ADL) due to total dependence on staff for care, being non-verbal, and left contracted hand. Review of the Physician order [REDACTED]. A physician order [REDACTED]. Review of the Medical Record Quick Notes dated 06/14/17 at 3:20 P.M. revealed the License Practical Nurse (LPN) #200 arrived in room after the State tested Nurse Aide (STNA) #100 requested. Resident #1 was observed laying on her back on the floor beside bed. The Hoyer (Mechanical) lift sling was between her legs, with her occipital area observed with a large laceration approximately 10 centimeter (cm) in length with small amount of bleeding. Her right hip appeared too rotated outward. STNA #100 reported she was transferring Resident #1 to bed, the lift sling ripped and the resident's head fell to the floor. Vital signs were taken. Resident #1 was transferred to local emergency room and son was notified. Review of the local Hospital Records dated 06/14/17 revealed Resident #1 had a nondisplaced fracture of the right lateral mass of Cervical Spine fracture (C1). No evidence of central spine canal stenosis. The X-ray of right hip revealed no acute fracture dislocation or frank bond destruction is clearly seen. Resident #1 was sent back to facility with pain management and Philadelphia collar. Review of the STNA #100's undated statement revealed she was in Resident #1's room preparing to lay the resident down for the day. She revealed she retrieved the Hoyer lift to transfer the resident. Resident #1 was sitting on the Hoyer sling in her wheel chair, STNA #1 placed the straps of the Hoyer lift on the handles of the Hoyer lift. She revealed after making sure the straps were secure, she turned on the lift and began to raise Resident #1 from the chair. She revealed after lifting Resident #1 from the chair and starting to move the resident towards the bed, Resident #1's body began to flip upside down with the top half of her body going completely through the Hoyer as the lift pad ripped. STNA #100 revealed as she struggled to grab control of the resident, she was only able to get her by the mid sections and legs causing her to hit her head, as they both went to the floor. She revealed she then called for assistance and the nurse in charge came to the room. Interview with the Director of Nursing (DON) and the Administrator on 06/25/17 at 10:17 A.M. revealed they were alerted to the resident falling and did a complete investigation of the fall. The DON revealed the investigations showed the Hoyer sling had ripped down the middle. The DON verified STNA #100 only used one person to transfer the resident with the lift. The DON revealed Resident #1 was using the correct pad for her weight. Resident #1 was returned to the facility with pain management and a cervical collar for alignment. Interview with Registered Nurse (RN) #10 and RN #11 on 06/25/17 at 11:30 A.M. revealed they were the nurses taking care of this resident post fall until the ambulance arrived. They also confirmed the STNA #100's statement. Interview with the STNA #100 on 06/25/17 at 11:40 A.M. revealed she was transferring Resident #1 back to her bed when the Hoyer sling started to rip. She revealed she was not the person who originally put Resident #1 in the sling, it was the night shift STNA. She also revealed she did not notice the sling was defective until it started to rip and she grabbed for the resident. STNA #1 verified she attempted to transfer the resident alone with the Hoyer lift. She also revealed it was not common practice to do this but she felt she could transfer her by herself. Interview with STNA #101 on 06/25/17 at 3:00 P.M., revealed she was the aide who put Resident #1 in the Hoyer sling in the morning. STNA #101 revealed the sling did not have any rips or tears in it when she placed Resident #1 in it. Review of the facility's policy titled Lifts-Sit to Stand and Passive Sling Style dated 08/2014 revealed the Hoyer (passive swing style lift) may be used by two staff for a resident who is unable to assist with transfers (extensive to total staff assistance). This deficiency substantiates complaint number OH 939. This is an example of past noncompliance.

Based on medical record review, review of hospital records, and interviews, the facility failed to provide adequate care and supervision for a resident during turning and positioning. This resulted in actual harm when the resident sustained [REDACTED].#19 rolled a resident away from her while providing care and the resident fell out of bed. This affected one resident (#1) out of three residents reviewed for falls. The facility census was 107. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual comprehensive assessment dated [DATE] revealed Resident #1 had short and long term memory deficits, required two assistance for transfers and bed mobility, and was dependent on staff for total care. Review of Resident #1's care plan revealed the resident rarely made her self understood and had cognitive impairment. She had a care plan in place for potential for falls and included intervention of two assistance for all care, geriatric chair when out of bed, bed in lowest position, gripper socks at all times, bed bolsters and two assist for turning in bed dated 01/13/17. Review of progress note dated 01/12/17 revealed Resident #1 was noted on the floor with her face up next to the bed. STNA #19 stated the resident fell out of bed when she was changing and repositioning her. Resident #1 was noted with a cut to back of her head. The physician and family were made aware. Resident #1 was then transferred to the hospital for evaluation per physician's orders [REDACTED].#1 was kept overnight for observation and for Computerized Tomography (CT) scan scheduled on 01/13/17. Review of hospital report dated 01/12/17 revealed Resident #1 presented to hospital after rolling out of bed. Resident #1's CT scan revealed a small right temporal subarachnoid hemorrhage (SAH) on right temporal lobe with no mass affect and facial fractures from the fall. The hospital report further revealed Resident #1 was bed bound and was rolled out of bed. Review of CT scan imaging results of Resident #1's face from the hospital records revealed the resident had acute bilateral nasal bone fractures, acute displaced right maxillary spine fracture, right supraorbital scalp hematoma, and a small right sided subarachnoid hemorrhage. Interview with the Director of Nursing (DON) on 02/02/17 at 1:00 P.M. revealed Resident #1 was a one person assist prior to 01/12/17. The DON further stated STNA #19 was providing care to Resident #1 and when she turned Resident #1 over (away from her) the resident's top half of her body fell to the floor, and after she hit the floor, the resident then rolled the rest of the way off the bed. The DON stated education was completed with STNA #19 on 01/19/17 on proper bed mobility, which was to turn the resident toward you while providing care, not away from you. Phone interview with STNA on 02/02/17 at 2:00 P.M. confirmed she took care of Resident #1 on 01/12/17 when she rolled out of bed. STNA #19 stated turned Resident #1 away from her to provide care and she fell out of bed and hit her face. This deficiency substantiates Complaint Number OH 176.

Based on observations, record review, staff interview, review of facility investigations and review of the elopement policy and procedure, the facility failed to provide adequate supervision, monitor alarms, and implement the elopement policy for a resident residing in the secured facility. This resulted in Immediate Jeopardy when one resident (#100) was placed at risk for serious harm when she exited the facility unsupervised and was found walking outside on two separate occasions by a visitor and an off duty staff member. Additionally, the facility failed to implement the elopement policy after the first elopement on 01/09/16 and then again at the time of the second elopement on 05/07/16. This affected one (#100) of three residents reviewed who were at risk for elopement. The facility identified a total of 11 (#17, #50, #60, #74, #76, #87, #88, #100, #102, #104 and #115) residents as being at risk for elopement. The facility census was 134. On 05/27/16 at 10:46 A.M., the Administrator was notified that Immediate Jeopardy began on 01/09/16 at 4:00 P.M. when Resident #100 was found outside in the parking lot by a visitor and the staff was unaware the resident was missing. The resident was identified at risk for wandering from the facility and had a physician's order for a WanderGuard (device which activates a door alarm when it passes through). The resident was not wearing a WanderGuard at the time she wandered outside to the parking lot. Registered Nurse (RN) #2 had noted Resident #100 had cut her WanderGuard off on 12/20/15 and the WanderGuard was not replaced due to the resident experiencing an increase in her behaviors due to the presence of the WanderGuard. The nurse did not call the physician or put any other interventions in place to prevent the resident from wandering from the facility. On 05/07/16 at 6:20 P.M., Resident #100 was again discovered ambulating in the parking lot by State tested Nursing Assistant (STNA) #6 who was off duty. The staff was unaware the resident was missing on either occasion. The facility was equipped with an alarm system to alert staff when a resident wearing a WanderGuard bracelet attempts to exit the facility. The Immediate Jeopardy was removed on 05/07/16, when the facility implemented the following corrective actions: · On 01/22/16, the Administrator had an alarm company add a relay and sounder to the Glenview stairwell, the Skyview stairwell by the elevator, and to the Accutech (alarm detection device) at Skyview elevator 3. · On 01/27/16, the facility added additional alarms to the doors to allow alarms to be heard down the hallway. · On 05/07/16, Resident #100 was assessed by Register Nurse #8 as having no injuries and placed on 15 minute visual checks. · On 05/07/16, elopement risk assessments were updated by the Director of Nursing, and nursing station had all current residents identified at risk for exiting the building. · On 05/07/16, all residents identified at risk for elopement had physician orders written to check placement and function of their WanderGuards. · On 05/07/16, the Director of Nursing reviewed the WanderGuard books to ensure all residents identified at risk were included. · On 05/07/16, the elevator on the Skyview hall was shut down by the facility until further alarms could be added. · On 05/07/16, the Administrator and Director of Nursing (DON) provided an in-service to all licensed nurses and STNAs regarding the Elopement and Safety policy. This in-service was repeated on 05/24/16 and 05/26/16. · Random observations on 05/23/16 and 05/27/16 revealed no residents exhibiting exit seeking behaviors. · Random observations on 05/23/16 and 05/27/16 revealed residents were wearing physician ordered WanderGuard devices and door alarms were functioning properly. Although the Immediate Jeopardy was removed when the facility implemented the corrective actions, the deficiency remains at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility has not completed all of the alarm modifications to the elevators. Findings include: Review of the medical record for Resident #100 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the care plan revealed the resident was at risk for wandering and was exit seeking at times. Interventions included wearing a WanderGuard to the right lower extremity at all times and to respond immediately when door alarm sounds to ensure resident was not attempting to leave the facility. Review of the monthly physician's orders revealed the resident had an order for [REDACTED]. Review of a nurse's note dated 12/20/15 documented the WanderGuard was discontinued due to the resident cutting off the band. The resident had increased behaviors associated with presence of the WanderGuard. The note documented the resident has not displayed any recent behaviors of exit seeking. There was no documentation of the nurse calling the physician to get an order to discontinue the WanderGuard and no physician's order was written or signed by the physician to discontinue the WanderGuard. Review of the Elopement Risk Assessment completed 12/20/15, revealed the resident was at risk to wander from the facility. There was no documentation any additional interventions were put in place to prevent elopement for this resident. Review of the nurse's notes dated 01/09/16 revealed Resident #100 was found by a visitor outside the building walking down the street with her walker. The resident was dressed appropriately for the weather. The visitor accompanied the resident back into the building without incident. The nurse and supervisor were notified. The WanderGuard was then placed back on the resident's right lower extremity per physician's order. The physician and family were notified. The resident was assessed to have no injuries and placed on 15 minute checks. Review of the Elopement Risk assessment dated [DATE] revealed the resident remained at risk to wander from the facility. Review of the nurse's notes dated 05/02/16 at 2:27 A.M., revealed the resident was on antibiotics for a urinary tract infection and had increased confusion and agitation. The resident was exit seeking and unable to be redirected. Staff attempted to distract the resident with Cheerios, but was unsuccessful. While staff was attending to other residents, Resident #100 got into the Skyview elevator and was stopped by staff on Riverview Hall which was located on the first floor. The resident currently resided on Skyview Hall which was located on the second floor. The resident was brought back to the second floor by staff. Review of the nurse's notes dated 05/07/16 at 12:00 P.M. revealed Resident #100 was observed multiple times to be waiting by elevator #3, at the end of Skyview Hall. The resident was easily redirected from the area. The note documented the resident was observing staff getting on and coming off the elevator. The resident had also been observed acting aggressive towards staff and becoming very agitated. Review of the nurse's note dated 05/07/16 at 6:59 P.M. documented Resident #100 was observed walking outside in the parking lot. A night shift STNA (#6) observed the resident in the middle of the street. The STNA brought the resident back to the Skyview Hall. The WanderGuard was checked and was working properly. The physician and family were notified of the incident. Fifteen minute checks were initiated for 12 hours. Review of the facility investigation of the elopement dated 05/07/16 revealed the facility felt the resident had gone down an elevator at the end of the Skyview Hall. Observation on 05/23/16 at 3:10 P.M. revealed all the alarmed doors and elevators were checked with the Administrator and Maintenance Director #1. The alarms were all working and were loud enough to be heard at the nurse's station. Interview on 05/23/16 at 9:46 A.M. with the DON revealed on 05/07/16 at 6:45 P.M., a staff member was on break and observed Resident #100 in the parking lot. The staff member assisted the resident back into the facility. Staff was interviewed and the last time anyone had observed the resident was at dinner. One staff member stated the resident was last seen at 5:45 P.M. and another stated 6:15 P.M. The DON stated the elevator will alarm if anyone gets on who was wearing a WanderGuard, or if a resident with a WanderGuard was near the elevator when the door is open. She stated the alarm was functioning but was more difficult to hear if you were at the nurse's station, depending on what is going on and the noise level. The elevator was removed from service, and remains out of service at this time. The DON stated the Administrator had a new system ordered for the elevator which required staff to swipe a badge to use the elevator. This elevator is for staff use only and is not for residents or visitors use. Interview with the DON on 05/23/16 at 2:15 P.M. revealed the Unit Manager interviewed all the staff and was unable to find anyone who admitted to turning off the elevator alarm. The DON stated she assumed this was the route the resident used to leave the Skyview Hall because it was the only elevator you could go down on and exit out of the facility. The elevator opens on the lower level to a service hall with an exit door nearby. The exit door was not alarmed as it was located behind a locked corridor door away from the resident living areas. The DON verified the resident was assessed on 12/20/15 as an elopement risk, the WanderGuard was removed on 12/20/15, and no additional elopement interventions were implemented after the removal. The DON verified the facility policy was to place residents on a one-to-one observation after any elopements. The DON verified the resident was not placed on one-to-one observations after the 01/09/16 and 05/07/16 elopements of Resident #100. Interview with RN #8 on 05/23/16 at 2:20 P.M. revealed none of the staff admitted they had reset the elevator alarm. She stated she was in the facility at the time of Resident #100's elopement on 05/07/16, but not in the immediate area. The resident was found in the parking lot toward the front of the building. RN #8 admitted if the elevator alarm was working, as she stated it was when the resident was returned, someone had to reset the elevator alarm without looking to see if anyone had left the unit. Interview on 05/27/16 at 8:00 A.M. with the DON included review of incidents on 01/09/16 and 05/07/16. She confirmed there were no other interventions put in place after the WanderGuard was cut off by the resident on 12/20/15 to ensure her safety. She confirmed the investigation after the 05/07/16 elopement was not able to determine how the elevator alarm was reset or by who. Interview on 05/27/16 at 9:24 A.M. with STNA #6 confirmed she found Resident #100 in the parking lot when she came to work for the 7:00 P.M. shift. She stated she recognized the resident and brought her back into the facility to the Skyview Hall. She stated the alarm did work when she brought the resident back into the facility. She stated she found the resident in the facility parking lot and was not in the street. Interview on 05/27/16 at 9:53 A.M. with RN #1 revealed Resident #100 was in the parking lot. She stated she didn't recall hearing any exit alarms sounding. RN #1 stated she and the Unit Manager, RN#8, asked the staff if anyone reset the elevator alarm and no one stated they had reset the alarm. Interview with Licensed Practical Nurse (LPN) #89 on 05/27/16 at 10:07 A.M. revealed she had taken the phone call from the front desk on 01/09/16 when the staff at the desk called and said they needed someone to come down and get Resident #100. One of the staff went down and returned the resident to her unit. Staff notified the doctor and family of the incident and placed the resident on 15 minute checks. The front desk stated a visitor had found the resident in the parking lot. The resident stated she was going to see her mother. Review of the facility policy titled Elopement Prevention and Management of Missing Residents, dated October 2004 and revised June 2012, revealed each resident will be assessed at admission to identify if the resident has a known history of exit seeking behaviors. Each resident with known exit seeking behaviors will be reviewed quarterly and/or after a significant change in condition. Residents identified at risk for elopement will have an alarm bracelet and will be placed on the resident's wrist or ankle to audibly alert staff of attempts by resident to exit the facility. A telephone order will be generated for each resident who is wearing a bracelet to improve communication to the interdisciplinary team. Under the section titled Missing Residents revealed when the resident is located, the resident will be placed on one-to-one observation until the interdisciplinary team meets to reassess the resident. When a door alarm sounds: Check the alarm panel to determine which door has been opened. DO NOT ASSUME someone else has already done this. Check all exit doors for any existing resident by means of a visual check. Visual check means observing the area around the exit and completing a perimeter search of the property. Reset the door alarm at the exit door only after it is determined that all residents are accounted for and no resident has exited inappropriately. This deficiency substantiates Complaint Number OH 508.

Based on surveyor observation, facility clinical record review, facility staff interview, facility resident interview, and review of the facility guidelines for prevention and treatment of [REDACTED]. The facility failed in multiple areas of pressure ulcer care including assessment, monitoring, and physician notification. This resulted in harm for one resident (Resident #59) of three sampled residents with pressure ulcers. The facility identified 19 residents with pressure ulcers in a census of 138. Findings include: Facility clinical record review revealed Resident #59 was admitted to the facility on [DATE], with a cumulative [DIAGNOSES REDACTED]. A comprehensive assessment was completed on 08/14/07, and revealed Resident #59 had no cognitive impairment and required assistance in transfers, bed mobility, and wheelchair mobility. The care plan dated 04/28/11, for Potential Pressure Ulcer included, update physician as needed regarding change in condition, need for treatment, or order change, to assess skin with routine care for evidence of breakdown, giving special attention to skin over any bony prominence, and to evaluate need for, and provide as indicated, specialty, pressure relieving/reducing foot protection, remove foot protection every shift to assess skin and to provide skin care. Record review of Physicians order dated 05/24/12, by Physical Therapist (PT), revealed for staff to place wedge cushion under lower extremities to float heels and maintain neutral ankle alignment/prevent plantar flexion contracture when patient was positioned supine. Resident #59 Treatment Administration Record (TAR) dated 06/01/12 thru 06/30/12, revealed to apply skin prep to bilateral heels twice daily, and skin sweeps every Tuesday by the Nurse on the 7:00 A.M. to 3:00 P.M. shift. Record review of Resident #59 Nursing Progress Notes revealed there were no entries made between the period of 05/15/12 thru 07/02/12. Clinical record review of Weekly Skin Assessment, including weekly skin sweeps for Resident #59, included skin sweeps dated 06/05/12, 06/12/12, and 06/19/12, revealed no new skin impairment. Weekly skin sweep dated 06/26/12, revealed the box was marked with an "X" beside no new skin impairment, however, on the skin grid a circle was drawn on the right heel with a line extending to the word redness. Record review revealed there was no skin and wound assessment completed at that time. There was no further documentation or monitoring of the effected area until the weekly skin sweep dated 07/03/12, revealed box for skin grid-pressure was checked and skin grid was circled on the right heel with the word Unstageable written beside the right heel. Record review of Skin Grid-Pressure Ulcers for Resident #59 identified on 07/03/12, there was an unstageable pressure ulcer on the right heel measuring a length of six centimeters (cm) by a width of four cm with zero measured as the depth; no drainage, odor, or color indicated. The wound bed type was checked Eschar (described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound). Pain was indicated by checking yes, controlled on 07/03/12. The Skin Grid noted that Physician and Family were notified on 07/03/12. Staff signature completing the skin grid was Licensed Practical Nurse (LPN) #1. Record review of Resident #59's Nursing Progress Notes revealed on 07/03/12 at 1:00 P.M., an entry was recorded by a facility staff member, (the facility was unable to identify the staff member by signature); a 6 cm x 4 cm blackened area found on Resident #59's heel. The area was with a small amount of clear drainage; some reddened edges. Resident states she bumped it, but unable to describe further details. Area is hardened, does not appear fluid filled. Heels immediately floated and skin prep applied per order. CNP(Certified Nurse Practitioner) notified. Unable to reach daughter. Record review of Infinity NP Wound/Skin Progress Note dated 07/03/12, revealed Certified Nurse Practitioner (CNP) was asked by staff to see Resident #59 for right heel wound. CNP revealed Resident #59's mobility was confined to bed. Description of skin problems revealed right heel wound 6 x 4 x ?cm, 100% eschar, peri-wound skin node, without drainage, wound edges intact. Assessment/Plan for right heel unstageable pressure ulcer treatment was to clean with normal saline, apply skin prep everyday, float heels off bed at all times. Record review of Physicians Order dated 07/03/12, revealed to discontinue wedge cushion under left and right heels, float heels on pillow while in bed, continue skin prep bilateral heels every shift, and start Prostat (protein supplement) 30 cubic centimeters (cc) by mouth every day for wound healing. Record review of the TAR for Resident #59 dated 07/01/12, indicated that skin prep to bilateral heels twice daily was documented as completed and Resident #59 was being placed side-to-side every two hours while in bed as ordered by the Physician. A review of Resident #59's Nursing Progress Notes dated 07/04/12 at 10:00 A.M., and signed by LPN#1 revealed the daughter was notified regarding areas of concerns from above Nurse notes. Awaiting call back. Record review of Duplex Scan, Veins, Lower Extremity, Unilateral/Limited study of Right Lower Extremity as indicated for swelling of limb and pain in limb dated 07/06/12, revealed unremarkable vascular ultrasound of the visualized leg veins. Record review of Skin Grid-Pressure Ulcer for Resident #59 dated 07/10/12, revealed there was an unstageable pressure ulcer on the right heel measuring in length of six centimeters (cm) by a width of four cm with zero measured as the depth; no drainage, odor, or color indicated. The wound bed type was checked Eschar. Pain was indicated by checking yes, controlled. Staff signature completing the skin grid was Licensed Practical Nurse (LPN) #1. Record review of Skin Grid-Pressure Ulcer for Resident #59 dated 07/17/12, signed by LPN#1 revealed there was an unstageable pressure ulcer on the right heel measuring in length of six cm by a width of four cm with zero measured as the depth; no drainage, odor, or color indicated. The wound bed type was checked Eschar and [MEDICATION NAME]. Tissue was around edges. Pain was indicated by checking yes, controlled. On 07/17/12 at 12:15 P.M., surveyor made an observation and had an interview with Resident #59. Observation revealed Resident #59 was lying in bed with head of bed raised approximately 40 degrees, and a large area on her right heel approximately four cm by 4 cm with eschar tissue covering wound and a small amount of granulation (pink-red moist tissue that fills an open wound when it starts to heal) on the wound edges surrounding the eschar. During interview, Resident #59 stated the wound to the right heel was very painful. Resident #59 was asked if she remembers what day or approximate date she had bumped her heel as documented in the clinical record. Resident #59 could not recall the date the area was discovered and didn't recall bumping her heel. During interview with LPN #1 and observation of Resident #59's right heel wound on 07/17/12 at 1:20 P.M., LPN #1 stated that she was the primary wound care nurse on the unit, and that she performed wound care for the residents residing on the unit. Observation revealed that LPN#1 asked resident for permission to measure wound and determined that wound was 6 cm by 4 cm with depth unknown due to the eschar tissue covering wound bed. LPN #1 stated that the wound was an unstageable Stage IV pressure ulcer. LPN #1 further stated that she was not made aware of right heel wound until 07/03/12. During an interview on 07/17/12 at 3:30 P.M., with the Director of Nursing (DON) and LPN #1 in the DON's office, LPN #1 stated that she was not made aware of the change in skin condition by LPN #100 (no longer employed by facility), who had documented the change in assessment as being a reddened area to right heel. When asked by surveyor how long Resident #59 had been confined to bed, she stated always. When asked if she had assessed and documented Resident #59's wound to right heel when she had applied skin prep to affected area between 06/26/12 and 07/03/12, LPN #1 was silent and did not answer. The DON stated that LPN #100 had not informed anyone of her notice of change in assessment of resident's wound, even though she had charted in the clinical record the change in skin condition of Residen t#59 and stated LPN #100 was no longer employed by the facility. This deficiency substantiates Complaint Number OH 044.