Every finding on record at Forest Glen Rehabilitation and Healthcare Center

Based on record review, observations, resident and staff interviews and policy review, the facility failed to ensure residents were treated with dignity when they failed to ensure residents did not have long unwanted facial hair. This affected one (#01) out of one residents reviewed for dignity. The facility census was 74. Findings include: Review of the medical record for Resident #01 revealed an admission date of 04/02/24 with diagnoses of Parkinson's disease without dyskinesia, osteoarthritis, contracture, left hand, muscle wasting and atrophy right thigh, and muscle wasting and atrophy, left thigh. Review of the quarterly Minimum Data Set (MSD) dated 11/27/25 revealed resident with moderate cognitive impairment, she has functional limitation in range of motion impairment on both sides of upper and lower extremities. Resident #01 required set-up assistance with eating. Resident #01 required supervision assistance with ambulation. Resident #01required partial assistance with oral hygiene and transfers. Resident #01 required substantial assistance with bathing, personal hygiene, and bed mobility. Resident #01 was dependent on staff assistance with toileting hygiene, dressing, and wheelchair mobility. Review of the Care Plan dated 12/04/25 revealed resident had an activities of daily living (ADL) self-care performance deficit related to fluctuating ADLs, impaired vision, Parkinson's disease, poor balance, and poor coordination with interventions of allow time for resident to express feelings of frustration regarding the need for assistance in ADL tasks, encourage participation in daily care and provide positive reinforcement for activities attempted and/or partially achieved. Review of the nurses' note dated 01/28/26 at 3:15 P.M. revealed a bed bath was given by the Certified Resident Care Assistant (CRCA) without difficulty. Observation on 01/27/26 at 8:53 A.M. revealed Resident #01 was resting in bed with multiple hairs present on her chin, some approximately a half (1/2) inch long. During the observation Resident #01 expressed concern that staff do not assist with her care needs. Observation on 01/29/26 at 11:34 A.M. Resident #01 lying in bed with multiple, inch long chin hair coming from her chin. Interview on 01/29/26 at 11:35 A.M. with Resident #01 confirmed she has multiple, inch long, hair coming from her chin. Interview with Resident #01 confirmed that no one gave her the razer to shave them, no one told her about her chin hair, being there even though she had a bed bath yesterday. Interview on 01/29/26 at 11:43 A.M. with Certified Nursing Assistant (CNA) #209 confirmed she did not shave Resident #01. Interview with CNA #209 also confirmed that Resident #01 has multiple inch long chin hairs present on her chin. Interview with CNA #209 also confirmed that Resident #01 is unable to shave herself and needs assistance from staff. CNA #209 confirmed there is not a reminder to perform personal hygiene on Resident #01. CNA #209 also confirmed that Resident #01 did not refuse to be shaved. CNA #209 confirmed she did not know Resident #01 had an electric razer available in the bathroom. Interview on 01/29/26 at 11:47 A.M. with Registered Nurse (RN) #237 confirmed she did not know Resident #01 had multiple long chin hairs present on her chin. RN #237 confirmed Resident #01 should be offered to shave with each bath. Review of the Activities of Daily Living (ADLs) policy dated October 2025 revealed residents will be provided care, treatment, and services as appropriate. Residents who are unable to perform their own care will receive the services to maintain good grooming and personal hygiene.

Based on record review, review of facility self-reported incidents (SRI), staff interview, and policy review, the facility failed to ensure an allegation of abuse was reported to the state agency in a timely manner as required. This affected one (#48) of three residents reviewed for abuse. The facility census was 74. Findings include: Review of medical record for Resident #48 revealed an admission date of 10/10/23 with diagnoses of major depressive disorder and dementia moderate with behavioral disturbance. Review of minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of three which indicated severe cognitive impairment. Review of communication-with family/next of kin/power of attorney note dated 01/10/26 at 7:54 P.M. revealed this nurse contacted family regarding staff finding the resident in bed naked with another resident who was also naked. Staff immediately removed the resident from the room and took her back to her room. 15-minute safety checks were initiated. Review of the facility's SRI Form Initial Report Resident #48 abuse was reported to the state agency on 01/11/26 at 7:11 A.M., 10 hours and 17 minutes after becoming aware of Resident #48 being found naked in another resident's bed. Date of discovery per SRI was 01/10/26 at 7:50 P.M. Further review of medical record for Resident #48 revealed a nurse's note dated 01/11/26 at 6:45 P.M. late entry revealed the aide reported to the nurse that while doing 15-minute checks on the resident they found the resident in her room with a male resident standing at the bedside as they were kissing. The residents were immediately separated and checks continued. Review of the facility's SRI form initial report Resident #48 abuse was reported to the state agency on 01/11/26 at 8:46 P.M., two hours and two minutes after becoming aware of Resident #48 being found kissing a male resident. Date of discovery per SRI was 01/11/26 at 6:44 P.M. Further review of medical record for Resident #48 revealed a nurses note dated 01/13/26 at 1:30 A.M. revealed observation of the resident in her room laying in bed with another resident on top of her both naked fondling one another. The residents were separated and skin assessments completed with no new areas noted. The resident continues 15-minute checks currently. Review of the facility's SRI form initial report for Resident #48 abuse was reported to the state agency on 01/13/26 at 6:58 A.M., eight hours and eight minutes after becoming aware of Resident #48 being found naked in bed with another resident. Date of discovery per the SRI was 01/12/26 at 10:50 P.M. Interview on 02/10/26 at 1:46 P.M. with the Administrator revealed that she did not file the report the SRI within two hours as she was confused as to the timing of the reporting. Administrator stated she thought she had 24 hours since there was no bodily injury to Resident #48 for any incident. Administrator verified the reports were not submitted within two hours for abuse per the policy. Review of policy titled Abuse Investigation and Reporting dated October 2025 revealed an alleged violation of abuse, neglect, exploitation or mistreatment including injury of unknown source and misappropriation of resident property will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury.This deficiency represents non-compliance investigated under Complaint Number 2739464.

Based on record review, staff interview, and policy review, the facility failed to ensure the comprehensive care plan was developed to address a resident's aggressive behaviors. This affected one (#55) of two residents reviewed for behaviors. The facility census was 74.Findings include: Review of medical record for Resident #55 revealed an admission date of 11/25/25 with diagnoses including but not limited to dementia with agitation and major depressive disorder. Review of Resident #55's care plan dated 11/26/25 revealed there was no care plan to address aggressive behaviors. Review of minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of six which indicated severe cognitive impairment. Disorganized thinking was present but fluctuated. Review of nurses note dated 01/15/26 at 6:52 P.M. revealed the resident was requiring frequent redirection as she is attempting to initiate physical contact with a male resident and becomes agitated with staff stating that is her husband. Review of nurses note dated 01/20/26 at 5:07 A.M. revealed while attempting to give the resident morning medication, the resident spit in the nurse's face. The nurse attempted to redirect the resident when she became increasingly agitated and combative with staff. Review of nurses note dated 01/20/26 at 1:15 P.M. revealed the resident becomes very agitated and argumentative with the nurse when redirected away from another male resident due to her reaching for his hand. The nurse redirects the resident away from the male resident each time. Interview on 01/29/26 at 8:52 A.M. with MDS #198 revealed there was no behavioral care plan for aggressive behaviors for Resident #55. MDS #198 confirmed Resident #55 has exhibited aggressive behaviors. Interview on 01/29/26 at approximately 11:30 A.M. with MDS #198 verified that Resident #55's care plan for behaviors was initiated after it was brought to her attention that there was not one currently by the surveyor. Review of policy titled Care Plans, Comprehensive Person-Centered dated 11/25 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will incorporate identified problem areas.

Based on record review, staff interview, and policy review, the facility failed to timely revise a resident's care plan regarding a change in fluid restrictions. This affected one (#10) of 23 residents reviewed for care plan revisions. The facility census was 74. Findings include: Review of medical record for Resident #10 revealed an admission date of 10/29/25 with diagnoses including but not limited to type two diabetes, sepsis, atrial fibrillation, congestive heart failure, and compression of brain. Review of care plan dated 10/29/25 revealed the resident is at risk for fluid volume deficit related to congestive heart failure, diuretic use, and fluid restriction. Resident is non-compliant with fluid restriction. Physician is aware. Interventions included 1800 ml fluid restriction: 480 ml for breakfast, 480 ml for lunch, and 360 ml for dinner. 480 ml from nursing and snacks, labs as ordered and monitor weight per physician order. Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of current physician orders revealed fluid restriction starting on 11/20/25 of 2000 milliliters (ml) in 24 hours: dietary 1080 ml (breakfast 480 ml, lunch 360 ml, dinner 240 ml) nursing 920 ml (day shift 500 ml, evening shift 300 ml, night shift 120 ml). Interview on 02/09/26 at 12:26 P.M. with MDS #198 stated resident care plans are updated if an acute process occurs, the MDS update is due, and that anyone can update or revise the care plans. MDS #198 verified that the care plan was not updated to reflect the new fluid restriction of 2000 ml in 24-hour period. MDS #198 verified the care plan still had 1800 ml fluid restriction. Review of policy titled Care Plans, Comprehensive Person-Centered dated 11/25 revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on record review, review of facility self-reported incidents (SRI's) observations, staff interviews, and policy review, the facility failed to provide adequate supervision regarding residents sexual behaviors on the memory care unit. This affected two (#48 and #73) of two residents reviewed for supervision. Additionally, the facility failed to ensure residents were transferred in a proper manner. This affected one (#28) of one reviewed for transfers. The facility census was 74. Findings include: 1.Review of medical record for Resident #48 revealed an admission date of 10/10/23 with diagnoses of major depressive disorder and dementia moderate with behavioral disturbance. Review of minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of three which indicated severe cognitive impairment. Review of communication-with family/next of kin/power of attorney note dated 01/10/26 at 7:54 P.M. revealed this nurse contacted family regarding staff finding the resident in bed naked with another resident who was also naked. Staff immediately removed the resident from the room and took her back to her room. 15-minute safety checks were initiated. Review of nurse's note dated 01/11/26 at 6:45 P.M. late entry revealed the aide reported to the nurse that while doing 15-minute checks on the resident they found the resident in her room with a male resident standing at the bedside as they were kissing. The residents were immediately separated and checks continued. Review of revealed a nurses note dated 01/13/26 at 1:30 A.M. revealed observation of the resident in her room lying in bed with another resident on top of her both naked fondling one another. The residents were separated and skin assessments completed with no new areas noted. The resident continues 15-minute checks currently. 2. Review of medical record for Resident #73 revealed an admission date of 04/26/25 with diagnoses including but not limited to dementia, major depressive disorder, and generalized anxiety disorder. Review of MDS dated [DATE] revealed a BIMS score of three indicating severe cognitive impairment. Review of communication- with family/next of kin/power of attorney note dated 01/10/26 at 7:59 P.M. revealed this nurse called and notified family about staff finding the resident naked in his bed with another resident also naked in his bed. Staff immediately removed the other resident from the room. One staff member stayed with Resident #73 and made sure he got clothes back on and that he was okay. 15-minute safety checks initiated. Review of nurses note dated 01/11/26 at 6:45 P.M. late entry revealed the aide reported to nurse that upon 15-minute check she found this resident in Resident #48's room leaning over the resident in bed kissing her. Residents were separated immediately and administrator notified. Review of nurses note dated 01/13/26 at 2:05 A.M. revealed observations of resident lying in bed with another resident with clothes off fondling one another. The residents were separated and assisted back to their room. Skin assessments performed with no new areas noted. The resident continues 15-mnute checks. On-call assistant director of nursing and family made aware. Review of facility SRI dated 01/13/26 at 6:56 A.M. with a date of discovery of 01/12/26 at 10:50 P.M. revealed the following details: On 01/10/26 at 7:50 P.M. aides were rounding. On 01/10/26 at 7:54 P.M. Residents #73 was found naked in bed in room with Resident #48. The residents were immediately separated and family, physician, and administrator were notified. 15-minute checks were initiated. On 01/11/26 at 6:44 P.M. Resident #73 was found in Resident #48's room. The residents were immediately separated and family, physician, and administrator was notified. One on One supervision was implemented. On 01/12/26 at 10:50 P.M. staff were rounding and Resident #73 was found in Resident #48's room in bed with her. The residents were immediately separated. On 01/12/26 at 10:52 P.M. families, physician, and administrator notified. One on One supervision was implemented. Interview on 02/10/26 at 1:46 P.M. with the Administrator revealed that 15-minute checks were initiated after the first incident on 01/10/26 where Resident #73 and #48 were found naked in bed. The Administrator stated on 01/11/26 after the residents were found kissing that one-on-one supervision was initiated. The Administrator stated that on 01/12/26 Resident #73's roommate had passed away and the staff were in that room getting the resident cleaned up for transport. Administrator stated the staff member who was supposed to be with Resident #73 also went to help the staff leaving Resident #73 unattended. Administrator stated that during that time Resident #73 went into Resident #48's room and both were found lying in bed naked fondling each other. Administrator verified if one-on-one was completed on 01/11/26 then the residents would not have been able to get into bed together on 01/12/26. Observation on 02/10/26 at 2:15 P.M. of the memory care unit revealed that Resident #48 and Resident #73's rooms were beside each other. 3. Review of the medical record for Resident #28 revealed an admission date of 11/07/22 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, hypertensive chronic kidney disease , and chronic systolic (congestive) heart failure. Review of the Quarterly MDS dated [DATE] revealed Resident #28 had moderate cognitive impairment and requires substantial assistance with transfers and Resident #28 was dependent on staff assistance with wheelchair mobility. Review of the care plan, dated 07/14/25 revealed Resident #28 had ADL self-care functional performance deficit related to anxiety, congestive heart failure, chronic fatigue, generalized weakness, impaired mobility, and seizures. Interventions include assist with activities of daily living as needed, place call light within reach and transfer with one person assistance. Further review of the care plan revealed a revision on 01/31/26 of the fall care plan revealed Resident #28 was at risk for falls related to cerebral vascular accident affecting the left side and abnormal gait. Interventions included non-skid socks / peroper footwear during transfers, gait belt use, therapy referral and staff education. Review of the nurses note dated 01/25/26 at 6:15 P.M. revealed Resident #28 complained of pain to her right lateral chest and stated she was being transferred from her wheelchair to the recliner by staff and the staff member did not lift her all the way causing her to hit her side on the wheelchair. Bruising was present on her right lateral chest. Physician notified and new orders for a chest X-ray of lateral right side and an X-ray of Resident #28's right hip was ordered. Review of the Interdisciplinary Team (IDT) Meeting Note dated 01/26/26 at 10:25 A.M. revealed Resident #28 informed nurse of pain in her right lateral chest. Upon assessment nurse observed dark purple bruising to her right side. Bruising extends from mid lateral right chest to her right hip, bruising observed in the right side of her groin. Resident #28 stated she was being transferred from her wheelchair to her recliner by staff and the staff member did not lift her all the way causing her to hit her side on the wheelchair. Resident #28 is on 5mg Eliquis twice daily. Nursing Recommendations: Clinical staff education on proper transfer techniques Review of the fall investigation dated 01/25/26 at 6:15 P.M. revealed Resident #28 reported she was being transferred from the wheelchair to the recliner by staff and they did not lift Resident #28 all the way causing Resident #28 to hit side on the wheelchair. Dark purple bruising was observed from Resident #28's right lateral chest to the right hip. Physician was notified and orders were received for a chest X-ray of lateral right side and an X-ray of Resident #28's right hip. Review of the Statement of Witness Form dated 01/25/26 revealed CNA #331 was transferring Resident #28 when the resident was not able to completely stand causing Resident #28 to hit her right side on the wheelchair. Review of the root cause analysis dated 01/30/26 revealed Resident #28 was improperly transferred from the wheelchair to the recliner. CNA #331 was educated on proper transfers on 01/30/26. Interview on 02/09/26 at 10:47 A.M. with CNA #331 confirmed on 01/25/26 at 6:15 P.M. she was transferring Resident #28 when the resident did not stand up fully. Interview confirmed CNA #331, continued the transfer Resident #28 causing Resident #28 to hit her right side on the wheelchair. Interview also confirmed Resident #28 was a one person transfer at the time. Interview also confirmed CNA #331 did not ask for assistance when she noticed the resident did not stand up fully. Review of the Activities of Daily Living (ADL) policy, dated October 2025 revealed resident will be provided care and services as appropriate to maintain their abilities to care out their ADLs including appropriate assistance with mobility and transfers. This deficiency represents non-compliance investigated under Complaint Number 2739464.

Based on observation, staff interview, and review of facility policy, the facility failed to distribute meals in a sanitary manner in the memory care unit. This had the potential to affect all 20 residents that eat in the memory care unit. The census was 71. Findings Include:Observation of lunch being served in memory care unit on 08/19/25 at 11:28 A.M. revealed meals are served from a plastic table set up in the hallway outside the dining area. Utensils used to serve food, plates, cups, and pitchers of drinks were sat directly on the table. The table was not observed to be sanitized before the start of meals service.Food was brought to the hall by a heated carrier at 11:50 A.M. Metal pans of mashed potatoes, salisbury steak, and brussel sprouts were set directly on the table by Activity Assistant (AA) #102. There was not a steam table or any appliance to maintain food temperatures.At 11:52 A.M. the meals were started to be served by AA #102. No food temperatures were taken before meal service. Food was served from the pan on the table using utensils that were sat directly on the plastic table. At 12:10 P.M. Resident #50 requested more food. Certified Nursing Assistant (CNA) #104 brought Resident #50's used lunch plate to AA #102 who scooped more portions of each item onto the plate. Interview with AA #102 and CNA #103 on 08/19/25 at 12:15 P.M. confirmed the table was not sanitized right before meals being served. The table is cleaned by dietary staff when meals are cleaned up, but that would have been right after breakfast. The table is in the hallway and can be touched by staff, residents, or visitors between meals. AA #102 confirmed food temperatures are not taken when food arrives at the hall and before food is served to residents. AA#102 also confirmed she had scooped food onto Resident #50's used lunch plate.Review of the facility's policy titled Food handling dated September 2021 revealed food will be stored, prepared, handled and served so that the risk of foodborne illness minimized.The facility identified Residents (#1, #2, #3, #4, #25, #29, #34, #38, #40, #42, #44, #50, #52, #54, #58, #59, #62, #65, #66, and #67) as eating in the memory care unit.This deficiency represents an incidental finding discovered during the course of the complaint investigation.

Based on medical record review, staff interview, nurse practitioner (NP) interview, and review of facility policy, the facility failed to ensure adequate follow up to a critically low laboratory result. This affected (#74) of four closed records reviewed. The census was 71.Findings Include:Review of Resident #74's closed medical record revealed an admission date of 05/14/25. Diagnoses listed bacterial pneumonia, type two diabetes mellitus, chronic obstructive pulmonary disease, and obesity. Resident #74 was discharged on 05/31/25.Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #74 was cognitively intact.Review of laboratory results dated [DATE] revealed Resident #74 potassium level was critically low at 2.5 milliequivalents per liter (mEq/L) on 05/29/25. The normal range for potassium was 3.5 to 5.3 mEq/L.Review of physician orders revealed Resident #74 was given 40 mEq of Potassium Chloride by mouth at two different times on 05/19/25. A daily dose of Potassium Chloride was changed from 20 mEq to 40 mEq.Review of discharge paperwork dated 05/31/25 revealed no instructions for Resident #74 to have any laboratory test completed.Review of progress notes revealed Resident #74 and family were called on 05/31/25 and told to go the hospital for a critical potassium level of 2.5 mEq/L.Review of hospital records dated 05/31/25 revealed Resident #74's potassium level was at a critical level of 2.9 mEq/L. Resident #74 was admitted for hypokalemia (low potassium) and stayed in the hospital until discharge on [DATE].Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 08/20/25 at 8:00 A.M. revealed Nurse Practitioner (NP) #112 was called on 05/29/25 for the Resident #74's critical potassium level and medications changes were made. The DON stated Resident #74 was called by the former ADON on 05/31/25 when the critical potassium level from 05/29/25 of 2.5 mEq/L was received again from the laboratory. The former ADON did not realize medication changes had been made. The DON confirmed Resident #74's potassium level was not re-checked after 05/29/25 before the resident discharged home on [DATE].Phone interview with NP #112 on 08/20/25 at 11:07 A.M. revealed he made medications changes to attempt correct Resident #74's low potassium level. NP #112 wanted a metabolic panel collected to re-check Resident #74's potassium level. NP #112 was not informed that Resident #74 was discharging on 05/31/25 or he stated he would have had her potassium level re-checked sooner and before Resident #74's discharge. Review of the facility's policy titled Discharge Summary and Plan dated October 2022 revealed when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The facility must permit each resident to remain in the facility, and not transfer or discharge.This deficiency represents non-compliance investigated under Complaint Number 1281294.

Based on medical record review, review of hospital documentation, staff interview, nurse practitioner interview, and facility policy review, the facility failed to ensure residents received medications as ordered which resulted in a significant medication error. This affected one (#72) of three residents reviewed for medication administration. The facility census was 69. Findings Included: Review of the medical record for Resident #72 revealed an admitted d of 12/13/24. Diagnoses included displaced intertrochanteric fracture of the left femur, hemiplegia, hemiparesis following cerebral infarction affecting the left dominant side, hypertensive chronic kidney disease, tachycardia, and personal history of transient ischemic attack. The resident was discharged on [DATE]. Review of a hospital discharge summary dated 12/13/24 revealed Resident #72 was admitted to the hospital on 12/02/24 for a fracture to the left hip after suffering a fall. Resident #72 had surgery and a post open reduction and internal fixation (ORIF) with transfemoral nails. Resident #72's active problems included systemic lupus erythematosus, chronic kidney disease, transient ischemic attack, nonrheumatic aortic valve insufficiency, carotid stenosis bilateral, anti-phospholipid syndrome, tachycardia, palpitations, hypertension, intertrochanteric fracture of the left femur, and valvular heart disease. Further review revealed the resident was discharged with orders for the anticoagulant medication warfarin (Coumadin) five (5) milligrams (mg) with instructions to take one tablet by mouth for two days. It was indicated Resident #72 required 7.5 mg of warfarin. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact, required set up help for meals, supervision for oral care, toileting hygiene, dressing the upper body, and personal hygiene, and required partial to moderate assistance for putting on and off footwear, bathing, and dressing the lower body. Review of physician orders dated 12/26/24 revealed Resident #72 had an order for a one time dose of warfarin 7.5 mg at 1:30 P.M. Review of the December 2024 medication administration record (MAR) revealed Resident #72 only received a one time dose of warfarin 7.5 mg on 12/26/24 at 1:30 P.M. for the resident's entire stay at the facility. Review of a progress note dated 12/27/24, written by Licensed Practical Nurse (LPN) #229, revealed the indication for Resident #72 to use warfarin was a prior to history of transient ischemic attack (TIA). Interview on 03/13/25 at 2:23 P.M. with LPN #229 stated she talked to Certified Nurse Practitioner (CNP) #243, and stated the facility checked Resident #72's prothrombin time/international normalized ratio (PT/INR, a blood test that measures how long it takes blood to clot) and then notified CNP #243 of the results. LPN #229 stated CNP #243 spoke to Resident #72 and was educated to contact the provider when discharged . Interview on 03/12/25 at 2:41 P.M. with LPN #270 stated the nurse asked LPN #229 how to place Resident #72's warfarin order in the chart since the order was not normal. LPN #270 stated she never put the order in the electronic medical record because it needed clarification. LPN #270 stated the nurse on the next shift was to review the warfarin order and the nursing supervisor checked the medical records for errors. LPN #270 verified she never clarified Resident #72's warfarin order with the provider who wrote the order. LPN #270 stated the Administrator and Clinical Nurse Supervisor #229 contacted her on 12/26/24 to discuss why Resident #72's warfarin order was missed from the hospital record. Interview on 03/12/25 at 2:52 P.M. with CNP #243 stated he was aware of Resident #72's order for warfarin from the hospital documentation, but there were concerns about when to begin the medication. CNP #243 stated there was no record of him telling the nursing staff to contact the prescriber to address Resident #72's warfarin order. CNP #243 confirmed Resident #72 did not timely receive the ordered warfarin as per the hospital records. Interview on 03/12/25 at 3:20 P.M. with LPN #265 stated she never called the provider who ordered Resident #72's warfarin to verify the order. Interview on 03/12/25 at 4:10 P.M. with LPN #305 stated she worked on 12/26/24 and stated Resident #72 had asked her to check her PT/INR. LPN #305 stated Resident #72 asked to have her PT/INR checked because she was on warfarin in the past. LPN #305 stated she looked in the hospital discharge summary and found Resident #72 had an order for warfarin and she told LPN #229 right away. LPN #305 stated she never called the provider who ordered the medication for Resident #72 for clarification. Review of the facility policy titled, Guidelines for Medication Orders, dated 05/2016, revealed each resident shall be under the care of a licensed physician authorized to practice medicine in the state where care was provided and shall be seen by the physician in accordance with regulations and as resident condition warrants. A current list of orders will be maintained in the electronic clinical record of each resident. This deficiency represents non-compliance identified under Complaint Number OH00163064.

Based on medical record review and staff interviews, the facility failed to ensure a resident was transported to and from off campus medical appointments in a timely manner resulting in delayed treatment. This affected one (Resident #24) of three residents reviewed for transportation to outside appointments. The facility census was 66. Findings include: Review of the medical record for Resident #24 revealed a readmitted [DATE]. Diagnoses included unspecified displaced fracture of second cervical vertebra with routine healing, hypertensive heart and chronic kidney disease, unspecified dementia and left frontal parietal scalp lesion consistent with known angiosarcoma. Resident #24 started radiation treatments to the left frontal parietal scalp on 09/19/23. Review of physician's orders revealed an order for Resident #24 to see the Brain and Spine Physician on 09/18/23. The resident was to be picked up at 8:15 A.M. and his daughter would meet him at the appointment. Special instructions included to have paperwork ready and to have the resident in a regular sized wheelchair. Further review of the medical record and progress notes from 07/03/23 to 09/26/23 revealed Resident #24 was scheduled for an initial appointment to have a stimulation evaluation on 08/09/23. There was no documentation as to why the resident missed the appointment. The stimulation evaluation was rescheduled for 08/16/23 and canceled due to transportation issues. The stimulation evaluation was rescheduled for 08/23/23, the resident missed the appointment and there was no documentation as to why the appointment was missed. The appointment was rescheduled for 08/28/23 and canceled due to transportation issues. Interview on 09/26/23, at 10:46 A.M. with Resident #24's daughter revealed she met her father for his appointment on 09/18/23 and stood in the parking lot while the driver of the van worked for an hour to get her dad out of the van. Resident #24 was an hour late for his appointment. She was upset, because this had happened before, and the facility had been instructed to put her father in a standard sized wheelchair prior to appointments. This was not the first time he was stuck. Resident #24's daughter stated the resident must be in a regular size wheelchair, because the insurance company's transportation contracts do not have transportation vans for wide wheelchairs. Interview on 09/26/23 at 10:55 A.M. with Facility's Transportation Associate (FTA) #112 revealed she arranged transportation for Resident #24 and instructed staff to ensure the resident was in a regular sized wheelchair. Resident #24 was picked up as scheduled on 09/18/23 at 8:15 A.M. About an hour later, FTA #112 received a call from the driver explaining he could not get Resident #24 out of the van. She told the driver to call back if he had additional problems, and he never called back. Resident #24 returned to the facility later that day. It was unknown which transportation company brought Resident #24 back to the facility. Interview on 09/26/23 at 5:56 P.M. with the Cab Representative #502 confirmed their driver picked up Resident #24 on 09/18/23 at 8:15 A.M. The driver stated Resident #24 was in a wide wheelchair. The driver was able to get Resident #24 loaded into the van, but it took several minutes of maneuvering to get him out of the van upon arrival to the appointment. The driver notified the facility of the issue. When transportation arrangements were made, it was assumed the wheelchair would fit in a certified van used to transport standard sized wheelchairs. Interview on 09/27/23 at 1:53 P.M. with Occupational Therapist (OT) #600 revealed Resident #24 had two wheelchairs, one was wide, which provided the resident more room, and one was normal sized, which was to be used when transporting the resident to and from appointments. The normal or standard size wheelchair was about 16 to 20 inches wide and had orange grippers to identify its size. OT #600 periodically checks to ensure the resident has a standard sized wheelchair is in his room available for when he has an outside appointment. Interview on 09/26/23 at 1:00 P.M. with Radiation Therapist (RT) #500 revealed the doctor saw Resident #24 on 07/26/23 for an initial consult for radiation treatment. Resident #24 was scheduled to have his stimulation evaluation for his angiosarcoma treatment on 08/09/23 and was to be transported via stretcher. The facility canceled the appointment, and Resident #24 was rescheduled four different times (4 within weeks) because the facility kept calling the clinic and canceling the evaluation. Resident #24 finally had his stimulation evaluation on 08/31/23. His radiation therapy started 09/19/23. Interview on 09/27/23 at 3:00 P.M. with Regional Clinical Director (RCD) #205 explained they followed Resident #24's insurance coverage when scheduling transportation for appointments. If the doctor wanted Resident #24's appointments sooner, he should have had the resident admitted as emergent to have the stimulation done. Interview on 10/02/23 at 9:26 A.M. with Radiation Physician (RP) #700 revealed Resident #24 missed the simulation evaluation four weeks in a row, which delayed his radiation treatment. The stimulation evaluation did not take place until 08/31/23. The facility denied having a policy or procedure for scheduling outside appointments for residents and making transportation arrangements. This deficiency represents non-compliance investigated under Complaint Number OH00146741.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observations, resident and staff interview, review of hospital report, review of employee education and in service records, review of the facility fall investigation, review of policy, review of facility audits, the facility failed to ensure Resident #84 was safely assisted during a wheelchair transport resulting in an avoidable fall. This resulted in Actual Harm when Administrator #15 failed to apply foot pedals to the wheelchair prior to transporting Resident #84, who placed his feet on the ground resulting in Resident #84 falling from the wheelchair and suffering bilateral First Cervical (C1) lamina fracture with minimal displacement. This affected one (Resident #84) of three residents reviewed for accidents. There were 35 current residents documented by the facility requiring foot pedals for transport. The facility census was 56. Findings include: Review of medical record for Resident #84 revealed admitted [DATE]. Medical diagnoses included but were not limited to heart failure, dementia, anxiety, and hypotension. The resident remains in the facility. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition and was totally dependent upon staff for locomotion off the unit which included from the dining area. Review of the significant change MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of nine indicating impaired cognition. He required extensive two-person assistance for bed mobility, toileting, supervision for eating and total dependence for transfers. Review of the nursing progress note dated 06/07/23 at 3:37 P.M., revealed Resident #84 was observed face down in the service hallway, he was placed on his back and assessment revealed pupils were non-reactive and he was sent to the hospital for evaluation. Review of the care plan related to risk for falls initiated 10/18/22 related to immobility, cognitive impairment, incontinence medications and fracture revealed individualized interventions with measurable goals. Interventions included: for staff to assist resident with transfers as needed with full mechanical lift; ensure floor is free of foreign objects; keep call light and frequently used items within reach; bed in lowest position at all times when not receiving care; use call light for assistance; provide fall mats on the floor beside the bed; (initiated 06/23/23) utilize foot pedals at all times as resident will tolerate and allow to support feet; and Dycem(R) (nonslip material) to seat to reduce risk of sliding out of chair, initiated 06/08/23. Review of the hospital documentation dated 06/07/23 revealed the Resident #84 presented to the hospital following a fall out of his wheelchair. A Computed Tomography (CT) scan was performed which revealed Odontoid (toothlike projection from the second cervical vertebra on which the first vertebra pivots) fracture and bilateral First Cervical (C1) lamina fracture with minimal displacement. Review of the 06/07/23 fall investigation completed by the facility for Resident #84 revealed Resident #84 had been assisted by a team member from the dining room, in a wheelchair without foot pedals. Resident #84 planted his feet down and slid forward out of the wheelchair and onto the carpet. This resulted in a C1 fracture, the root cause was documented as being pushed without foot pedals. Review the Interdisciplinary Team (IDT) notes dated 06/08/23 at 10:37 A.M., revealed on 06/07/23, Resident #84 was being assisted by Administrator #15, from the dining room when Resident #84 planted his feet, stopping his wheelchair, sliding forward, and landed face down on the carpet. The fall was witnessed and Resident #84 was immediately assessed and after denying pain and answering questions appropriately, he was assisted onto his back. Resident #84 was not documented as complaining of pain, was observed talking and joking with staff prior to Emergency Medical Services (EMS) arrival. A large rug abrasion was noted to his forehead. Interventions upon return were to always have foot pedals as Resident #84 tolerated and a Dycem(R) will be applied to the seat of the wheelchair to reduce sliding. Review of all staff education dated 06/08/23, provided by the Director of Nursing, regarding wheelchair safety and propelling included educating staff residents were not to be transported without foot pedals at any time unless they have been care planned as such due to their refusal and safety education had been provided to them first. Review of the 06/11/23 progress note revealed Resident #84 returned to the facility around 9:00 P.M., with a C1 fracture and a neck collar to be always worn. Bruising to left elbow, skin tear to left ankle due to fall and abrasion to forehead were documented. Interview on 07/06/23 at 11:12 A.M., with Registered Nurse (RN) #10 revealed she was working on 06/07/23 when Resident #84 fell from his wheelchair. She stated he was being pushed by Administrator #15 in his wheelchair, without his foot pedals. Resident #84 fell , after he planted his feet during transport, which caused him to fall forward onto the carpet. Interview on 07/06/23 at 11:24 A.M., with Administrator #15 revealed on 06/07/23 Resident #84 went to lunch late and she attempted to assist him back to his room. She acknowledged he usually had foot pedals on his wheelchair, however, on that day he did not. She admitted it was completely my fault, she did not ensure the foot pedals were in place prior to transport. Resident #84 dropped his feet as she was assisting him down the hall, which caused him to fall from the wheelchair. Administrator #15 stated after the incident, therapy did a facility audit to identify the residents who required foot pedals, education was provided to the staff in general and she received one on one education from the Director of Nursing, Dycem(R) was also placed on Resident #84's wheelchair and his care plan was updated. Interview and observation on 07/06/23 at 12:29 P.M., revealed Resident #84 was observed in his room with cervical collar in place, sitting in his wheelchair with foot pedals present. Resident #84 was unable to recall the exact events of his fall. Interview on 07/06/23 at 1:37 P.M., with Physical Therapist (PT) #16 revealed residents who could not self-propel in a wheelchair were identified by the therapy staff and the name list was provided to the facility to ensure pedals were in place. PT #16 stated Resident #84 had leg strength to self-propel for a short time up to around 30 feet upon discharge from therapy in April, but he required assistance from staff to and from the dining room to his room (111 feet) and for any outings, and appointments. Review of the policy titled, Fall Management Program Guidelines revised 03/16/22 revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. As a result of the incident, the facility took the following action to correct the deficient practice by 06/09/23. On 06/08/23, one-on-one education for general safety measures when assisting residents while in wheelchairs and the use of adaptive equipment such as foot pedals and to review profiles and care plans for prevention of falls or injury provided for Administrator #15 by the Director of Nursing. On 06/08/23, all staff in-service was provided on the use of adaptive equipment and wheelchair safety, by the administrative staff or designee. All staff signed as receiving the training via electronic signature or in person signature. On 06/08/23, the Therapy department assessed all residents and identified 35 residents as requiring foot pedals for wheelchair transportation. On 06/08/23, care plans for the identified residents utilizing foot pedals/rest were updated by the MDS nurse. On 06/08/23, the Quality Assurance team met and discussed corrective action plan of in-service and audits for safely transporting resident with wheelchair pedals on. On 06/09/23, audits of wheelchairs utilizing foot pedal/rest during transports were completed by the Administrator or designee and will continue for six weeks. Review of wheelchair audits revealed audits were completed on 06/09/23, 06/12/23, 06/15/23, 06/22/23, 06/28/23 and 07/05/23 revealed foot pedals were present on the wheelchairs of each of five random residents reviewed on those dates. Interview on 07/10/23 from 2:57 P.M. to 3:07 P.M., with Registered Nurse #10 and State tested Nurse Aides (STNA) #18, #19 revealed each acknowledged they had received education on wheelchair safety and the use of foot pedals for residents who were not able to propel the wheelchair on their own. All staff was able to verbalize the procedure. This deficiency represents the non compliance investigated under Complaint Number OH00143687.

Based on employee file review and staff interview, the facility failed to ensure nurse aides received performance evaluations at 90 days and annually thereafter. This affected four (#3, #21, #32, and #71) Certified Resident Care Associate (CRCAs) of four employee files reviewed and had the potential to affect all residents. The census was 63. Findings include: 1. Review of Certified Resident Care Associate (CRCA) #3's employee file revealed a start date of 06/07/22. Review of the employee file found CRCA #3 had no record of a 90-day evaluation. 2. Review of CRCA #21's employee file revealed a start date of 01/08/20. Review of the employee file found CRCA #21 had no record of a 90-day or annual evaluations. 3. Review of CRCA #32's employee file revealed a start date of 09/20/22. Review of the employee file found CRCA #32 had no record of a 90-day evaluation. 4. Review of CRCA #71's employee file revealed a start date of 02/03/11. Review of the employee file found CRCA #71 had no record of a 90-day or annual evaluations. Interview on 04/06/23 at 12:02 P.M. with Human Resources (HR) #109 and Administrator #113 stated the facility does not complete any evaluations for the staff including the evaluations for CRCA #3, #21, #32, and #71. HR #109 stated they only review performance for employees having disciplinary issues. HR #109 and Administrator #113 stated they were aware these were not being done, and stated it was due to an issue with department heads not tracking when the evaluations were due and not wanting to complete performance evaluations.

Based on medical record review, staff interview, review of a self-reported incidents, and policy review, the facility failed to timely report an allegation of resident-to-resident physical abuse. This affected two (#46 and #57) out of four residents reviewed for abuse. The census was 63. Findings include: 1. Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified severe protein-calorie malnutrition, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hypothyroidism, type two diabetes mellitus without complications, other schizoaffective disorders, and other recurrent depressive disorders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 07. The resident was assessed to require extensive assistance for bed mobility and toilet use, limited assistance for transfer and dressing, and supervision for eating and personal hygiene. 2. Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's disease, schizoaffective disorder, and anemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 04. The resident was assessed to require limited assistance for personal hygiene and dressing, and supervision for bed mobility, transfer, eating, and toilet use. Review of the self-reported incident (SRI) regarding the alleged incident involving Resident #46 and Resident #57 revealed the SRI was created and submitted to the State Survey Agency on 04/04/23. The SRI indicated the alleged incident was reported to facility staff on 03/29/23. Interview on 04/06/23 at 2:45 P.M. with Assistant [NAME] President of Clinical Support #130 confirmed the alleged incident occurred on 03/29/23 and the SRI was not timely submitted. Review of the facility policy titled, Abuse and Neglect Procedural Guidelines, revised 08/29/19, revealed all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on observation, daily staffing posting review, review of staffing schedules, and staff interview, the facility failed to post an accurate staff posting daily. This had the potential to affect all 63 residents residing in the facility. The census was 63. Findings include: Observation on 04/03/23 at 12:10 P.M., revealed the daily staff posting indicated zero registered nurses (RN), licensed practical nurses (LPN), and Certified Resident Care Associate (CRCA) working in the facility that day. Review of a revised copy of the daily staff posting dated 04/03/23 revealed one RN, nine LPNs, and seven CRCAs working in the facility that day. Review of the daily staff schedule provided for 04/03/23 revealed the facility had six nurses, with one in training, and nine CRCAs. Review of the daily staff posting that was posted on 04/04/23 revealed the facility had four RNs, nine LPNs, and nine CRCAs working in the facility that day. Review of the daily staff schedule provided for 04/04/23 revealed the facility had six nurses and 12 CRCAs working in the facility that day. Interview on 04/04/23 at 5:18 P.M., with Administrator #113 stated she was doing the schedule and confirmed the schedules and the daily staffing did not match what staff were on the floor providing direct care. Administrator #113 stated the facility used a software system that did not always accurately reflect the staffing. Review of the daily staff posting that was posted on 04/05/23 revealed the facility had six RNs, four LPNs, and 11 CRCAs working in the facility. Review of the daily staff schedule provided for 04/05/23 revealed the facility had six nurses and 12 CRCAs, with one in orientation, working in the facility that day. Review of the staff posting that was posted on 04/06/23 revealed the facility had four RNs, six LPNs, and nine CRCAs working in the facility. Review of the daily staff schedule provided for 04/06/23 revealed the facility had six nurses and twelve CRCAs working in the facility. Observation on 04/06/23 at 10:00 A.M., revealed the daily staff posting had three nurses and four CRCAs working in the facility, and observation of direct care staff at that time revealed five CRNAs were working on the floor. Interview on 04/06/23 at 10:25 A.M. with Administrator #113 and Assistant Director of Nursing (ADON) #125 stated the computer software the facility uses for the daily staff postings had errors that are reviewed on Mondays. Administrator #113 acknowledged the daily staff posting should be accurate each day. Interview on 04/06/23 at 2:40 P.M. with Assistant [NAME] President of Clinical Services (AVPSC) #130 stated the facility should provide accurate account of staffing and should post the accurate staffing daily as required. AVPSC #130 confirmed the facility postings are not accurate and do not match the staffing schedule or the staffing actually working on the floors.

Based on record review, staff interview and review of facility policy, the facility failed to provide discharge instruction for treatment of wound when a resident was discharged to another skilled nursing facility. This affected one (#54) out of three residents reviewed for discharge. Facility census was 62. Findings include: Review of medical record for Resident #54 revealed admitted [DATE]. Diagnoses atherosclerotic heart disease, type two diabetes mellitus, neuromuscular dysfunction of the bladder, incontinence, depression, mood disorder, hypertension, and chronic fatigue. The resident was discharged on [DATE] to another skilled nursing facility. Review of Resident #54's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition. Resident #54 required extensive two-person assistance for transfers, toileting, one person assistance for bed mobility, personal and supervision for eating. Resident #54 was documented as always incontinent of bowel and bladder. Resident #54 did not have a pressure ulcer documented. Review of Resident #54's care plan initiated 08/15/22 revealed he required staff assistance for Activities of Daily Living (ADL's) with interventions to allow the resident to complete all or part of the task and not rush, encourage resident to do as much as safely possible for self, observe for deterioration in ADL's and report if it occurs and provide assistance with ADL's as needed. A care plan for skin integrity revealed interventions to conduct weekly skin assessments, float heels as needed, pressure reducing cushion to chair and mattress to bed. Record review of the electronic medical record for Resident #54 revealed a Skin Integrity Event which was created on 12/30/22. The form documented blisters on three toes on left foot which were documented as round, red, blister like and crusty. Antibiotic ointment and band aid applied as treatment. No measurements were documented. Review of Resident #54's nursing progress note dated 01/03/23 at 12:39 P.M. revealed skin prepped was applied to fluid filled areas on left foot, third and fourth toes. There was no further assessment of the areas to the left foot/toes. Further review of the medical record including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no physician order for a treatment to the pressure ulcer to Resident #54's blisters on three toes on the left foot. Review of the discharge instructions for Resident #54 dated 01/03/23 revealed there was no documentation or information regarding the presence of pressure ulcers or blisters to the residents toes on the left foot. Further review of the discharge instructions also revealed there no direction or instructions a treatment to the pressure ulcers or blisters. Interview on 01/12/23 at 9:15 A.M. with Registered Nurse (RN) #12 revealed Resident #54 was discharged to another skilled nursing facility on 01/03/23. RN #12 confirmed Resident #54 had pressure ulcers or blisters on the several of the toes on the left foot. RN #12 stated she provided discharge instructions to Resident #54 and his spouse prior to the residents discharge. RN #12 stated she did instruct them to apply skin prep to the blisters on the toes on his left foot but verified that order was not documented on the discharge instructions. RN #12 further confirmed the discharge instruction contained no documentation regarding the pressure ulcer or blisters to the toes on the left foot. Review of the facility policy titled Guidelines for Discharge Instructions last reviewed 12/01/21 revealed there was no specific information related to wounds, however the policy did document the instructions shall include any special instructions. This deficiency represents non-compliance investigated under Complaint Number OH00138819.

Based on record review, staff interviews and review of a facility policy, the facility failed to provide regular care conferences to residents and/or their representatives. This affected two (#33 and #54) of three residents reviewed for care planning. The facility census was 62. Findings include: 1. Review of medical record for Resident #54 revealed admitted [DATE]. Diagnoses atherosclerotic heart disease, type two diabetes mellitus, neuromuscular dysfunction of the bladder, incontinence, depression, mood disorder, hypertension, and chronic fatigue. The resident was discharged on [DATE] to another skilled nursing facility. Review of Resident #54's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition. Resident #54 required extensive two-person assistance for transfers, toileting, one person assistance for bed mobility, personal and supervision for eating. Resident #54 was documented as always incontinent of bowel and bladder. Resident #54 did not have a pressure ulcer documented. Review of Resident #54's care plan initiated 08/15/22 revealed he required staff assistance for Activities of Daily Living (ADL's) with interventions to allow the resident to complete all or part of the task and not rush, encourage resident to do as much as safely possible for self, observe for deterioration in ADL's and report if it occurs and provide assistance with ADL's as needed. A care plan for skin integrity revealed interventions to conduct weekly skin assessments, float heels as needed, pressure reducing cushion to chair and mattress to bed. Further record review for Resident #54 revealed there was a care conference on 07/21/22 and a second on 12/29/22. There was no other care conferences documented in Resident #54's medical record. 2. Review of medical record for Resident #33 revealed admitted [DATE]. Diagnoses include type two diabetes mellitus, atrial fibrillation, stage three (of four) kidney disease, depression and anxiety. Resident #33 remains in the facility. Review of Resident #33's quarterly MDS dated [DATE] with a BIMS score of 15 indicating intact cognition. Resident #33 revealed he required extensive two person assistance for transfers, one person assistance for bed mobility, toileting, personal hygiene, and supervision for eating. Record review for Resident #33 revealed he had one care conference on 04/25/22 and a second on 11/08/22. There was no other care conferences documented in Resident #33's medical record Interview on 01/05/23 at 3:52 P.M. Social Worker #30 verified care conferences for Resident #54 and Resident #33 were not held regularly. Social Worker #30 verified there was no documentation in Resident #54 and #33's medical record as to a rationale for not having care conferences with the residents or their representatives. Review of a facility policy titled Resident First Meeting (Care Conference) Guidelines last reviewed 03/16/22 revealed the first meeting should be held within the first five days of admission and then conducted at a minimum of quarterly and with significant change. This deficiency represents non-compliance investigated under Complaint Number OH00138819.

Based on record review, staff interview, review of facility policy and pressure ulcer and review of information from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to accurately assess and implement a treatment for a residents newly developed pressure ulcer. This affected one (#54) out of three residents reviewed for skin breakdown. Facility census was 62. Findings include: Review of medical record for Resident #54 revealed admitted [DATE]. Diagnoses atherosclerotic heart disease, type two diabetes mellitus, neuromuscular dysfunction of the bladder, incontinence, depression, mood disorder, hypertension, and chronic fatigue. The resident was discharged on [DATE] to another skilled nursing facility. Review of Resident #54's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition. Resident #54 required extensive two-person assistance for transfers, toileting, one person assistance for bed mobility, personal and supervision for eating. Resident #54 was documented as always incontinent of bowel and bladder. Resident #54 did not have a pressure ulcer documented. Review of Resident #54's care plan for skin integrity dated 08/15/22 revealed interventions to conduct weekly skin assessments, float heels as needed, pressure reducing cushion to chair and mattress to bed. Record review of the electronic medical record for Resident #54 revealed a Skin Integrity Event which was created on 12/30/22. The form documented blisters on three toes on left foot which were documented as round, red, blister like and crusty. The form did not document specifically which toes on the left foot were affected. Antibiotic ointment and band aid applied as treatment. No measurements were documented. Review of Resident #54's nursing progress note dated 01/03/23 at 12:39 P.M. revealed skin prepped was applied to fluid filled areas on left foot, third and fourth toes. There was no further assessment of the areas to the left foot/toes. Further review of the medical record including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no physician order for a treatment to the pressure ulcer to Resident #54's blisters on three toes on the left foot. Interview on 01/12/23 at 10:44 A.M. with Licensed Practical Nurse (LPN) #41 revealed she had worked on 12/30/22 and Resident #54's wife and daughter called her into the room to show her a blister on each of the residents three toes on his left foot. LPN #41 stated they were blisters, which she believed were from his shoe. LPN #41 did measure the areas, and believed she charted it. LPN #41 stated she applied triple antibiotic ointment, applied a Band-Aid and contacted Certified Nurse Practitioner (CNP) #34. LPN #41 verbalized CNP #41 gave an order, to use skin prep as needed and contact the wound nurse. LPN #41 did not recall if she placed the orders in Resident #54's medical record. Interview on 01/12/23 at 12:12 P.M. with the Director of Nursing (DON) verified there was no order placed for skin prep and no measurements of the blisters areas documented to Resident #54's toes on the left foot. The DON further confirmed the assessment did not include a staging of the area and there was no identification as to which toes on the left foot were affected. Review of facility policy titled Guidelines for General Wound and Skin Care last reviewed 12/01/21 required documentation of type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, periwound tissue and treatment of the wound weekly . Review of information from the NPIAP at https://npiap.com/ revealed a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. A Stage 2 Pressure Injury is partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). This deficiency represents non-compliance investigated under Complaint Number OH00138819.

Based on medical record review, resident, staff, and urology staff interview, observation, review of the urology consult, review of the hospital record, and policy review, the facility failed to ensure a resident received catheter care and was transported timely to urology follow-up appointments. This resulted in Actual Harm when Resident #29, who had a newly placed suprapubic catheter, missed three follow up appointments and subsequently was sent to the local emergency room where she was given intravenous antibiotics for a urinary catheter complication and a urinary tract infection. This affected one resident (#29) of three residents reviewed for catheter care. The facility census was 62. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29 had a suprapubic catheter (SPC) placed on 02/01/22 for long standing urinary incontinence. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had adequate communication, no cognitive impairment, and required extensive to total assistance for all activities of daily living. The resident had a SPC and an [CONDITION(S)] (a stoma). Review of the plan of care for Resident #29 revealed she is extensive to total assistance for all aspects of care including SPC and [CONDITION(S)] care. There were no specific interventions in place for the SPC care. Review of the urology consult dated 02/11/22 revealed Resident #29 had difficulty with the new SPC including abdominal pain, leakage from the urethra, and tenderness at the insertion site. The urologist ordered the facility to have a Computed Tomography (CT) scan of the abdomen and the pelvis without contrast of the abdomen, wash the SPC site daily with warm soapy water, and to follow-up in two to three weeks for the first SPC change in the urology office. Review of the attending physician note dated 02/19/22 revealed Resident #29 complained of leaking urine. Review of the progress notes dated 03/20/22 revealed Resident #29's SPC was still leaking with no urine found in the catheter bag. There was no documentation the physician had been notified. A progress note dated 03/22/22 revealed a urology appointment had been scheduled for 03/28/22 at 1:30 P.M. There were no progress notes in Resident #29's record on 03/28/22 indicating she attended the appointment. Review of the medical record for Resident #29 revealed the facility set up a follow-up urology appointment on 04/28/22 at 1:50 A.M., and the CT scan was ordered for 04/22/22 at 12:45 P.M. Review of the progress note dated 04/22/22 for Resident #29 revealed the CT scan appointment scheduled needed to be rescheduled for 04/29/22 because transportation was unavailable. The progress notes had no documentation about the condition of the SPC site or any notification to the urology office of the CT scan needed/being rescheduled. A new appointment for a CT scan was made for 04/29/22 at 2:00 P.M. Review of the progress note dated 04/26/22 for Resident #29 revealed the CT scan appointment scheduled 4/22/22 needed to be rescheduled because transportation was unavailable. There was no documentation about the condition of the SPC site or notification to the urology office the CT scan needed rescheduled, or Resident #29 had not completed the scan as ordered. A new appointment for a CT scan was made for 04/29/22 at 2:00 P.M. Review of the medical record dated 05/06/22 revealed the facility set up a follow-up urology appointment for Resident #29 on 05/23/22 at 11:10 A.M. and the CT scan was ordered for 05/13/22 at 12:45 P.M. The progress notes had no documentation about the condition of the SPC site or notification to the urology office the resident was not able to attend the appointment on 05/23/22. Review of the physician orders for Resident #29 revealed the facility called the urology office on 05/31/22 to request the facility nursing staff change her SPC since she was diagnosed with the coronavirus (COVID-19) on 05/24/22. A new order was obtained for the facility nursing staff to change the SPC at the facility. Review of the progress notes dated 05/31/22 for Resident #29 revealed there was no documentation of a discussion with the urology office about the details of the catheter removal, the condition of the SPC site, or whether a new appointment needed scheduled. There was no documentation the SPC had been changed as ordered. Review of the May 2022 Treatment Administration Record (TAR) and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders for Resident #29 dated 07/07/22 documented staff were to call the urology office to clarify an appointment scheduled for 07/15/22. Review of the progress notes for Resident #29 revealed there was no documentation the urology office was called on 07/07/22 to clarify the appointment scheduled on 07/15/22. Further review of the progress notes revealed there was no documentation if Resident #29 had attended the 07/15/22 scheduled appointment with urology. Review of the progress note dated 07/17/22 revealed Resident #29 had complained of severe abdominal pain and requested to go the emergency room to have her SPC changed since her 07/15/22 appointment had been rescheduled. Resident #29 also requested the emergency room visit since there was no transportation to the urology appointments. Resident #29 was transported to the emergency roiagnom on [DATE]. Review of the hospital records dated 07/17/22 revealed Resident #29 was diagnosed with a urinary catheter complication and a urinary tract infection. Resident #29 was given intravenous (IV) antibiotics and returned to the facility. During an interview with Resident #29 on 07/29/22 at 9:25 A.M., revealed she was upset because she had a urinary tract infection ([CONDITION(S)]) because the facility had not taken her to her appointments to change the SPC. Resident #29 stated the catheter site had caused her pain because it became infected after it was placed back in February 2022. Resident #29 said she was unaware why the facility could not provide transportation to see the urologist. During an observation on 07/29/22 at 12:19 P.M., Resident #29's catheter site care performed by State tested Nursing Assistant (STNA) #200 and the Director of Nursing (DON) revealed it was without redness or infection. Resident #29 stated during the procedure the SPC felt much better than it used to. The DON verified the SPC site used to be infected but looked much improved. During a telephone interview on 07/29/22 at 3:38 P.M. with the urology office Staff #47 revealed they had asked the facility to schedule an appointment with their office so her SPC could be changed since it was new in February. The urology Staff #47 stated she was not aware of the reason for the missed appointments and verified the facility should have changed the SPC on 05/31/22. During an interview on 07/29/22 at 4:45 P.M. with the DON, the Executive Director, and the Regional Director of Clinical Services (RDCS) #718, verified the appointments for Resident #29 had been missed on 03/28/22, 04/28/22, and 07/15/22 and no alternative arrangements were obtained. The RDCS #718 stated the cause for the missed appointments was the inability to obtain adequate transportation. The DON confirmed there was no evidence Resident #29's SPC had been changed as ordered on 05/31/22. Review of the facility policy titled Urinary Catheter Care, dated 12/01/21 revealed nursing staff are to monitor for changes in care plan or physician orders to be sure they are followed. Any complaints of burning, tenderness, or pain is to be reported to the DON. This deficiency substantiates Complaint Number OH 231.

Based on record review, facility policy review and interviews with staff, the facility failed to notify a resident and/or resident representative 30 days prior to discharging the resident from the facility. This affected one (#26) of three residents reviewed for discharge. Findings include: Review of Resident #26's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to the hospital. Review of the Minimum Data Set (MDS) assessment, dated 03/27/20, revealed the resident displayed cognitive deficits. Review of the facility's Ohio Admission /Move In Agreement, dated 08/28/18, revealed the facility may terminate the agreement and a resident's stay, and transfer or discharge a resident if provided 30 days advance notice. Review of the nursing progress notes, from 04/13/20 through 04/22/20, revealed Resident #26 was readmitted to the facility from the hospital on [DATE] and placed on droplet isolation for 14 days due to being in the hospital during the COVID-19 pandemic. On 04/18/20, Resident #26 developed swelling in her right hand and [MEDICAL CONDITION] on bilateral arms and legs. Resident #26 was sent to the hospital per suggestion of physician and agreement of the family. The progress note, dated 04/22/20, revealed Resident #26's family member called the facility to ensure Resident #26's bed was being held. Licensed Social Worker (LSW) #135 explained to the family member Resident #26 was discharged from the facility because of a new policy forbidding admittance to the facility if one has pneumonia. Resident #26 did not return to the facility. Review of Resident #26's transfer sheet to the hospital revealed a Medicaid assisted resident who leaves the facility to the hospital that the resident's bed will be reserved for the applicable number of days paid for a reserved bed under the state Medicaid program. Review of the Resident Bed Hold Authorization Form, dated 04/20/20 revealed the facility sent the form by certified United States (US) mail and was signed as received by the family on 04/25/20. The form revealed Resident #26's bed was to be held starting 04/18/20 and continued under the guidelines of Medicaid for 20 days. On 10/28/20, at 8:45 A.M., an interview with the Administrator and Director of Nursing revealed a policy was created in 04/16/20, to forbid any person with the [DIAGNOSES REDACTED]. The Administrator stated at the time, the facility could not take a chance of someone coming into the facility with COVID-19. The policy was revised on 04/23/20 to reflect the facility will now accept residents with respiratory diagnoses. On 10/29/20 at 2:25 P.M., an interview with LSW #135 confirmed she did tell the family of Resident #26 she was discharged from the facility because of a new policy that would not allow resident's with pneumonia return to the facility. Resident #26 had pneumonia. Review of the facilities Bed Hold Policy, revised 11/23/16, revealed if a resident was eligible for or was receiving Medicaid Assistance, and the resident leaves the facility for hospitalization or therapeutic leave, the resident's bed will be reserved for the applicable number of days paid for a reserved bed under the State Medicaid program. Review of the COVID-19 Admissions/Readmission/emergency room (ER) Visits Policy, effective on 4/16/20 and revised on 04/23/20, revealed new admissions, readmission or ER admission with the following [DIAGNOSES REDACTED]. A person cannot be positive for COVID-19, have bilateral infiltrates, pneumonia, fevers in the last 72 hours per Centers for Disease Control and Prevention (CDC) guidelines, flu diagnose or flu like symptoms, require nebulizer treatments, use a bi pap or C-pap machine will be denied admission or readmission to the facility. This deficiency substantiates Complaint Number OH 214.

Based on observations, record review, facility policy review, Center for Disease Control (CDC) websites review, and staff interviews, the facility failed to ensure proper personal protective (PPE) equipment was worn when providing care to a resident on quarantine for exposure of COVID-19. This affected one (#59) of 52 residents on quarantine for COVID-19. The census was 66. Findings include: Review of the medical record for Resident #59 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the significant change minimum data set assessment dated [DATE] revealed Resident #59 was severely cognitively impaired. Review of Resident #59's active physician orders revealed an order dated 09/25/20 for contact and droplet precautions. Interview with Clinical Support #205 on 09/29/20 at 11:20 A.M., revealed all residents were under quarantine due to potential exposure to COVID-19. Observation of State tested Nurse Aide (STNA) #210 on 09/29/20 at 1:47 P.M., revealed STNA #210 was in Resident #59's room assisting Resident #59 with eating. STNA #210 was not observed wearing a gown or gloves while assisting Resident #59 with eating. Interview with STNA #210 on 09/29/20 at 1:47 P.M., verified Resident #59 was on contact and droplet precautions due to potential exposure to COVID-19. The Interview further verified STNA #210 was not wearing a gown or gloves while assisting Resident #59 with eating. The interview with STNA #210 revealed she was not wearing a gown or gloves while assisting Resident #59 with her eating because she thought she only had to wear a gown/gloves when providing care such as incontinence care, oral care, etc. and not when assisting with eating. Review of the facility policy titled Enhanced Infection Prevention and Control Program for COVID-19, last revised 06/01/20, revealed eye protection, gown, and gloves continue to be recommended for the care of residents with known or suspected COVID-19. Review of the CDC websites article titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, undated, revealed preferred PPE includes isolation gown, one pair of clean, non-sterile gloves, face shield or goggles, and N95 or higher respirator. When respirators are not available, use the best available alternative, like a facemask. Acceptable alternative PPE includes isolation gown, one pair of clean, non-sterile gloves, face shield or goggles, and facemask.

Based on record review, interview and policy review, the facility failed to ensure a resident's pain was properly managed when the resident ran out of narcotic pain medication and no alternative pain relief was offered. This resulted in actual harm to Resident #171 who had uncontrolled pain. This affected one (Resident #171) of one resident reviewed for pain management. The facility identified 24 residents on a pain management program. The census was 71. Findings include: Record review for Resident #171 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of physician orders dated 10/09/19 revealed Tylenol 325 milligrams (mg), four times a day as needed for pain. On 10/11/19, [MEDICATION NAME] 50 mg three times a day was ordered for pain. Review of the admission Minimum Data Set (MDS) assessment, dated 10/15/19, revealed Resident #171 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use. Under Section J, Pain Management, the assessment interview was dashed out and the staff assessment for pain was not completed. Review of care plan revealed the resident was at risk for pain due to pain in the left knee related to a Baker's cyst. Interventions were to notify the physician of increased pain, and observe for and record verbal and nonverbal signs and symptoms of pain. Review of the Medication Administration Record [REDACTED].M. because the medication wasn't available and the facility was waiting on a written prescription. The [MEDICATION NAME] was not given on 10/20/19 at 4:50 [NAME]M. because the drug was still unavailable. According the MAR indicated [REDACTED].M. and 2:00 P.M. No other pain medication was documented as given the evening of 10/19/19 or the early morning of 10/20/19. Tylenol was given on 10/20/19 at 10:17 [NAME]M. and was documented as somewhat effective. Interview on 10/21/19 at 10:59 [NAME]M. with Resident #171 revealed she was in excruciating pain on the night of 10/19/19 into the morning of 10/20/19. She rated her pain a 10 out of 10 on the pain scale and stated it made her feel so bad, terrible and the pain brought her to crying. She stated the night was rough. She stated the prescription was sent in on 10/20/19 at 6:30 [NAME]M. and she didn't receive her [MEDICATION NAME] until about 12:30 P.M. She stated she received Tylenol on 10/20/19 at around 10:15 [NAME]M. but it didn't help with the pain. Interview with Registered Nurse (RN) #55 on 10/24/19 at 7:31 [NAME]M. revealed she took care of Resident #171 on 10/19/19 from 7:00 P.M. to 10/20/19 at 7:30 [NAME]M. She stated she could not give the scheduled [MEDICATION NAME] doses on 10/19/19 at 8:45 P.M. and the dose for the morning of 10/20/19 because there was not a written prescription for the medication. She stated she had to have a new prescription for the drug to be able to get it out of the emergency medication box (E-box). RN #55 stated there was [MEDICATION NAME] in the E-box on this night, but since she didn't have a prescription, she could not access the E-box. She stated she called the physician on 10/19/19 at around 9:00 P.M. and he said he would call in the medication. She said she called the pharmacy but didn't know the time and they said they didn't receive anything from the physician so she said she called the physician again on 10/20/19 at 6:00 [NAME]M. The physician said he would send it again. She stated the resident was crying in pain after midnight, but she didn't give her any Tylenol for her pain and couldn't remember what the resident's pain rating was either. She stated the [MEDICATION NAME] ran out on the day shift on 10/19/19 and she didn't know why it wasn't taken care of at that time. Interview with Pharmacy Technician (PT) #103 on 10/24/19 at 9:15 [NAME]M. revealed it was the policy of the pharmacy that there has to be a written prescription for narcotics to be able to pull out of the emergency box in the facility. She stated if there a prescription on file for the resident then the staff could call the pharmacy for a code and pull from the E-box. She said if there wasn't a prescription on file then the facility staff person would have to get the physician to fax a prescription for the medication if it was a controlled substance, such as [MEDICATION NAME], to the pharmacy. She stated there wasn't any documentation of prescription faxed to the pharmacy from the physician for Resident # /20/19 at 6:30 [NAME]M. on 10/20/19. She further said there wasn't any communication from the facility until that time either. Interview with Pharmacist #102 for the facility on 10/24/19 at 9:27 [NAME]M. revealed the first pull from the E-box for the [MEDICATION NAME] was on 10/20/19 at 12:00 P.M. and another one was at 6:00 P.M. Interview with Licensed Practical Nurse (LPN) #27 on 10/24/19 at 10:19 [NAME]M. revealed she worked on 10/19/19 and 10/20/19 from 7:00 [NAME]M. to 7:30 P.M. She didn't know the [MEDICATION NAME] had run out for Resident #171. She stated she called the pharmacy on 10/20/19 before her medication pass and they said they didn't get the prescription yet. She called the physician on 10/20/19 shortly thereafter, but the physician said he had faxed the prescription to the pharmacy and sent her the confirmation of it. She stated Resident #171 was in pain and was very uncomfortable. Review of progress notes from 10/19/19 through 10/20/19 contained no documentation the facility had called the physician for the prescription. Review of the facility policy titled Controlled Substance Prescriptions, dated 01/01/17, revealed before a controlled substance can be dispensed, the pharmacy must have a clear, complete, and signed written prescription from a person lawfully authorized to prescribe.