Every finding on record at Forest Hills Healthcare Center.

Based on observation, staff interview, resident interview, and policy review, the facility failed to store food in a manner to prevent against the potential spread of foodborne illness. This had the potential to affect 109 of 112 residents in the facility. The facility identified three residents (#01, #05, and #37) who did not receive food from the kitchen. The facility census was 112. 1.Observation on 04/27/26 at 8:22 A.M. with Director of Dietary Services (DDS) #505 of the walk-in cooler revealed it contained the following items:two cartons of heavy whipping cream opened and partially used, with no open date, a cart with two bins of individually poured and covered beverages with no date, a tray of individual fruit cocktail bowls which were covered but did not have a date, a large pan of pasta with ground meat with the serving scoop inside, resting on the food, covered with plastic wrap and not dated. A cart containing a 22-quart container of a dark liquid with no label or date, a pink plastic pitcher next to the bin resting directly on the cart which was coated with a dark unidentified material, a box of bacon on the floorInterview on 04/27/26 at 8:23 A.M. with DDS #505 verified there were undated, unlabeled and improperly stored food items in the walk -in cooler. 2. Observation on 04/27/26 at 8:27 A.M. with DDS #505 of the walk-in freezer revealed it contained the following items: a bag frozen chicken breasts which were not sealed or dated, a bag of pork pizza topping which was not sealed or dated.Interview on 04/27/26 at 8:28 A.M. with DDS #505 verified there were undated and unsealed items in the walk -in freezer. 3. Observation on 04/27/26 at 8:35 A.M. with DDS #505 revealed the reach-in cooler next to the counter utilized for tray line had a variety of pre-poured juices, milk, thickened beverages, and tea which were covered but were not dated. Interview on 04/27/26 at 8:35 A.M. with DDS #505 verified there were undated items in the reach-in cooler. 4. Observation on 04/30/26 at 9:26 A.M. with Licensed Practical Nurse (LPN) #380 revealed the refrigerator at the [NAME] nurses' station contained the following items: a plastic bag of food labeled with Resident #112's name and dated 04/21/26, three half-sandwiches wrapped in plastic but not dated. Interview on 04/30/26 at 9:27 A.M. with LPN #380 verified the bag of Resident #112's food was dated 04/21/26 and the three sandwiches did not have a date. Review of the facility policy titled Food Storage: Cold Foods dated February 2026 revealed all foods would be stored six inches above the floor and all foods would be stored wrapped or in covered containers, labeled, and dated. 5. Observation on 04/30/26 at 9:16 A.M. revealed the personal refrigerator in Resident #20's room contained three undated bags of grapes with visible mold. Interview on 04/30/26 at 9:17 A.M. with Certified Nursing Assistant (CNA) #314 verified the three bags of grapes were moldy and undated. Review of the facility policy titled Storage of Resident Food undated revealed resident refrigerators would be monitored daily, food would be labeled appropriately, and unsafe foods, including food with mold, would be discarded. This deficiency represents noncompliance investigated under Complaint Number 2708220.

Based on review of Resident Council minutes, resident interview, and staff interview, the facility failed to respond to resident concerns expressed during Resident Council meetings. This affected (Residents #4, #7, #17, #24, #48, #67, #91, #96, #101, #107, #108, #118 and #132) who have attended Resident Council in the previous three months and had the potential to affect all of the residents residing in the facility. The facility census was 112 residents. Findings include: Review of the Resident Council Minutes dated January 2026, February 2026, March 2026 revealed residents expressed the following concerns: noise at night, aides not staying on task on nightshift, not being assisted out of bed in time for activities, bathrooms not being cleaned properly, running out of food ordered, rooms not being cleaned on the weekends. Review of the minutes revealed no follow-up to the concerns expressed by the residents in the Resident Council meetings. Interview on 04/29/26 at 10:59 A.M. with Resident #132, the Resident Council President, with Resident #20 and with Resident #96 confirmed Resident Council meetings were no longer well attended. Resident #132 stated several residents who had regularly come to Resident Council have reported they stopped coming to the meetings because they felt nothing ever changed when they expressed concerns. Interview on 04/29/26 at 11:13 A.M. with Resident #132 confirmed the former facility cook came to a meeting several months ago and listened to the food concerns expressed. The cook told the residents he was going to make some changes to the menus and the preparation process to try to improve the flavor and presentation of the meals. Resident #132 stated nothing had changed and the food continued to be lacking flavor and was frequently cold. Interview on 04/29/26 at 11:20 A.M. with Resident #96 verified concerns had been raised in Resident Council regarding staff using their cell phones during work time which caused a slow response to call lights and other assigned tasks. Resident #96 stated no changes had had been regarding cell phone usage by the staff, and she did not believe the concern had been addressed. Interview on 04/29/26 at 3:12 P.M. with the Administrator confirmed the facility had no standard method of addressing concerns that were brought up in Resident Council meetings. The Administrator verified concerns were addressed once the minutes of the meeting were completed but communication didn't get back to the residents. The Administrator confirmed communication could be improved and done in a manner where information was formally disseminated to the residents, so they would know action had been taken on their concerns.This deficiency represents noncompliance investigated under Complaint Number 294964 and Complaint Number 2968329 and Complaint Number 2963128 and Complaint Number 2646120.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure resident medications were properly labeled and stored. This affected two (Residents #82 and #95) of six residents reviewed for insulin administration. Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medication carts were locked. This had the potential to affect three facility identified cognitively impaired and mobile residents (Residents #8, #10, and #75) of 26 residents residing on the 1100 hallway. The facility census was 112 residents.Findings include: 1.Review of the medical record for Resident #95 revealed an admission date of 12/16/25 with diagnoses including fibromyalgia, type two diabetes, and polyneuropathy. Review of the physician's orders for Resident #95 dated April 2026 revealed an order for insulin aspart injection per sliding scale. Observation on 04/29/26 at 11:35 A.M of the Rehab South medication cart with Licensed Practical Nurse (LPN) #432 revealed Resident #95's insulin aspart pen was opened and undated. Interview on 04/29/26 at 11:36 A.M with LPN #432 confirmed Resident #95's insulin aspart did not have an open date. 2.Review of the medical record for Resident #82 revealed an admission date of 03/28/26 with diagnoses including cerebral atherosclerosis, hyperlipidemia, and type two diabetes. Review of the physician's orders for Resident #82 revealed an order dated 03/29/26 for insulin glargine injection 10 units. Observation on 04/29/26 at 11:27 A.M of the Rehab South medication cart with LPN #432 revealed Resident #82's insulin glargine was dated 03/28/26. Interview on 04/29/26 at 11:28 A.M. with LPN #432 confirmed Resident #82's insulin glargine open date was 03/28/26 and the insulin was expired and should be discarded. Review of facility policy titled Storage of Medications revealed insulin was to be discarded after 28 days and all multi-use vials required an open date. Expired medications would be removed from the active supply and destroyed. 3.Observation on 04/28/26 from 2:36 P.M. to 2:45 P.M. of the 1100 Hallway revealed an unattended unlocked medication cart was sitting in the hallway. Several unlicensed staff and several residents walked past the unlocked cart. Interview on 04/28/26 at 2:45 P.M. with LPN #432 confirmed the 1100 hallway medication cart had been left unattended and unlocked. Interview 04/28/26 at 4:10 P.M with the Director of Nursing confirmed nurses are never to leave a med cart unlocked and unattended. Review of facility policy titled Storage of Medications revealed medication carts are to be locked when not attended by people with authorized access

Based on observation, staff interview, and review of the facility recipe, the facility failed to prepare pureed foods in a manner to preserve the nutritional content of the food. This had the potential to affect 13 residents in the facility who received pureed foods. The facility census was 112 residents.Findings include: Observation on 04/29/26 at 11:20 A.M. of [NAME] #500 preparing pureed peas revealed the cook poured peas from a large metal pan into the food processor and added approximately one quart of chicken broth and two tablespoons of thickening powder. [NAME] #500 began to blend the contents together and checked the consistency of the peas and added approximately one tablespoon of thickener and continued to run the food processor. [NAME] #500 continued on to run the food processor, adding an additional six tablespoons of thickener and blended until he achieved the appropriate consistency. Interview on 04/29/26 at 11:35 A.M. with [NAME] #500 verified he blended approximately two liters of peas, one quart of chicken broth, and nine tablespoons of thickener when preparing pureed peas. Interview on 04/29/26 at 11:52 A.M. with District Manager (DM) #515 verified food should be blended before the addition of liquid to minimize the use of excess liquid and the need for excess thickener to be added. Interview on 04/30/26 at 10:56 A.M. with Registered Dietitian (RD) #510 verified adding too much liquid to a food could necessitate the need to add more thickener to the food to achieve the desired consistency which could negatively affect the nutritional content of the food. RD #510 further stated such a practice could also impact the consistency as the food cooled leading to a potential choking hazard. Review of the facility recipe for pureed peas undated revealed the desired amount of peas should blended in the food processor until smooth. After blending the peas either thin liquid or commercial thickener should be added to achieve the desired consistency.

Based on medical record review, staff interview, and policy review, the facility failed to implement a baseline care plan which included information regarding resident activities of daily living (ADL) care needs. This affected one (Resident #16) of 13 residents reviewed for baseline care plans. The facility census was 112 residents.Findings include: Review of the medical record for Resident #16 revealed an admission date of 04/09/26 with diagnoses including postprocedural intestinal obstruction and dementia. The resident transferred to the hospital on [DATE] and had not yet returned to the facility. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 04/13/26 revealed the resident had severely impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the baseline care plan for Resident #16 dated 04/09/26 revealed the resident had an ADL self-care performance deficit due to her comorbidities. The care plan did not include further details regarding the basic ADL care needs of the resident. Interview on 04/29/26 at 12:37 P.M. with MDS Licensed Practical Nurse (LPN) #377 verified the information included in the chart for the baseline care plan did not include the basic information needed to care for the resident. Review of the facility policy titled Baseline Care Plan/48 Hour Care Plan dated 03/01/26, revealed the baseline care plan would include information regarding the resident needs for assistance with activities of daily living. This deficiency represents noncompliance investigated under Complaint Number 2963128.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's limited range of motion was addressed in the comprehensive care plan. This affected one (Resident #1) of one resident reviewed for limited range of motion. The facility identified eight residents who had a limited range of motion. The facility census was 112 residents. Findings include: Review of the medical record for Resident #1 revealed an admission date of 03/09/26 with diagnoses including anoxic brain damage, persistent vegetative state, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 03/16/26 revealed the resident was in a persistent vegetative state with no discernible consciousness, was dependent on staff for all activities of daily living (ADLs), and had impaired range of motion to all extremities. Review of the care plan for Resident #1 dated 04/27/26 revealed it did not include interventions related to the resident's impaired range of motion. Interview on 04/29/26 at 12:37 P.M. with MDS Licensed Practical Nurse (LPN) #377 verified Resident #1's limited range of motion was not addressed on the care plan. MDS LPN #377 stated the information should be on the care plan, so the staff are aware of the limitations. Review of the facility policy titled Plan of Care Overview undated revealed the care plan was the written treatment provided for a resident and the provision of optimal personalized care and services to enable the resident to live with dignity. This deficiency represents noncompliance investigated under Complaint Number 2963128.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure all residents received adequate assistance with activities of daily living (ADLs). This affected two (Residents #1 and #113) of five residents reviewed for ADLs. The facility census was 112 residents.Findings include: 1.Review of the medical record of Resident #113 revealed an admission date of 09/12/25 with diagnoses including type two diabetes mellitus, legal blindness, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment for Resident #113 dated 03/22/26 revealed the resident had intact cognition and required partial/moderate assistance with bathing and personal hygiene. Observation on 04/27/26 at 11:50 A.M. revealed Resident #113's fingernails were long and extended approximately one half inch beyond the fingertip. Interview 04/27/26 at 11:50 A.M. with Resident #113 confirmed he did not like having his fingernails so long because it interfered with his ability to press buttons on his tv remote. Interview on 04/27/26 at 12:06 P.M. with Activity Director (AD) #370 verified Resident #113's fingernails were long and needed to be trimmed. Observation on 04/28/26 at 10:14 A.M. revealed Resident #113's fingernails remained long and extended approximately one half inch beyond the fingertip. Interview at 04/28/26 at 10:14 A.M. with Resident #113 confirmed no one had offered to cut his fingernails since the previous day. 2. Review of the medical record for Resident #1 revealed an admission date of 03/09/26 with diagnoses including anoxic brain damage, persistent vegetative state, and type two diabetes mellitus. Review of the MDS assessment for Resident #1 dated 03/16/26 revealed the resident was in a persistent vegetative state with no discernible consciousness, was dependent on staff for all activities of daily living, and had impaired range of motion to all extremities. Observation on 04/28/26 at 2:14 P.M. with Licensed Practical Nurse (LPN) # 309 revealed Resident #1's fingernails were long and extended approximately one quarter inch beyond the fingertip. Interview on 04/28/26 at 2:14 P.M. with LPN #309 verified Resident #1's fingernails were long and needed to be trimmed. Review of the facility policy titled Routine Resident Care undated revealed the facility would provide routine daily care including assistance with activities of daily living. This deficiency represents noncompliance investigated under Complaint Number 2804249 and Complaint Number 2966392 and Complaint Number 2964964 and Complaint Number 2799354 and Complaint Number 2738678 and Complaint Number 2673312 and Complaint Number 2704933 and Complaint Number 2968329.

Based on medical record review, observation, staff interview, family interview, and policy review, the facility failed to provide the care and services to prevent a decrease in range of motion on a resident who was at risk for the development of contractures. This affected one (Resident #1) of one resident reviewed for limited range of motion. The facility identified eight residents who had limited range of motion. The facility census was 112 residents.Findings include: Review of the medical record for Resident #1 revealed an admission date of 03/09/26 with diagnoses including anoxic brain damage, persistent vegetative state, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 03/16/26 revealed the resident was in a persistent vegetative state with no discernible consciousness, was dependent on staff for all activities of daily living and had impaired range of motion to all extremities. Interview on 04/27/26 at 2:13 P.M. with Resident #1's responsible party stated she noticed during her visit the day prior the resident's hands seemed stiff and she tried to stretch them, but they were not moving easily. Review of the medical record revealed no evidence of occupational therapy being consulted for Resident #1's limited range of motion. Interview on 04/28/26 at 2:38 P.M. with Director of Therapy (DOT) #700 verified Resident #1 admitted [DATE] and had not been evaluated nor screened by occupational therapy (OT). DOT #700 verified Resident #1's persistent vegetative state would put him at risk for contractures. DOT #700 stated nursing refers to therapy when therapy services are needed, and therapists follow up on the referrals. Observation on 04/28/26 at 2:47 P.M. with OT #411 revealed the OT assessed Resident #1's range of motion. Interview on 4/28/26 at 2:47 P.M. with OT #411 confirmed Resident #1's shoulders were tight and had quite a bit of increased muscle tone, and the resident could definitely benefit from range of motion exercises and staff education. OT #411 verified Resident #1 was at risk for worsening contractures and had not been evaluated by OT since being admitted to the facility on [DATE]. Review of facility policy titled Plan of Care Overview undated revealed members of the care planning team will coordinate care to meet the resident care needs.

Based on medical record review, resident interview, and staff interview the facility failed to ensure medications were available for administration per physician order. This affected two (Residents #17 and #55) of 23 facility-identified residents with orders for routine opioid analgesics. The facility census was 112 residents.Findings include: 1.Review of the medical record for Resident #17 revealed an admission date of 08/27/25 with diagnoses including wedge compression fractures of T1, T7-T8 and T11-T12, muscle weakness and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 02/13/26 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Review of the physician's orders for Resident #17 revealed an order dated 03/27/26 for oxycodone 10 milligrams (mg) every six hours. Review of the Medication Administration Record (MAR) for Resident #17 revealed the 6:00 P.M. evening dose of oxycodone for 04/27/26 was not signed off as administered. Interview on 04/29/26 at 4:30 P.M. with Resident #17 confirmed the facility had run out of his routine oxycodone recently and he had missed a dose of scheduled pain medication. Interview on 04/30/26 at 11:44 A.M with the Director of Nursing (DON) confirmed Resident #17 did not receive his 6:00 P.M. dose of oxycodone on 04/27/26 because the medication was not available for administration. 2.Review of the medical record for Resident #55 revealed an admission date of 09/20/23 with diagnoses including polyneuropathy, diabetes mellitus type two, prostate cancer and anxiety disorder. Review of the MDS assessment for Resident #55 dated 09/28/25 revealed resident had intact cognition and required staff assistance with ADLs. Review of the physician's orders for Resident #55 revealed an order dated 02/19/26 for oxycodone-acetaminophen 5-325 mg one tablet every six hours. Review of the MAR for Resident #55 revealed the 6:00 P.M. evening dose of oxycodone-acetaminophen was not signed off as administered. Interview on 04/27/26 at 10:05 A.M. with Resident #55 confirmed in the previous month there was a day where he did not receive his scheduled pain medication because it was not available. Interview on 04/29/26 at 4:00 P.M. with the DON confirmed Resident #55 did not receive his 6:00 P.M. dose of oxycodone-acetaminophen on 03/16/26 because the medication was not available for administration.This deficiency represents noncompliance investigated under Complaint Number 2704502 and Complaint Number 2656097 and Complaint Number 2673312.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure medications were administered only with an appropriate indication for use. This affected one (Resident #13) of five residents reviewed for unnecessary medications. The facility census was 112 residents.Findings include: Review of the medical record for Resident #13 revealed an admission date of 03/06/26 with diagnosis including heart disease, myocardial infarction, and tobacco use. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 03/13/26 revealed resident was cognitively intact and required minimal assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #13 dated April 2026 revealed an order for a transdermal nicotine patch to be applied once daily for smoking cessation. Review of the Medication Administration Record (MAR) for Resident #13 dated April 2026 revealed the resident was documented for refusal of the patch from 04/14/26 to 04/29/26. Interview on 04/29/26 at 9:29 A.M with Resident #13 confirmed he had not smoked or vaped since admission to the facility. Resident confirmed he had refused the nicotine patch on some days. Observation on 04/29/26 at 10:19 A.M. of Resident #13 with Licensed Practical Nurse (LPN) #432 revealed the resident was wearing an undated nicotine patch on his left upper arm. Interview on 04/29/26 at 10:19 A.M. with Resident #13 confirmed the nicotine patch had been on his left upper arm for several days. Interview on 04/29/26 at 10:20 A.M. with Licensed Practical Nurse (LPN) #432 on 04/29/26 at 10:19 A.M confirmed Resident #13 was wearing an undated nicotine patch on his left upper arm. LPN #432 stated she did not think Resident #13 was a smoker. Interview on 04/30/26 at 9:36 A.M. with the Director of Nursing (DON) confirmed Resident #13 was not a smoker and the facility staff had not asked the resident about his tobacco use upon admission. The DON confirmed Resident #13 should not have an order for a nicotine patch because he was not a smoker.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were placed in enhanced barrier precautions (EBP) as appropriate. This affected one (Resident #13) of 34 facility-identified residents on transmission-based precautions. The facility census was 112 residents.Findings include: Review of the medical record for Resident #13 revealed an admission date of 03/06/26 with diagnosis including heart disease, myocardial infarction, and tobacco use. Review of hospital discharge summary for Resident #13 dated 03/06/26 revealed was colonized with candida auris and was in contact isolation while in the hospital. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 03/13/26 revealed resident was cognitively intact and required minimal assistance with activities of daily living (ADLs.) Interview on 04/30/26 at 1:27 P.M. with the Director of Nursing (DON) confirmed he was unaware of Resident #13's diagnosis of candida auris. The DON confirmed the diagnosis had not been on the facility diagnosis list nor had resident been in any type of isolation, nor had the facility tested the resident for candida auris since admission. Interview on 04/30/26 at 1:45 P.M. with the DON verified he had spoken with the facility Medical Director regarding Resident #13's diagnosis of candida auris from the hospital and MD gave an order for the resident to be placed in EBP. Review of the facility policy titled Enhanced Barrier Precautions undated revealed EBP are designed to reduce transmission of multi-drug-resistant organisms. Personal protective equipment required for use with someone in EBP included gowns and gloves during any high contact resident care activities such as dressing, bathing, transferring etc.

Based on observation, staff interview and review of the facility policy, the facility failed to maintain the confidentiality of residents' medical records. This affected one (Resident #178) and had the potential to affect all of the residents residing in the facility. The facility census was 122 residents. Findings include:Observation on 11/05/25 at 11:07 A.M. revealed the laptop on top of the medication cart in the 400 hall was open and displayed Resident #178's name and medication list. The cart was unattended by staff and Resident #178's private health information was viewable by residents, staff, and visitors passing by the cart. Interview on 11/05/25 at 11:10 A.M. with Registered Nurse (RN) #825 confirmed she had left the laptop on top of the 400-hall medication cart unattended with Resident #178's private health information visible to residents, staff, and visitors passing by the cart. Observation on 11/05/25 at 11:14 A.M. revealed the laptop on top of the medication cart in the 400-hall was open and displayed multiple resident records. The cart was unattended by staff and multiple resident records were accessible to residents, staff, and visitors passing by the cart. Interview on 11/05/25 at 11:17 A.M. with RN #825 confirmed she had left the laptop on top of the 400-hall medication cart unattended with multiple resident records accessible to residents, staff, and visitors passing by the cart. Interview on 11/06/25 at 1:55 P.M. with the Administrator confirmed all nursing staff are to lock their laptop screens when walking away from the medication cart to ensure the privacy of resident health information. Review of the facility policy titled Health Insurance Portability and Accountability Act undated revealed staff should ensure computer screens are turned off so a passerby would not see or have access to residents' private health information. Staff should not walk away from open medical records.

Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility failed to ensure residents received vision services as needed. This affected one (Resident #186) of three residents reviewed for ancillary services. The facility census was 122 residents.Findings include:Review of the medical record for Resident #186 revealed an admission date of 03/04/20 diagnoses including Alzheimer's disease, major depressive disorder, and hypertension. Review of the physician's orders for Resident #186 revealed an order dated 04/03/23 for the resident to be seen by an outside eye doctor as needed. Review of the Minimum Data Set (MDS) assessments for Resident #186 dated 12/06/24, 03/08/25, and 06/08/25 revealed the resident had adequate vision and did have corrective lenses. Review of the physician's orders for Resident #186 revealed an order dated 01/05/25 revealed Latanoprost eye drops at bedtime for glaucoma. Review of the care plan for Resident #186 initiated 03/25/25 revealed the resident had impaired visual function and had a diagnosis of glaucoma. Interventions included the following: arrange consultation with and eye care practitioner as needed, observe/document/report acute eye problems to the medical provider. Review of the care conference progress note for Resident #186 dated 06/30/25 revealed the Social Services Designee (SSD) educated the resident on the availability of ancillary services available to residents. Resident #186 wanted to be seen by the facility eye doctor. SSD sent a referral in for Resident #186 to be seen. Review of the MDS assessment for Resident #186 dated 09/08/25 revealed Resident #186 had severely impaired cognition, required staff assistance with activities of daily living (ADLs.), had adequate vision and was not coded for use of corrective lenses. Interview on 11/06/25 at 9:50 A.M. with Director of Social Services (DSS) #335 confirmed the facility had sent in a referral for Resident #186 to be seen by the facility eye doctor in June 2025 but the resident had not been seen by an eye doctor since her admission to the facility in 2020. Interview on 11/06/25 at 9:55 A.M. with Resident #186 confirmed she wore glasses, but she did not know where they were. Interview on 11/06/25 at 1:15 P.M. with Certified Nursing Assistant (CNA) #775 confirmed the aide had worked for the facility for nine months and had never seen Resident #186 wearing glasses. Interview on 11/06/25 at 1:55 P.M. with the Administrator confirmed the staff were unable to find glasses Resident #186's glasses. The Administrator confirmed Resident #186 had not been seen by the facility eye doctor since her admission to the facility. Review of the facility policy titled Social Services dated 2017 revealed the facility would ensure residents were referred for eye care appointments as needed. This deficiency represents noncompliance investigated under Complaint Number 2655929.

Based on observation, interview, review of facility policy, and review of the 2022 Food Code, the facility failed to ensure dietary staff performed hand hygiene as directed by the facility policy, and failed to ensure milk was held on the tray line at 41 degrees Fahrenheit (F) or less. This had the potential to affect all residents. The facility census was 102. Findings include: 1. During an observation of the lunch tray line on 05/13/2025 from 12:09 P.M. to 12:12 P.M., Dietary Aide (DA) #18, while waiting for the meal tray line to begin, scratched the left side of her head with her left hand, scratched the right side of her head with her right hand, put her hands in her pockets, then touched a plate, touched her face, and took a plate from the cook and put it on a meal tray. DA #18 proceeded to scratch her face, touch her clothes, and then took a sandwich from the refrigerator next to the meal tray line, placed the sandwich on plate on a meal tray. DA #18 did not perform hand hygiene during this time. During a concurrent observation and interview on 05/13/2025 at 12:17 P.M., DA #18 touched her pants and scratched her head and then continued to participate on the lunch line without completing hand hygiene. The Dietary Manager (DM) #19 stated DA #18 should wash her hands. During an observation of breakfast tray line on 05/15/2025 at 7:38 A.M., DA #18 touched her face and then the top of a plate and put the meal tray with the plate on the cart. DA #18 did not wash her hands after touching her face. At 7:41 A.M., DA #18 touched her pants and her hair and continued to prepare plates for residents' breakfast meal and put the plates on a meal cart. At 8:01 A.M., DA #18 spooned cream of wheat into a container, put a top on it, and then put it on a meal tray. DA #18 proceeded to wipe her hands on her pants. DA #18 did not complete hand hygiene during the observation. During an interview on 05/15/2025 at 7:24 A.M., DA #18 stated she should wash her hands if she stepped away from the meal tray line or touched anything. During an interview on 05/16/2025 at 11:49 A.M., the Director of Nursing stated he expected staff to sanitize their hands after touching clothing and things of that nature. During an interview on 05/16/2025 at 11:13 A.M., the Administrator stated she expected staff to complete hand hygiene according to the policy. Review of an undated facility policy titled, Handwashing Procedure for Dining Services revealed, hand hygiene continues to be the primary means of preventing the transmission of infection. The handwashing procedure revealed, the following is a list of some situations that require hand hygiene, which included, after blowing your nose, coughing, sneezing, or touching your hair, face, or clothes. 2. During a concurrent interview and observation of the breakfast tray line on 05/15/2025 at approximately 8:18 A.M., Dietary Aide (DA) #18 poured lactose free milk into seven cups to be served to residents. DA #18 placed the seven glasses on the tray line and did not hold cups of milk in ice to maintain the temperature. At the request of the surveyor, at 8:28 A.M., the Dietary Manager took the temperature of the milk of the lactose free milk in each of the seven cups. The DM stated the temperature of the milk was 43 degrees Fahrenheit (F). and further added the facility could not serve the milk. During an interview on 05/16/2025 at 11:49 A.M., the Director of Nursing stated his expectation was the food was adequately heated, and the milk was at an appropriate temperature. During an interview on 05/16/2025 at 11:13 A.M., the Administrator stated her expectation was the food and drink temperatures were kept within acceptable and required temperature ranges. Review of the 2022 Food Code published by the United States Food and Drug Administration, indicated, (3-501.16) temperature control for the safety and hot and cold holding stated hot food shall be maintained at 135 degrees Fahrenheit or higher and cold food items at 41 degrees Fahrenheit or less.

Based on record review, resident and staff interview, the facility failed to transcribe a change of an advance directive order. This affected one Resident (#2) of three residents reviewed for advance directives. The facility census was 102. Findings include: Review of the medical record for Resident #2 revealed an admission date of [DATE]. According to the admission record, Resident #2's code status was listed as a full code, meaning the resident wanted cardiopulmonary resuscitation (CPR). A quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Review of Resident #2's current orders as of [DATE], revealed Resident #2 had an order dated [DATE], indicating the resident's code status was a full code. Review of Resident #2's care plan included a focus area for code status initiated [DATE] and revised [DATE], that indicated Resident #2's code status was Do Not Resuscitate (DNR), Comfort Care. Interventions directed staff to obtain the medical provider order for the residents' code status. Review of Resident #2's DNR] Order Form, dated [DATE], indicated the resident's code status was DNR Comfort Care. Interview on [DATE] at 11:01 A.M., Resident #2 stated they were their own responsible party and wished to have a DNR code status. The resident stated they no longer wanted to have full code status. Interview on [DATE] at 3:23 P.M., Registered Nurse (RN) #1 stated a change in a resident's code status should be updated by the management staff immediately in the resident's electronic health record (EHR). RN #1 stated when she would receive a change in code status order, she notified the nurse practitioner, the Director of Nursing (DON), and changed the order in the resident's EHR. Interview on [DATE] at 7:36 P.M., the Director of Social Services (DSS) stated advanced directives were reviewed with each resident annually to determine if they were still accurate. She stated if a resident wished to change from full code to DNR, she met with the resident, consulted with responsible parties, and sent the form to the physician. She stated changing a resident's code status in the EHR should be completed by the nurses. She stated the resident's code status was changed a couple of weeks before she started employment at the facility. She stated she expected the change in code status to be documented by the social worker who was responsible and the paperwork to be forwarded to the nursing staff and physician so the residents' orders and medical record could be updated. Interview on [DATE] at 8:57 A.M., the DON stated that he expected a resident's code status to be updated in the resident's EHR when the resident decided to change it. He stated the DSS was responsible for making sure any change in code status were given to the nursing staff after all the forms were completed. He stated Resident #2 signed their DNR in June of 2024 when the facility did not have a DSS. He stated it was signed a couple of weeks before the current DSS started, and Resident #2's change in code status was missed. He stated the former medical records nurse should have uploaded the resident's DNR form and changed their status in the EHR at that time and was unsure why it was not completed. Interview on [DATE] at 8:26 A.M., the Administrator stated she expected any changes to a resident's code status should be updated in the EHR at that time.

Based on medical record review, staff interview, and facility policy review, the facility failed to provide copies of resident records as requested and per requirements. This affected one (Resident #110) of three residents reviewed for medical records request. The census was 108. Findings Include: Resident #110 was admitted to the facility on [DATE]. Her diagnoses were other specified fracture of left pubis, unspecified fall, anemia, hypertension, cognitive communication deficit, hypothyroidism, hyperlipidemia, syncope and collapse, osteoporosis, vitamin D deficiency, osteoarthritis, hypotension, and muscle weakness. Review of her minimum data set (MDS) assessment, dated 07/31/24, revealed she was cognitively intact. Review of Resident #110 progress notes, dated 07/25/24 to 08/21/24, revealed she was discharged from the facility on 08/21/24. There was no documentation to support a request of medical records. Review of facility Authorization for the Release of Health Information form, dated 01/13/25, revealed Resident #110 signed this document to request a copy of her complete medical records. The records were to be sent to an attorney's office. There was no documentation to support this request had been addressed and/or completed. Interview with Administrator on 01/31/25 at 2:50 P.M. confirmed the request had not been completed. She confirmed the facility received a request for Resident #110's complete medical records, which was signed by Resident #110, on 01/13/25. She confirmed the facility's typical process was to receive a written request for medical records, have the request sent to their legal department to verify the authenticity of the request/signature(s), and then within 30 days, start processing the medical records request. Review of facility Releasing Clinical Records procedures, undated, revealed the facility will only release confidential information to authorized persons/entities, and only in accordance with facility policy, federal, and state laws. The procedure includes the following: a written request if required, requires a properly executed authorization unless not required by law, complete the Authorization for Release of Health Information form, and the requested documents are produced and released in compliance with HIPAA regulations. The Authorization for Release of Health Information form is to be completed and emailed back to the facility. The resident may access his/her electronic record. A staff member is to accompany the resident during the inspection process. If a resident requests a copy of his/her record, the record will be provided in compliance with regulations. If a family member is the legal representative, the records will be released to him/her by the company's attorney. Release of confidential information to a third party with properly executed authorization. Third party includes attorneys. Unless otherwise specified by state statute, a valid authorization form must include at least the following: name of the individual, name of organization which is to make the disclosure, name of individual or organization requesting information, purpose of need for disclosure, statement that consent is subject to revocation at any time except to extent that action has been taken, statement that authorization will expire on a specific date or at least 90 days from the date of the signature by individual or authorized person, and signature of individual or authorized person. The facility will verify authenticity of signature by comparing it to other documents signed by that individual in your facility's records. This deficiency represents non-compliance investigated under Complaint Number OH00161560.

Based on medical record review, staff interview, Nurse Practitioner (NP) interview, and policy review, the facility failed to ensure neurological (neuro) checks were completed when resident's had unwitnessed falls and falls involving the head. This affected two (#63 and #85) of three residents reviewed for falls. This had the potential to affect all 108 residents in the facility. Findings include: 1) Review of the medical record of Resident #63 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, dementia, type two diabetes mellitus, and obstructive sleep apnea (OSA). Review of the quarterly Minimum Data Set (MDS) assessment for Resident #63 dated 09/20/24; revealed the resident had severely impaired cognition. Review of a fall investigation for Resident #63 dated 11/15/24, revealed, at approximately 4:30 A.M., Resident #63 was found sitting on the floor close to his geriatric (geri) chair. The resident was assessed with no injuries. The on-call physician was notified of the fall at 7:30 A.M. and the resident's son was notified of the fall at 8:11 A.M. Review of neuro-checks for Resident #63 dated 11/15/24; revealed the first four 15-minute checks and first hour check was not signed off as complete until 11/22/24, by the Director of Nursing (DON). Interview with the DON on 12/17/24 at 4:14 P.M., verified the first four 15-minute checks and first hour check was not signed off until 11/22/24. The DON stated he had no doubt the checks were being done; however, he found staff were not signing them off as complete at the time they were due, so he had to go back and ensure they were completed. 2) Review of the medical record of Resident #85 revealed an admitted [DATE]. Diagnoses included right ulnar fracture, resistant hypertension, dysphagia, and a history of falling. Review of the comprehensive MDS assessment for Resident #85 dated 10/15/24, revealed the resident had moderately impaired cognition. The resident required partial/moderate assistance with bed mobility, substantial/maximal assistance with bathing and was dependent on staff for toileting, dressing, and transfers. Review of a nursing progress note for Resident #85 dated 10/21/24, revealed the nurse witnessed Resident #85 attempting to pick something up off the floor in the hallway and fell on her face. The resident sustained abrasions to her left eye and nose and lost a lens of her glasses during the fall. The physician was notified, and an x-ray of the face was ordered. Review of the medical record revealed no evidence of neuro-checks being completed following Resident #85's fall on 10/21/24. Interview with the DON on 12/18/24 at 10:35 A.M., verified no neuro-checks were completed following Resident #85's fall on 10/21/24. The DON stated NP #405 assessed the resident after the fall and ordered an x-ray of the face but did not order any neuro-checks. Upon review of the policy with the DON, the DON verified the type of fall Resident #85 sustained, should have included neuro-checks following the incident. Interview with NP #405 on 12/18/24 at 3:49 P.M., revealed she assessed Resident #85 following a fall on 10/21/24 and ordered a facial x-ray. NP #405 stated neuro-checks should have been completed per the facility's protocol as Resident #85's head was involved with her fall, evidenced by her broken glasses and significant bruising on her left side. Review of the facility policy titled, Neurological checks, undated, revealed neurological assessment should be completed for falls with suspected head injury, falls with unknown head injury, and blows to the face every 15 minutes, then hourly, then daily for four days. This deficiency represents non-compliance investigated under Complaint Number OH00160169.

Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications. This affected one (#59) of three residents reviewed for infection. This had the potential to affect all 108 residents in the facility. Findings include: Review of the medical record of Resident #59 revealed an admitted [DATE]. Diagnoses included cellulitis, insomnia, cognitive communication deficit, and dysphagia. Review of a nursing progress note for Resident #59 dated 11/23/24 revealed new orders were received to discontinue Miralax (laxative) due to diarrhea and check the resident's stool for Clostridium difficile (C.diff). Per report obtained from the hospital, the resident had one episode of diarrhea that morning, but this was due to the administration of Miralax. Review of the physician orders for Resident #59 revealed an order dated 11/24/24 to check the resident's stool for C.diff. Orders on 11/27/24 revealed the resident was ordered Vancomycin (antibiotic) oral solution 25 milligrams (mg) per milliliter (mL) to give five ml (125 mg) every six hours for C.diff for 10 days. The medication was completed 12/07/24. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #59 dated 11/28/24 revealed the resident had severely impaired cognition. Review of the medical record revealed no documented evidence of Resident #59's stool being checked for C.diff as ordered. Interview with the Director of Nursing (Don) on 12/19/24 at 11:12 A.M., verified Resident #59 was given 10 days of Vancomycin without having positive C.diff culture results. The DON stated the medication should not have been prescribed without written positive results and, through an investigation, discovered a nurse had verbally told the Nurse Practitioner (NP) that Resident #59 had positive C.diff results and the NP gave a verbal order for antibiotics without reviewing the written results. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review and staff interview, the facility failed to ensure laboratory (lab) tests were drawn as ordered by the physician. This affected two (#59 and #109) of three residents reviewed for labs. This had the potential to affect all 108 residents in the facility. Findings include: 1) Review of the medical record of Resident #59 revealed an admitted [DATE]. Diagnoses included cellulitis, insomnia, cognitive communication deficit, and dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Review of a nursing progress note for Resident #59 dated 11/23/24, revealed new orders were received to discontinue Miralax (laxative) due to diarrhea and check the resident's stool for Clostridium difficile (C.diff). Per a report obtained from the hospital, the resident had one episode of diarrhea that morning, but this was due to the administration of the Miralax. Review of physician orders for Resident #59 dated 11/24/24, revealed orders for the resident to have stool tested for C.diff. Review of the medical record revealed no documented evidence of Resident #59's stool being tested for C.diff as ordered. Interview with the Director of Nursing (DON) on 12/19/24 at 11:12 A.M., verified there was no documented evidence of Resident #59's having a stool culture for C.diff completed as ordered. 2. Review of the medical record of Resident #109 revealed an admitted [DATE]. The resident transferred to the hospital on 11/17/24 and returned to the facility on [DATE]. Diagnoses included dysarthria, aphasia, hemiplegia and hemiparesis following cerebral infarction, anxiety, depression, vascular dementia, breast cancer. Review of the quarterly MDS assessment for Resident #109 dated 12/09/24 revealed the resident had intact cognition. The resident utilized a walker for mobility. Review of a nursing progress note for Resident #109 dated 11/14/24, revealed the resident complained of feeling weak and more tired than usual. Nurse Practitioner (NP) #405 was notified and gave orders for a complete blood count (CBC) on 11/15/24. Review of a NP #405 progress note dated 11/14/24 revealed the resident was not feeling well and recommended for the resident have a CBC completed. Review of the physician orders revealed an order dated 11/14/24 for the resident to have a CBC with differential on 11/15/24. Review of the medical record for Resident #109 revealed no documented evidence of the labs being completed as ordered. Interview with the DON on 12/18/24 at 1:38 P.M., verified a CBC for Resident #109 was not completed per orders on 11/15/24. The DON stated the facility changed lab companies during that week and Resident #109's labs were missed. This deficiency represents non-compliance investigated under Complaint Number OH00160169.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observations, medical record review, review of the incident log, review of facility in-service records, review of a personnel file, review of the safety inspection bus checklist, review of witness statements and the facility's internal investigation, review of policies, review of the emergency medical services (EMS) report, review of emergency room (ER) notes, interview with the Medical Director, and resident and staff interviews, the facility failed to ensure a resident dependent on staff, was safely secured in the wheelchair with an appropriate seat belt during transportation in a facility van to a physician's visit. This resulted in Immediate Jeopardy when one resident (#15) was placed at potential risk for serious life-threatening harm and/or injuries, when Former Transport Driver (FTD) #34 abruptly stopped the facility van, causing Resident #15 to come out of her wheelchair and landing on the floor, towards the front of the van sustaining a hematoma (a solid swelling area of clotted blood within the tissues), causing increased pain, and lacerations that required sutures. This affected one (#15) of three residents reviewed for use of assistive devices during transportation. The facility identified a total of 23 residents who utilized a wheelchair, the transport van, and would be required to have their seat belt engaged. The facility census was 100. On 04/30/24 at 3:23 P.M., the Administrator, and Director of Nursing (DON) were informed that Immediate Jeopardy began on 03/15/24 at approximately 12:30 P.M., when Resident #15 was being transported to a physician's appointment via the facility's transportation bus, when FTD #34 failed to properly and safely secure Resident #15 in her wheelchair prior to leaving the facility. During the trip to the physician's office, the driver abruptly stopped for a traffic signal, causing Resident #15 to come out of her wheelchair by sliding under the seat belt and landing on the floor towards the front of the van. FTD #34 stopped to check on Resident #15, and when the resident stated she was hurt and wanted to go the hospital, FTD #34 drove back to the facility with Resident #15 lying on the floor of the van unsecured and rolling around on the floor. Once FTD #34 returned to the facility, he alerted the receptionist to get the Administrator and a nurse and Emergency nine-one-one (911) was called and Resident #15 was then taken to the emergency room for evaluation and treatment. Resident #15 was treated for a hematoma (a solid swelling area of clotted blood within the tissues), pain, and laceration to her lower right leg that required sutures. The Immediate Jeopardy was removed on 03/20/24; however, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 04/26/24 when the facility implemented the following corrective actions: On 03/15/24 between 12:30 P.M. and 12:40 P.M., Resident #15 slid from her wheelchair in a facility owned and operated van while being transported by a facility staff member (FTD #34) to a routine scheduled physician appointment. Resident #15 is an [AGE] year-old female admitted to facility on 8/29/23 to reside long term. Resident notes to have diagnoses to include morbid obesity, fibromyalgia, disc degeneration, cerebral infarction, muscle weakness, gait abnormalities, chronic respiratory issues, polyarthritis, and hypertension. Resident #15 requires transportation via wheelchair. Resident #15 noted to have Brief Interview Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. The incident occurred 1.1 miles from the facility at a traffic light. The determination of the Root Cause Analysis (RCA) is inconclusive. FTD #34 stated Resident #15 took her arms out of the seatbelts to look at her papers. Resident #15 denied removing her arms from the seatbelts and stated she just slid out. The investigation revealed FTD #34 did not follow the facility policy that he had previously been educated on by returning the resident to the facility verses calling 911 immediately. On 03/15/24 at 12:45 P.M., Resident#15 arrived back at the facility and was immediately assessed by Licensed Practical Nurse (LPN)/Unit Manager #37 and former DON #38. The resident was discovered on the floor of the van in front of her wheelchair. Resident #15 was lying on her left side with her head up and looking at the staff. Resident#15 had a laceration to her right knee with no other injuries noted at that time. Resident #15 stated she slid from her wheelchair and her right leg was hurting. On 03/15/24 at 12:46 P.M., Nurse Practitioner (NP) #62 was notified and ordered Resident #15 to be sent to the ER. On 03/15/24 at 12:46 P.M., 911 was called by LPN #39. On 03/15/24 at 12:50 P.M., former DON #38 notified Resident #15's family. On 03/15/24 at 1:00 P.M., EMS arrived at the facility and transported Resident #15 to the ER for further evaluation and treatment. On 03/15/24 at 1:15 P.M., former DON #38 and LPN #39 updated Resident #15's care plan to include: Send Resident #15 to the ER, wheelchair safety education for the resident, provide an escort for all transport/appointments and skin/laceration care. On 03/15/24 at 1:35 P.M., the Administrator ceased all transportation for in-house facility transports. On 03/15/24 at 1:45 P.M., the Administrator and former DON #38 interviewed FTD #34 and an investigation started regarding the entire incident and actions that transpired during the incident. On 3/15/24 at 2:00 P.M., a van inspection was completed by Maintenance Director #41 and no mechanical issues or malfunctions were discovered. On 03/15/24 at 2:00 P.M., FTD #34 was interviewed, and a written statement was obtained. FTD #34 received a final level Corrective Action Form conducted for failure to follow transportation protocol. FTD #34 was suspended as of 03/15/24 pending an investigation of the incident to allow for investigation, education, and ensure no other incidents had occurred. FTD #34 did not return to work and made no other transportation after this incident for the facility. On 03/15/24 at 2:00 P.M., the transportation policy was reviewed with the three staff members authorized to complete resident transports. Maintenance Director #41, Transportation Driver (TD) #30, and FTD #34. On 03/15/24 at 2:30 P.M., the designated facility TD will perform inspections for the transportation vehicle/equipment to ensure safe and functional operation every day prior to any transportation needs. These inspections are to be verified by Maintenance Director #41 after each inspection is completed for the next 30 days then the facility will transition to three times weekly for three months and then monthly ongoing. Should Maintenance Director #41 not be available to complete this verification, it will be performed by Regional Director of Maintenance #40/Designee. On 03/15/24 at 3:30 P.M., Central Supply Coordinator/Transportation Scheduler #31 conducted an audit of a 30-day lookback of all resident's transportation provided by facility to ensure no other incidents had occurred. No concerns were identified from this audit. On 03/15/24 at 4:00 P.M., Resident #15 was immediately switched to another transportation service. The Administrator secured an outside transportation company for all facility transports until further notice. All appointments were transferred to the outside provider. Beginning 03/15/24, to monitor for ongoing compliance, Maintenance #41/Designee will audit the facility van three times weekly for three months and then will perform inspections monthly ongoing to ensure the transportation vehicle/equipment is safe and functioning. Beginning 03/15/24, to monitor for ongoing compliance, Maintenance Director #41/Designee will audit via observations and return demonstrations of the facility transportation drivers weekly for one month and then monthly for three months to ensure residents are secured appropriately and safely. Beginning 03/15/24, to monitor for ongoing compliance, Maintenance Director #41/Designee will supervise one transportation run monthly for one year to ensure appropriate transportation methods are in place per the facility's policy. This was implemented on 3/15/24 and started on 03/26/24 when in-house transports were resumed. All results of the audits will be included in each QAPI with any findings. On 03/16/24 at 8:30 P.M., Resident #15 was transported back to the facility. Resident #15 sustained a laceration on her right knee and seven sutures were placed. All other imaging and diagnostics tests were negative. On 03/17/24 at 10:00 A.M., former DON #38 interviewed Resident #15 and received her verbal statement. Resident #15 stated she was riding in the transport van and when the driver (FTD #34) stopped, she slid out of her wheelchair. Resident #15 indicated she stayed on the floor of the van until the driver got back to the building and then she went to the hospital. Resident #15 was educated on safety during transports. On 03/19/24 at 10:00 A.M., Regional Director of Maintenance #40 conducted one-on-one (1:1) training, conducted competencies and check offs with a return demonstration with all three authorized transportation drivers (Maintenance Director #41, FTD #34 and TD #30) to ensure previous education was understood and to remain compliant with safety precautions. FTD #34 was not reinstated afterwards due to FTD #34 providing the facility with his resignation. Education included: Vehicle safety, Safety and Health Programs, Mandatory Transport Driver Training, Drivers Training Classroom Curriculum, Company Vehicle Driver Program (Fleet Safety Program), Safer Transportation of Wheelchair Passengers, Passenger Safety During Transport, New Driver Request Forms, Transport Staff Performance Agreement, Emergency Supplies Check list, Monthly Preventative Maintenance, and Quarterly Vehicle Inspection Reports and initiated immediately. The policy was reviewed again on 03/19/2024 by Regional Director of Maintenance #40 with the Administrator, Maintenance Director #41, FTD #34 and TD #30. Regional Director of Maintenance #40 conducted competencies and check offs with a return demonstration to ensure previous education was understood and to remain compliant with safety precautions. On 03/19/24 at 11:00 A.M., the transportation policy was reviewed by the Administrator. All facility transportation remained stopped and no new changes were implemented to the policy. All facility transports were being conducted by an outside provider. On 03/19/24 at 4:00 P.M., a Post Traumatic Stress Disorder (PTSD) screen was completed on Resident #15 and added to the care plan by Director of Social Services #66. The following new interventions were added: To assist and identify what triggers PTSD episodes, encourage slow/deep breathing exercises, reassuring conversation with pleasant topics, observe for increased agitation, anxiety, and offer quiet areas and comfort items, observe resident in group situations and prevent resident from becoming over stimulated, sudden unexpected noises, and new/tv programming may also trigger resident incident, offer quiet area, speak in calm quiet voices and offer reassurance. On 03/20/24 at 11:00 A.M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with attendees including: The Administrator, Former DON #38, Medical Director (MD) #64, LPN/Clinical Manager #70, Maintenance Director #41, LPN/Unit Manager #37, Central Supply Coordinator #31, LPN #39, [NAME] President of Risk Management #72, Regional Director of Clinical Operations (RDCO) #78, and Regional Director of Operations (RDO) #80 regarding this incident and discussion was held regarding transportation protocols and safety, falls, and steps the facility is taking moving forward to prevent further reoccurrence of the incident. On 04/02/24 at 11:00 A.M., the vehicle insurance company obtained a report of the incident and once the insurance started their investigation their findings were handled through the insurance. No results/findings have been returned to the facility. On 04/08/24, Resident #15 had an outside appointment at a physician's office and did not have any identified concerns during the transport via the outside provider. On 05/07/24 between 1:00 P.M. and 2:00 P.M., interviews with TDs #30 and #58 and Maintenance Director #41, each stated they were in-serviced and educated on properly transporting residents and are utilizing the complete Q'Straint system. On 05/08/24, review of four (#27, #50, #38 and #21) additional resident's medical records who required assistive devices for transportation revealed no concerns. On 05/08/24, review of the facility's Transportation Safety Audits including Inspections and Ride Along's revealed the audits were performed as scheduled from 03/15/24 through 04/26/24 with no issues identified. Findings Include: Review of medical record for Resident #15 revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, morbid obesity, fibromyalgia, disc degeneration, cerebral infarction (stroke), muscle weakness, severe spondylosis, gait abnormalities, chronic respiratory, polyarthritis, and wheelchair dependent for propelling. Review of the plan of care for Resident #15 dated 08/29/23 and revised on 03/20/24, revealed the resident had a self-care performance deficit related to weakness. Resident #15 required substantial/maximal assist with Activities of daily living (ADLs). Review of the personnel file for FTD #34 revealed he was hired on 01/02/24 and was provided with training on safe resident transports. On 03/15/24, FTD #34 failed to follow proper transportation protocols, was suspended, and received a final written warning due to safety/carelessness. FTD #34 resigned his position on 03/19/24. Review of a facility document tiled Driver Essential Competencies assessment dated [DATE], revealed FTD #34 completed a competency assessment and met all requirements to complete the task of transportation and skills were observed by Regional Maintenance Director #40. Review of a facility document titled Appointment /Transportation Request Form dated 03/12/24 for Resident #15, revealed the resident had a follow-up physician appointment on 03/15/24 at 1:45 P.M. Resident #15 was going by a standard wheelchair in the facility's van. Review of the facility's timeline of events revealed on 03/15/24 at approximately 12:30 P.M., Resident #15 was placed in the facility's van by FTD #34 for a routine physician's appointment. FTD #34 reported that Resident #15 fell from the wheelchair during transport. At 12:45 P.M., the van arrived back at the facility and Resident #15 had remained on the floor and was immediately assessed. Resident #15 had complaints of generalized pain, with more specific complaints of pain to the right hip, neck, shoulders, and sustained a laceration to the right knee. Review of a written statement by FTD #34 dated 03/15/24, revealed at 12:40 P.M., he placed Resident #15 in the facility van. All four tie downs were securely placed on the wheelchair. FTD #34 checked the wheelchair, and it would not move, and then placed the seatbelt across Resident #15's waist and made sure she was properly secured. FTD #34 departed the facility at 12:45 P.M., heading to the resident's doctor appointment. He turned left out of the driveway heading towards State Route 32. Resident #15 requested to see her paperwork in the envelope due to her questioning the time of her appointment. FTD #34 was at a complete stop at a stop sign right outside the facility and handed Resident #15 her paperwork. FTD #34 assured the resident that he had the correct time. FTD #34 was watching the road, the light went from yellow to red, he applied the brakes and stopped at the red light in the right lane. FTD #34 glanced in the rearview mirror and observed Resident #15 sliding under the seat belt and making contact with the floor. FTD #34 immediately pulled over to the side of the road and asked Resident #15 if she was hurt and immediately turned around and went back to the facility. Once he returned to the facility, FTD #34 had the receptionist contact the nurse and the Administrator to come to the van. Review of a progress note dated 03/15/24 at 12:45 P.M. and recorded as a late entry by former DON #38, revealed Resident #15 had a fall from her wheelchair inside the transport van. Resident #15 complained of pain and was sent to the ER. Review of a facility document titled Fall Occurrence revealed on 03/15/24 at 12:45 P.M., resident had an observed fall off the premises while being transported. Resident #15 was found on her back/right side near the wheelchair in the transport van. Review of a progress note dated 03/15/24 at 12:56 P.M. and recorded as a late entry by former DON #38, revealed FTD #34 reported Resident #15 fell from her wheelchair while being transported to an appointment. The resident had head and skin injuries from a witnessed fall. Resident #15 complained of generalized pain, specific to right hip, neck, and shoulder, and had a laceration to her right knee. The Nurse Practitioner (NP) was notified and ordered to send the resident to the ER. EMS arrived and transported the resident to ER. Review of a Post Fall Evaluation dated 03/15/24 at 12:56 P.M. for Resident #15 and authored by former DON #38, revealed the resident had a witnessed fall on 03/15/24 at 12:45 P.M. while being transported in the facility's van by FTD #34. The resident was assessed to be at a high risk for falls. The resident was found inside the van lying on her right side, arms down to the side, right leg turned outward, and left leg was straight and one foot away from the wheelchair. The assessment revealed the resident had contusion and a gash to the back of the head and skin injuries. Resident #15 complained of pain at a six out of 10 (pain scale where zero is none and 10 is severe) in the back of her head, neck, right hip, and right knee which had bruising. The resident was sent to the ER. The root cause of the fall was determined to be resident positioning in wheelchair and diminished safety awareness and required assistance with ambulation/wheelchair. Interventions to prevent future falls included educating the resident and FTD #34 on wheelchair safety during transports. Review of the EMS run report dated 03/15/24 revealed upon EMS arrival at 1:00 P.M., Resident #15 was found in the transport van in front of the building in a semi-reclined position, alert and oriented, with complaints of right hip pain, head pain, and right knee pain. Resident #15 stated she fell out of her wheelchair during transport and the driver turned around and drove back to the nursing home after she became unsecured from the wheelchair. Resident #15 was assessed to have right knee pain with skin tear and a skin tear on right wrist and small hematoma on back of the right side of her head. Review of the hospital records dated 03/15/24 at 1:36 P.M. for Resident #15, revealed the resident was evaluated for complaints of a fall and neck pain secondary to being flung out of her wheelchair at a stoplight while in her Skilled Nursing Facility (SNF) transport vehicle which stopped suddenly at a traffic light. Resident #15 presented to the ER with neck pain, back pain, pain in her left mastoid area, right knee pain, headache, right arm pain, right dorsal forearm laceration and a laceration on her right knee. Resident #15 reported she hit the left side of the back of her head as well as her neck. The clinical impressions included laceration to resident's right knee which required seven sutures, a fall and cervicalgia (pain in or around your cervical spine). Resident #15 was discharged back to the facility on [DATE] at 7:24 P.M. with orders to follow-up with her physicians. Review of the Transportation Van/Bus Safety Inspection dated 03/15/24 and completed by Maintenance Director #41 after the incident involving Resident #15's fall, revealed the vehicle and all restraints were in proper working order with no malfunctions. Review of the Incident Log revealed on 03/15/24, Resident #15 had a fall. Review of a progress note dated 03/16/24 at 9:05 P.M. for Resident #15, revealed the resident returned from the hospital. Resident #15 received seven sutures to her right knee. The resident reported pain of seven (zero to ten pain scale where zero is no pain and 10 is severe pain). Review of a NP progress note dated 03/17/24 at 3:53 P.M. for Resident #15, authored by NP #62, revealed the resident complained of body pain and spasms. Resident #15 stated she had muscle spasms and increased pain since falling in the transport van and being treated at the ER. Resident #15 received sutures in her scalp and right knee. Resident #15 was diagnosed with acute pain due to trauma and received new orders for Tylenol every four hours and Robaxin (muscle relaxer) 750 milligrams (mgs) three times daily as needed. Review of a progress note dated 03/17/24 at 4:32 P.M. for Resident #15, revealed the on-call provider was notified due to the resident complaining of uncontrolled pain all over and decreased range of motion to both arms resulting in resident needing assistance with feeding. Orders were to continue Tylenol and Robaxin. Review of a NP progress note/post hospital note dated 03/18/24 at 2:29 P.M. for Resident #15, authored by NP #62, revealed the resident fell out of her wheelchair in the van. The resident was assessed with continuing pain, has seven sutures in right knee, and bruising on hands and face. Orders were to continue Tylenol and Robaxin. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact and required extensive assistance with all activities of daily living (ADLs). Interview with Transport Driver (TD) #30 on 04/30/24 at 9:35 A.M., revealed the staff would normally secure a resident's wheelchair to the van using the Q'Straint system (a system of four-point securement device with retractors or manual belts along with occupant securements [passenger lap and shoulder belts] and four separate anchor points on the floor of the vehicle) but they used the van's manufacturer's installed shoulder/lap belt to secure residents to their wheelchairs. TD #30 reported the facility implemented the Q'Straint system shoulder and lap restraints after the incident on 03/15/24 involving Resident #15 which provided more safety and security with securing residents to their wheelchairs. Interview with Resident #15 on 04/30/24 at 10:31 A.M., revealed when FTD #34 came to her room to get her, he was rushing her telling her to hurry up and they had to go. Resident #15 stated she told him there was plenty of time and his response was I got things to do. Resident #15 stated he put her in the van and as they took off, she asked for her folder with her medical information and FTD #34 handed it to her. Resident #15 stated FTD #34 was driving really fast, and as she was looking at her appointment paperwork, FTD #34 stopped so hard that the force of the stop, brought her to an almost standing position and on her way back down into the wheelchair, she slipped beneath the seat belt which did not lock when the van was stopping. Resident #15 stated that she was lying on her right side and her head was on the floor, and when FTD #34 asked if she was ok, she said no and wanted to go to the hospital. Resident #15 stated FTD #34 drove back to the facility while she was lying on the floor and her head was hitting the floor. Resident #15 stated she asked FTD #34 to stop but he did not and continued to drive back to the facility. Resident #15 stated the paramedics arrived at the facility and took her to the hospital. Telephone interview with FTD #34 on 04/30/24 at 2:16 P.M., revealed on 03/15/24 at approximately 12:30 P.M. he took Resident #15 out the front door and as he was putting the resident in the van, she was fixated on her appointment time. FTD #34 stated he used the four-point system that secured the resident's wheelchair in place to the van and the vehicles lap/shoulder belt to secure resident in the wheelchair. FTD #34 stated he was approximately one mile from the facility, when he stopped for a traffic light and when he looked back, Resident #15 had slid out of her wheelchair and onto the floor. FTD #34 stated he immediately pulled over to ask the resident if she was ok and Resident #15 stated her leg hurt. FTD #34 stated he did not move the resident from the floor for fear she may have other injuries, so he got back in the van and drove back to the facility, ran into the facility, and had the receptionist call the Administrator and the nurse. FTD #34 stated that staff came out to the van and started providing care to Resident #34. Interview with the Administrator on 04/30/24 at 2:30 P.M. revealed on 03/15/24 at approximately 12:30 P.M., FTD #34 left the facility with Resident #15 for a medical appointment. FTD #34 then returned to the facility at approximately 12:45 P.M., came into the facility and stated he needed a nurse and stated Resident #15 had fallen. The Administrator had the receptionist call 911, Licensed Practical Nurse (LPN) #37 grabbed the treatment cart and ran outside to the van with State tested Nursing Assistant (STNA) #36 to assist Resident #15. The Administrator stated when he got to the van, Resident #15 was observed laying on the floor of the van with laceration to her right knee. Resident #15 stated she wanted help getting up. The Administrator stated LPN #37 walked out with him and assessed the laceration and LPN #39 also came to help while he went to get the treatment cart. The Administrator reported that FTD #34 stated the resident took her arms out from under the seatbelt and the next thing he knew, the resident was on the floor. The Administrator stated FTD #34 failed to properly apply the seatbelt system for Resident #15. Interview with MD #64 on 04/30/24 at approximately 3:00 P.M. revealed he was informed about the incident involving Resident #15 and was okay with the facility calling 911. Observation of the van restraint system and demonstration on how Resident #15 was secured in the van on 05/07/24 at 12:08 P.M. with TDs #30 and #58, revealed Resident #15 was pushed in the van through the rear of the van and the wheelchair was secured using the Q'Straint system. The shoulder/lap belt that was installed by the van's manufacturer was then placed through the opening of the wheelchair's armrest and across the resident's waist and then fastened to an extended strap with a buckle pushed through the opening of the back of the wheelchair which was attached to the floor Q'Straint device. Observation revealed the van's shoulder portion of the seat belt would be across the resident's middle part of her upper left arm and the lap belt was very loose across the resident's lap. TD #30 stated at the time of the incident, the facility was only utilizing the Q-Straint system for securing the wheelchair and not for securing the residents in their wheelchairs. Review of the Q'Straint manufacturer instructions for use, revealed to secure a passenger, attach lap belts using the integrated stiffeners to feed the belts though openings between the seat back and bottoms and/or armrests to ensure proper belt fit around the occupant. The most common way of securing a wheelchair passenger is a four-point securement, which consists of four tie-downs (retractors or manual belts), along with occupant securements (passenger lap and shoulder belts), and four separate anchor points attached to the vehicle's floor. On the aisle side, attach belt with the female buckle to rear tie down pin connector ensuring buckle rests on passenger's hip. On the window side, attach belt with male tongue to rear tie down pin connector and insert into the female buckle. Attach shoulder belt by extending shoulder belt over the passenger's shoulder and across upper torso and fasten pin connector onto lap belt. Ensure belts are adjusted as firmly as possible but consistent with user comfort. Warning note indicated lap and shoulder belts should not be held away from passengers' body by wheelchair components or parts such as the wheelchairs wheels, armrests, panels, or frame. Review of an undated facility policy titled Resident Transport-Drivers revealed transport drivers would ensure a safe transport for residents, passengers and individuals operating any company motor vehicles while on company business. Additionally, drivers are to ensure operation of the vehicle and any components is as specified by the facility's vehicle use protocols and according to the manufacture guidelines. Loading, transporting, and unloading residents' safety from origin to destination, and if an incident occurs while on the road (i.e., resident slips out of wheelchair, becomes ill or distressed, or other unplanned events) immediately get off road to a safe spot, dial 911 and contact the nursing home and assist/comfort the resident until help arrives. This deficiency represents non-compliance investigated under Complaint Number OH00153374.

Based on medical record review, review of the hospital records, staff interview, review of the facility investigation, review of the incident log, review of the witness statement, and policy review, the facility failed to ensure residents were free from significant medication errors. This resulted in Actual Harm when Licensed Practical Nurse (LPN) #30 administered Resident #02 another resident's medication and subsequently Resident #02 was admitted to the hospital with an acute kidney injury and [CONDITION(S)]. The facility census was 84. Finding include: Review of the medical record revealed Resident #02 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #02 was discharged to the hospital on 08/13/22 and then went to a different facility. Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed the Resident #2 had moderate to severe cognitive deficits, required extensive assistance with activities of daily living, and was frequently incontinent of bowel and bladder. Review of the incident note dated 08/13/22 at 2:55 A.M. revealed a medication error performed on 08/12/22 at 8:30 P.M. revealed Resident #02 received [MEDICATION(S)] two milligrams (mg) (a benzodiazepine), [MEDICATION(S)] 100 mg (a beta-blocker), [MEDICATION(S)] (a medication for [CONDITION(S)]) 200 mg, [MEDICATION(S)] 750 mg (a medication for [CONDITION(S)]). When the nurse realized the medication error was made, the Licensed Practical Nurse (LPN) #30 checked Resident #02's vital signs and they were recorded as a blood pressure of 98/87 millimeters per mercury (mmHg), pulse 65 beats per minute, oxygen saturation 96 percent, temperature was 97.1 Fahrenheit, and respirations were 16 breaths per minute. LPN #30 attempted to contact the Director of Nursing (DON) and received no response. LPN #30 reported the incident immediately and was given an order from the on-call Nurse Practitioner (NP) #32 to start intravenous (IV) fluids half strength normal saline (NS) at 100 milliliters (ml) an hour times one liter (L) in six hours and check Resident #02's blood pressure every hour. LPN #30 attempted to start IV and the facility had no needle to start the infusion, so she contacted dynamic infusion therapy to have the company come out and start the IV, however there were two patients ahead of Resident #02. LPN #30 again checked Resident #02's vitals at 9:30 P.M. and they were as follows: blood pressure 92/64 mmHg, pulse 76 beats per minute, and oxygen saturation was 96 percent. At 10:40 P.M., LPN #30 rechecked Resident #02's vital signs and they were recorded as a blood pressure 82/58 mmHg, pulse 72 beats per minute and Resident #02 was not responding verbal or tactile stimuli. LPN #30 immediately called NP #32 and left a voicemail. NP #32 called back four minutes later and ordered to send Resident #02 to the hospital. LPN #30 called nine-one-one (911) and emergency medical services (EMS) arrived onsite and were given a report of the incident and EMS attempted to orient Resident #02 without success, so they transferred Resident #02 to the local emergency room . The LPN #30 talked to the hospital staff and was made aware Resident #02 had been admitted . Review of incident log dated from 07/11/22 through 08/22/22 revealed there was a medication error on 08/12/22 at 8:20 P.M. which required Resident #02 to go to the hospital. Review of the investigation timeline of medication error revealed LPN #30 prepared and administered medications prescribed for Resident #01 and administered them to Resident #02 on 08/12/22 at 8:15 P.M. At 8:20 P.M. LPN #30 realized the medication error and called the on-call physician group and obtained vital signs. At 8:25 P.M. LPN #30 continued with medication pass for the rest of 300/400 hall without starting IV fluids. At 10:20 P.M. Resident #02's Power of Attorney (POA) was made aware of the medication error and the new orders for IV fluids. At 10:30 P.M. called access to schedule their company to come place IV for Resident #02. The local company access stated there were two patients ahead of Resident #02. At 10:40 P.M. rechecked Resident #02's blood pressure which was 82/58 mm/Hg and told the on-call the IV was not placed. At 10:49 P.M. the on-call NP #32 gave an order to send Resident #02 to the emergency room for an evaluation. Resident #02 was taken to the emergency room for an evaluation. Review of the hospital records dated 08/13/22 revealed Resident #02 was accidentally given the wrong medications at the facility including a benzodiazepine, antiepileptic drugs, and beta-blockers. It was reported Resident #02 was given [MEDICATION(S)] two mg, [MEDICATION(S)] 100 mg, [MEDICATION(S)] 200 mg, and [MEDICATION(S)] 750 mg. Resident #02's POA did not want Resident #02 on mechanical ventilation despite a Glasgow Coma Scale (GCS) of six which was severe. Resident #02 continued spontaneously respirations but was not managing airway. Continued supplemental oxygen and supportive care, hold all narcotics, sedatives, hypnotics, or anxiolytics, support the low blood pressure with IV fluids as needed, refrain from using [MEDICATION(S)] (antidote to benzodiazepine) to reverse the benzodiazepine due to the risk of a [CONDITION(S)], which could potentially worsen the clinical status. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #02's [CONDITION(S)] was likely due to the beta-blocker and benzodiazepine. Review of the statement given by LPN #30 revealed she gave Resident #02 the wrong medications. LPN #30 stated she had not asked the residents their names and had not really looked at the photos in the electronic medical record (EMR). LPN #30 stated Resident #01 and Resident #02 were alert and oriented and talked to her. LPN #30 stated she knew the six rights of medication administration (right resident, right drug, right dose, right route, right time, and right documentation). LPN #30 stated she called the on-call, and they told her to start an IV, but LPN #30 stated she did not because she had to finish her medication pass, then LPN #30 called the IV company, but they were already booked with two people, and it would be a while. LPN #30 stated she looked around the nurse's station for the IV equipment but found none and had not checked the medication room. Interview on 08/23/22 at approximately 11:15 A.M., the DON verified LPN #30 administered Resident #01's medication to Resident #02 resulting in a medication error and admission to the hospital. A telephone interview on 08/23/22 at 12:50 P.M., was attempted with LPN #30, however she had not answered the telephone or returned the call. Review of the policy titled Medication Administration, dated 01/05/22 revealed prior to administering medications identify the resident by picture and stated name by resident, and observe the five rights: the right resident, the right time, the right medication, the right dose, and the right route. This deficiency substantiates Master Complaint Number OH 165 and Complaint Number OH 731.

Based on medical record review, observations, interviews with staff and residents, review of hospital records, review of a facility investigation/staff statements, review of a weather report, and review of facility policy, the facility failed to assess and develop a care plan regarding the cognitive status, wandering or elopement risk factors, and level of supervision for Resident #06, resulting in the resident eloping from the facility without staff knowledge. This resulted in Immediate Jeopardy with the potential for serious life-threatening harm, injuries, and/or death on [DATE] at approximately 7:15 P.M. when Resident #06 eloped from the facility without staff knowledge and was found by Licensed Practical Nurse (LPN) #140 who was driving through the parking lot of the facility on [DATE] with her family and spotted Resident #06 lying outside the door on the ground. Resident #06 was assessed and complained of pain to the left arm and was transferred to the hospital for evaluation and treatment. Resident #06 returned from the hospital with a diagnosis of a closed displaced fracture of the tuberosity of the left humerus. Additionally, the facility failed to conduct a thorough investigation of Resident #06's elopement to prevent the same action, situation, and/or practice from occurring in the future. This affected one (#06) out of three residents reviewed for elopements. The facility's census was 90. On [DATE] at 10:37 A.M., the Administrator was notified Immediate Jeopardy began on [DATE] at approximately 7:15 P.M. when Resident #06 eloped from the facility without staff knowledge. LPN #140 was off duty and was driving through the parking lot of the facility with her family on [DATE] at approximately 7:27 P.M. and spotted Resident #06 lying outside the door on the ground wearing a hospital gown and adult brief. The temperature outside was 57 degrees Fahrenheit (F). LPN #140 reported Resident #06 was shivering and appeared weak but insisted on standing. LPN #140's spouse obtained a wheelchair and escorted Resident #06 in a wheelchair inside the Assisted Living (AL) facility which was attached to the nursing home where the resident resided. STNA #69 was inside the AL facility and stated she knew which unit Resident #06 resided on. STNA #69 assisted Resident #06 back to the rehabilitation unit in the nursing home. Staff were unaware Resident #06 was gone until STNA #69 brought the resident back to his unit. LPN #130 assessed Resident #06 when he got off the elevator. LPN #130 reported this was at approximately 8:00 P.M. LPN #130 stated as she was returning Resident #06 to his room, and she overheard the door alarm to the stairwell alarming. LPN #130 observed Resident #06's wheelchair at the top of the stairwell in a locked position. Resident #06 was transferred to the hospital approximately 1.5 hours after the incident on [DATE] and returned to the facility on [DATE] at 6:59 P.M. with a diagnosis of non-displaced fracture of the greater tuberosity left humerus. Additionally, the facility failed to conduct a thorough investigation of Resident #06's elopement to prevent the same action, situation, and/or practice from occurring in the future. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], LPN #130 completed a head-to-toe assessment on Resident #06 and the resident was sent to the hospital for evaluation and treatment per physician orders. · On [DATE], nursing staff completed a whole facility head count to ensure all residents were located inside the facility. Employee statements were obtained from all employees working. Maintenance Supervisor (MS) #23 came to the facility and assessed all doors for proper function and to ensure they were secure. · On [DATE], a wandering/elopement risk UDA (user defined assessment) was completed by Unit Manager #102 on all residents on the unit. · On [DATE], after returning from the hospital, Resident #06 was placed on one-on-one supervision. · On [DATE] at approximately 5:00 P.M., Resident #06 had a room change to a room that was not near an exit door and one-on-one supervision was discontinued. · On [DATE] at approximately 9:00 A.M., the one-on-one supervision resumed for Resident #06 due to wandering behaviors. Resident #06 will continue one-on-one supervision until placed in a facility more appropriate to meet the needs of the resident or until the resident discharges home. · On [DATE], the Director of Nursing (DON) and Unit Manager #102 began education with all staff regarding elopement risk, elopement behavior and proactive preventative measures using the policy for elopement prevention, what to do when you hear an alarm, importance of responding to alarms and promptly responding to door alarms. Education was completed on [DATE]. · On [DATE], a wander/elopement assessment has been completed by the DON on all residents to identify any residents that are at risk. Any resident identified at risk had their plan of care updated with interventions to prevent elopement by Minimum Data Set (MDS) Nurse #12 and #21 and each resident's information has been added to the facility's elopement binder by Unit Manager #102. · On [DATE], elopement drills were completed on all shifts on [DATE] by MS #23 and Unit Manager #102. Staff were knowledgeable on the elopement policy and no concerns were identified. · On [DATE], Regional Maintenance Director #211 installed additional speakers on corridor exit doors to enhance alarm sounds. · The DON/designee will review all new admissions wander/elopement assessments to identify residents at risk. The DON/designee will review all new admissions for diagnosis of dementia, Alzheimer's, and altered mental status prior to admission to ensure resident is initially placed in the elopement binder on admission. Residents admitted at risk for elopement will have an individualized plan of care created with the residents' risk for elopement and interventions to prevent elopement. · The DON/designee will review all residents with a change in condition to identify if they are exhibiting new elopement risk factors. · The facility will monitor weekly through elopement drills the response to sounding door alarms for 90 days. This will be an on-going practice for the facility. The DON or designee will report to the Quality Assurance Performance Improvement (QAPI) committee findings related to the residents and family interviews and the QAPI committee will determine when compliance is achieved or if on-going monitoring is required. · On [DATE] from 4:46 P.M. to 06:18 P.M., interviews with LPN's #96 and #103, and STNA's #150 and #200 verified they received elopement training and how to respond to an elopement, participated in an elopement drill and were knowledgeable of the facility's elopement policy. · Medical record reviews for two (#25 and #26) additional residents identified at risk for elopement were conducted. Review of Resident #25 revealed the facility failed to assess the resident upon admission regarding wandering behaviors. During the survey, the elopement risk assessment was completed for Resident #25 and no further elopement concerns were identified. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #06's medical record revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], dehydration, Alzheimer's disease, amnesia, spondylosis, [CONDITION(S)], hypertension, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and cognitive communication deficit. Review of Resident #06's five-day MDS assessment, dated [DATE], revealed Resident #06 had impaired cognition as evidenced by his Brief Interview for Mental Status (BIMS) score of eight out of 15. Further review of the MDS assessment revealed Resident #06 required extensive assistance from staff with bed mobility and toilet use. Resident #06 required limited assistance from staff with transfers, walking on the unit, and personal hygiene. Resident #06 required supervision from staff with eating his meals. Review of Resident #06's initial assessment completed on [DATE] revealed he was not an elopement risk upon admission to the facility. Review of Resident #06's medical record revealed the following: · On [DATE], Resident #06 had noted confusion, he was standing in the room without clothes on with feces in his hands and various places within his room. · On [DATE], Resident #06 was noted to have increased confusion and hallucinations. · On [DATE] at 12:45 A.M., Resident #06 experienced a fall in the hallway outside of his room. · Review of Resident #06's occupational notes dated [DATE] at 12:17 P.M., revealed Resident #06 was seated in his wheelchair in the hallway by a window looking for a license plate. · On [DATE] at 1:37 P.M., the speech therapist reported Resident #06 continued to exhibit extreme confusion related to a suspected Urinary Tract Infection ([CONDITION(S)]). · Review of the physician orders dated [DATE] at 3:22 P.M., revealed Resident #06 received a new order for [MEDICATION(S)] 100 milligrams (mg) orally twice daily for 14 days for a possible [CONDITION(S)]. · On [DATE] at 8:37 P.M., an STNA notified the nurse Resident #06 was found on the ground outside of the Assisted Living doors. Resident #06 is unsure what made him fall currently. · On [DATE] at 4:40 P.M., Resident #06 returned from the hospital with orders to follow up with orthopedic surgeon. Further testing was completed, and Resident #06 did not have a [CONDITION(S)]. Resident #06 was diagnosed with a closed non-displaced fracture of greater tuberosity left humerus. Review of the hospital records for Resident #06, dated [DATE], revealed the hospital determined his urinalysis revealed no signs of a [CONDITION(S)]. Further review of the hospital records revealed an x-ray of the shoulder does potentially reveal proximal humerus fracture that is nondisplaced. Resident #06 will be placed in a sling and provided with orthopedic referral for definitive management. Resident #06 was transferred back to the facility. Review of the orthopedic surgeon follow up visit on [DATE] for Resident #06 revealed the resident had a diagnosis of closed displaced fracture of greater tuberosity of left humerus. The overall alignment of the fracture is good, and the orthopedic surgeon can try to treat the fracture non-operatively in a sling to the left shoulder, no heavy impact activities and gentle range of motion. The risk of nonunion and/or malunion was discussed. Plan for Resident #06 is to follow up in six weeks and may consider cortisone infection to the left shoulder. Review of the facility investigation file for Resident #06's elopement revealed the following: · Review of the statement from STNA #41 revealed she did not hear an alarm until she was entering a room around 8:00 P.M. on [DATE] and Resident #06 had returned to the unit. · Review of the statement from LPN #100 revealed the last time she saw Resident #06 was on [DATE] at 7:30 P.M. by his room. · Review of the statement from LPN #130 revealed Resident #06 had been seen wheeling himself up and down the unit. LPN #130 reported she saw the resident last at 7:30 P.M. LPN #130 reported Resident #06 was redirected to the rehabilitation unit by the west nurse station nurse (LPN #100) after the nurse found him on that unit. LPN #130 reported at approximately 8:00 P.M. she witnessed the assisted living aide pushing Resident #06 in a wheelchair out of the elevator. LPN #130 wrote Resident #06 reported he took the stairs downstairs. The assisted living aid (STNA #69) reported someone pushed him into the assisted living and reported he fell outside the assisted living doors. LPN #130 reported as she walked toward a room, she could hear the alarm sounding and found Resident #06's wheelchair in a locked position at the top of the stairwell. LPN #130 wrote Resident #06 left the unit around 7:35 P.M. to 7:45 P.M. after nurse report. · Further review of the elopement investigation revealed it did not include a statement from MS #23 or STNA #69. The investigation did not contain information to determine who found Resident #06 outside or a statement from LPN #140. The investigation did not contain information regarding an investigation on how the resident eloped or the path Resident #06 took during the elopement. On [DATE] at 8:34 A.M., an interview with the Administrator confirmed Resident #06 had an elopement on [DATE] at shift change. The Administrator stated Resident #06 was placed on one-on-one supervision following the elopement and then moved to another hallway. The Administrator stated Resident #06 came off the one-on-one supervision because there is only one exit where he was moved to, and it is to a secured courtyard. The Administrator stated when Resident #06 eloped the alarms were heard, and the resident was missing for approximately 30 minutes. The Administrator stated Resident #06 was found downstairs outside the main doors under the portico. The Administrator stated Resident #06 should be moved to a secured unit; however, the facility cannot reach the wife of Resident #06 because she would not answer a call. Interview on [DATE] at 9:23 A.M., interview with Activity Aide (AA) #28 who was sitting outside Resident #06's doorway revealed she is helping with the one-on-one supervision because Resident #06 wanders at night. AA #28 stated she believes Resident #06 has sundowners. AA #28 confirmed the door across the hall of Resident #06's room is not a secured door, and it leads to a courtyard. AA #28 stated the courtyard door is not secure; however, the courtyard is secured. AA #28 reported Resident #06 moved from the rehabilitation unit to the current room due to a recent elopement. On [DATE] at 11:47 A.M., observations of the room where Resident #06 resided the evening of the elopement on [DATE] were made with the DON. The DON stated Resident #06 turned right out of his room and wheeled his wheelchair down the hall a few feet and pushed on the stairwell alarm until it opened, a total of 15 seconds. The DON confirmed the alarm went off and the alarm remained on while Resident #06 exited through the doorway to descend the two flights of metal steps. The DON reported Resident #06 left his wheelchair at the top of the two flights of steps, 24 steps total, and exited through the next set of alarmed doors (the second set of alarming doors required to be pushed on for 15 seconds). The DON then reported Resident #06 walked through another set of unalarmed doors in the AL facility and was found on the ground outside of the AL. During the observation, two cameras were noted on the outside of the building; however, the DON stated the cameras do not work and have not been used since the new company took over the facility. Interview on [DATE] at 12:20 P.M. with Resident #06 revealed he was seated in his wheelchair in the activity room. Resident #06 was alert and oriented with mild confusion. Resident #06 stated he recently tried to walk down several steps. Resident #06 stated he fell down the steps and landed on his shoulder. Resident #06 reported that he hit the side of his head under his eye. Resident #06 stated he ended up outside. Resident #06 stated he fell two or three other times since he was admitted to the facility. Interview on [DATE] at 3:17 P.M. with MS #23 revealed he was called on the evening of [DATE] regarding Resident #06's elopement and was asked to test all the doors. MS #23 stated he arrived at the facility on [DATE] at 10:30 P.M. MS #23 reported all the doors were working correctly when tested . MS #23 confirmed if someone pushed the egress door for 15 seconds until it opens it will continue to alarm until the door is turned off by entering a code. Interview on [DATE] at 4:11 P.M. with STNA #69 regarding Resident #06's elopement on [DATE], revealed she was taking out the assisted living trash and a man walked through the glass doors with Resident #06 in a wheelchair. STNA #69 stated the man reported he found someone that may belong to them as he was pointing at Resident #06. STNA #69 stated she told the man she knew who Resident #06 was and right where the resident lived and guided the chair toward the elevator. STNA #69 reported she was not thinking and should have ask this man more questions. However, STNA #69 stated she was working one evening and helping with a one-on-one supervision for Resident #06 when she met LPN #140. STNA #69 told her the story of Resident #06's elopement and LPN #140 reported the man who found him was LPN #140's spouse. On [DATE] at 4:45 P.M. interview with LPN #140 revealed she was off-duty, and she was driving through the parking lot of the facility on [DATE] at 7:27 P.M. with her family and spotted Resident #06 lying outside the door on the ground. LPN #140 reported the door where Resident #06 was found outside of was brown and did not have a handle to re-enter the facility. LPN #140 reported to the left of the door, was the set of glass doors which were the main entrance to the AL. LPN #140 reported Resident #06 was lying on the ground wearing a hospital gown and adult brief. LPN #140 stated it was chilly outside and Resident #06 was shivering. LPN #140 reported Resident #06 insisted on standing; however, he was weak. LPN #140's spouse obtained a wheelchair from inside the facility and transported Resident #06 through the main doors of the AL. STNA #69 was inside the AL and LPN #140's spouse explained he found Resident #06 on the ground outside the facility. STNA #69 returned Resident #06 to his unit. On [DATE] at 4:55 P.M., Regional Operations Manager (ROM) #600, Regional Nurse (RN) #110, the DON, and Administrator were interviewed regarding Resident #06's elopement and the investigation. ROM #600, RN #110, the DON and Administrator walked back to Resident #06's former room on the rehabilitation unit. The observations revealed Resident #06 turned left (not right) out of his room and wheeled himself down a very long hallway and entered the dining room. The dining room had an alarmed door at the top of the stair well. The Administrator pushed on the door for 15 seconds and the alarm continued to sound. The group walked down the two flights of steps, a total of 24 metal steps. At the bottom of the steps there was an alarmed door to the AL facility straight ahead; however, to the right, was a brown exit door that was not alarmed. The group walked out the brown exit door. The door closed behind the group. The brown door did not have a handle to re-enter the facility. While facing the brown door, to the left, were the large glass doors and this was the main entrance to the AL. The DON and the Administrator confirmed the facility did not thoroughly investigate Resident #06's elopement as they did not obtain statements from MS #23, STNA #69 or LPN #140. The DON and Administrator confirmed the investigation did not contain information to determine who found Resident #06 laying outside and/or there was no further information regarding an investigation on how the resident eloped or the path Resident #06 traveled during the elopement. Interview on [DATE] at 6:47 P.M. with STNA #41 revealed she was the STNA for Resident #06 on the evening of the elopement on [DATE]. STNA #41 reported the evening of the elopement was very busy with call lights going off. STNA #41 reported she remembered Resident #06 sitting in the dining room in his wheelchair at one point. STNA #41 stated she remembered watching the elevator door opening and seeing Resident #06 in his wheelchair being pushed by the assisted living aide. STNA #41 stated Resident #06 told her and LPN #130 he took the steps and fell . STNA #41 stated she did not believe he took the steps because Resident #06 is alert with confusion; however, they did find he had scrapes on his knee and elbow. STNA #41 stated she was walking with LPN #130 and Resident #06 back toward his room when she heard the stairwell alarm sounding. STNA #41 reported her first thought was that must have been Resident #25 pushing on the door. STNA #41 reported Resident #25 would push on the doors until the alarm went off so often, that she associated the sound of the alarm with Resident #25; however, when STNA #41 and LPN #130 reached the stairwell, they found Resident #06's wheelchair at the top of the step with the wheels in a locked position and the door alarm was continuing to alarm. STNA #41 confirmed Resident #06 was wearing a hospital gown and an adult brief. STNA #41 reported Resident #06 was in a gown because he tended to get messy. Interview on [DATE] at 7:34 P.M. with LPN #130 confirmed she was the nurse on duty the night of Resident #06's elopement on [DATE]. LPN #130 reported she completed her medication count and transfer of information with the day nurse around 7:45 P.M. LPN #130 reported she watched the elevator door open, and the AL facility aide (STNA #69) was pushing Resident #06 in a wheelchair. LPN #130 confirmed Resident #06 was wearing a hospital gown. LPN #130 stated STNA #69 reported a visiting family member found Resident #06 outside and brought him to her in the AL main doors. LPN #130 stated Resident #06 told her he left through the steps and fell . LPN #130 reported his knee and arm with scraped. LPN #130 reported she assessed Resident #06 and began to walk him back to his room with STNA #41 and heard the alarm in the stairwell going off. LPN #130 stated the stairwell was in the dining room. LPN #130 reported the alarm was sounding and Resident #06's wheelchair was parked at the top of the stairwell in a locked position. LPN #130 reported she had the facility complete a head count to ensure no other resident was missing. LPN #130 reported Resident #06 was guarding his left arm and reported pain about one and half hours after finding him. LPN #130 contacted the physician, and the physician was going to order a stat (immediate) x-ray; however, the ultimate decision was to send Resident #06 to the emergency room (ER) for evaluation and treatment. LPN #130 stated she was not aware of Resident #06 wandering to the north nurse's station earlier in the evening on [DATE] until it was reported to her after the elopement. LPN #130 reported she thought she should add that to her statement because it was important. LPN #130 stated the physician was upset the Nurse Practitioner had ordered an antibiotic without obtaining a urinary analysis and this was another reason the physician chose to send Resident #06 to the ER for evaluation. Review of the weather report from wunderground.com revealed on [DATE] at 7:59 P.M. it was 57 degrees F outside. Review of the facility policy titled, Elopement Management, dated [DATE], revealed Centers for Medicare & Medicaid Services (CMS) defines elopement as when a resident/patient leaves the premises or a safe area without authorization and or necessary supervision. Review of the facility policy titled, Elopement Overview, dated [DATE], revealed the facility will identify residents who are at risk for elopement. This deficiency substantiates Complaint Number OH 454. This deficiency represents ongoing noncompliance from the survey dated [DATE].

Based on closed medical record review, interviews with facility staff, review of the facility neurological checks post fall, review of hospital records, and review of facility policies, the facility failed to ensure necessary care and services were provided to a resident who had an unwitnessed fall and staff had not performed neurological assessments according to the facility policy. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries, when Resident #115 suffered an unwitnessed fall on 01/04/22 at 4:45 A.M. and subsequently experienced a change in condition requiring hospitalization . Neurological checks were started, but were not completed after 01/05/22 at 10:00 A.M. On 01/06/22 at 8:13 P.M., Resident #115 ' s family requested the resident be sent to the emergency room (ER) for evaluation due to a change in condition as evidenced by lethargy and not eating. The resident was diagnosed with a stable brain bleed. This affected one (Resident #115) of three residents reviewed for falls. In addition, the facility failed to ensure oxygen use was clarified and ordered by the physician. This affected one resident (#120) of three reviewed for oxygen. The total facility census was 97. On 03/09/22 at 4:32 P.M., Regional Director of Operations #108 and Regional Nurse #107 were notified Immediate Jeopardy began on 01/05/22 at 10:00 A.M. when neurological assessments for Resident #115 were stopped status post [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/06/22, Resident #115 was lethargic and not eating. Resident #115 was transferred to the hospital and diagnosed with right posterior parietal intraparenchymal hemorrhage of the brain with surrounding [CONDITION(S)] with subarachnoid extension (a brain bleed with swelling due to trapped fluid). Resident #115 was treated at the hospital and returned to the facility on [DATE]. He was discharged from the facility to home on 02/07/22. The Immediate Jeopardy was removed on 03/10/22 when the facility implemented the following corrective actions: · On 03/10/22, Nurse Practitioner (NP) #105 reassessed other residents that have had a fall within the last 30 days for any change in condition and determine if further monitoring or follow up is required in coordination with the Director of Nursing (DON) and the physician. The Interdisciplinary Team (IDT) will complete any needed assessments, care plan revisions, and validate interventions are in place and being implemented by staff. Any findings that have not been assessed and reported to the physician will be assessed and any findings reported to the physician and family. All other residents will be assessed for change in condition and validate assessments are completed related to the change in condition, care plans revised if necessary, and interventions implemented. On 03/10/22, all licensed nurses and the IDT will be educated on the Fall Prevention and Management policy, Change in Condition, and the Neurological Policy by the DON/Designee. · The DON/Designee will audit all events in the daily clinical meeting and will be completed daily, five days a week as an ongoing practice of this facility starting 03/11/22. · Charge Nurses are to notify the DON at the time of a fall to allow for timely investigation, assessment, and plan of care revisions. · The DON/Designee will monitor progress notes during the morning clinical meeting to assure falls are identified, investigated and the plan of care is updated with neurological monitoring. · The DON/ designee will investigate falls and assure the plan of care is updated to include interventions. · All findings will be reported to the physician, family and/or resident. · The DON/Designee will report the results of audits at the Quality Assurance Performance Improvement (QAPI) committee meeting monthly for review. The QAPI committee will determine when 100% compliance is achieved or if ongoing monitoring is required. Although the Immediate Jeopardy was removed on 03/10/22, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #115 revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 12/13/21 documented Resident #115 was at risk for falls related to gait and balance problems, history of falls, and weakness. Interventions included to initiate neurological checks if fall is unwitnessed, or the head is involved. Review of the Minimum Data Set (MDS) assessment, dated 12/17/21, documented Resident #115 was moderately cognitively impaired. He required supervision for ambulation and the limited assistance of one person for toileting. Review of the progress notes dated 01/03/22 at 8:36 P.M. documented the physician and responsible party were notified Resident #115 had tested positive for COVID. Resident #115 was moved to an isolation room. Review of the progress notes dated 01/04/22 at 5:00 A.M. documented Resident #115 was sitting on the bathroom floor with his legs extended. Resident #115 stated he lost his balance while he was walking to the bathroom. Resident #115 denied pain or hitting his head. There were no visible injuries. The facility ' s Post Fall Evaluation documented on 01/04/22 at 4:45 A.M., Resident #115 was found on his buttocks in the bathroom. Resident #115 ' s responsible party and physician were notified at 5:05 A.M. A late entry dated 01/04/22 at 5:41 P.M. documented the physician was notified of the fall, but the resident ' s responsible party was not notified due to the facility having an incorrect telephone number on file. Review of the facility document titled Neurological Assessment Flow Sheet documented neurological (neuro) checks were started on 01/04/22 at 4:30 A.M. Neuro checks were completed at 4:45 A.M., 5:00 A.M., 5:15 A.M., 5:45 A.M., 6:15 A.M., 7:00 A.M., 8:00 A.M., 9:00 A.M., 10:00 A.M., 2:00 P.M., 6:00 P.M. and 10:00 P.M.; and on 01/05/22 at 2:00 A.M., 6:00 A.M. and 10:00 A.M. All neuro checks were documented as normal. There were no further neuro checks documented after 01/05/22 at 10:00 A.M. Review of the facility electronic document titled Amount Eaten documented on 01/04/22 and 01/05/22, revealed Resident #115 had eaten breakfast, lunch, and dinner. On 01/06/22, Resident #115 had refused all meals. Review of the facility electronic document titled Respiratory/COVID Symptoms Evaluation, dated 01/06/22 at 7:07 P.M. and completed by Licensed Practical Nurse (LPN) #122 documented Resident #115 had a new onset of acute illness of Covid-19. The form was marked Resident #115 seemed more lethargic and more confused than normal, but there was no change in his level of consciousness. His vital signs were blood pressure 112/84 millimeters of mercury (mmHg), pulse 82 beats per minute, respirations 16 breaths per minute, temperature 99.7 degrees Fahrenheit (F) and oxygen saturation of 97 percent. He had a normal breathing pattern and clear lungs. The resident required increased assistance in performance of activities of daily living. No further follow-up to this document was found in the electronic medical record. Review of Resident #115 ' s progress notes revealed no further documentation regarding the resident ' s status until 01/06/22 at 8:13 P.M. which documented Resident #115 left the facility via the responsible party ' s request to get IV [intravenous] fluids at hospital. Review of the Neurosurgery Consult Note from the hospital records, dated 01/07/22, revealed Resident #115 ' s responsible party stated Resident #115 had been at his baseline when out to dinner on Monday (01/03/22). On 01/05/22, he was barely responsive and [Responsible Party] was informed by the nursing facility that he had not been eating. [Responsible Party] decided to send him to the emergency room for evaluation. CT [Computed Tomography] of the head revealed right posterior parietal intraparenchymal hemorrhage with surrounding [CONDITION(S)] with evidence of subarachnoid extension. Subdural hematoma right frontal parietal lobe and along both tentorial leaflets. A follow-up CT showed the hemorrhages were stable. The Magnetic Resonance Imaging (MRI) of the brain without contrast, completed 01/07/22, documented moderate acute to early subacute right parietal parenchymal hematoma with moderate adjacent vasogenic [CONDITION(S)] and moderate patchy bilateral subarachnoid hemorrhage. The resident was discharged from the hospital on 01/18/22 and returned to the facility. He was subsequently discharged to home on 02/07/22. During telephone interview on 03/08/22 at 11:24 A.M., LPN #122 stated she was a contract nurse (agency) for the facility. She cared for Resident #115 on 01/06/22 on the COVID unit and this was her first time working at the facility. On 01/06/22, Resident #115 was lethargic and out of it. The State tested Nursing Assistant (#78) working the unit stated Resident #115 was not himself. LPN #122 stated she called Resident #115 ' s responsible party, who requested he be sent to the hospital for evaluation. During interview on 03/08/22 at 1:07 P.M., Regional Nurse #107 verified the medical record lacked documentation of any neurological checks being completed after 01/05/22 and lacked nursing notes documenting Resident #115 ' s condition prior to being sent to the hospital on 01/06/22. Review of the facility policy titled Fall Prevention and Management, dated 05/05/21, documented if the resident hit their head or it was an unwitnessed fall, begin neurological checks per the Neurological Check policy. Review of the facility policy titled Neurological Checks (Neuro-checks), dated 02/17/00, documented neurological assessments should be performed after a fall with an unknown head injury. For stable or unchanging neuro checks, use the following schedule: every 15 minutes times four; every 60 minutes times four; every four hours times four; and daily times four days. Other signs and symptoms to monitor and report that may be associated with head injuries are nausea/vomiting, dizziness, restlessness, confusion or dullness of thought different from baseline, increased sleepiness or inability to arouse resident at baseline, headache or new onset or stiff neck. 2. Review of the medical record for Resident #120 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 01/12/22, revealed Resident #120 had impaired cognition. The resident required assistance of one staff for activity of daily living (ADL) care. The resident had no oxygen therapy coded on the assessment. Review of the plan of care dated 01/10/22 revealed Resident #120 there was no plan related to oxygen therapy. Review of the physician orders for January 2022 revealed Resident #120 had no orders for oxygen in the medical record. Review of the medication administration records (MAR) for January 2022 revealed there was no oxygen signed off as administered. Review of the nursing progress notes dated 01/07/22 through 01/29/22 documented the oxygen was on at two liters per nasal canula. Review of the vital sign reports for oxygen saturation revealed the saturations for oxygen were documented as 88 percent to 98 percent on room air and oxygen. The lowest reading of 88 percent was dated 01/25/22 on oxygen via a nasal canula. The other dates were all above 90 percent. Interview on 03/08/22 at 2:00 P.M., the Regional Nurse #107 stated there were no orders for oxygen and Resident #120's oxygen use was not clarified with the physician. She also said she could not find pulse rates which coincided with the administration of [MEDICATION(S)]. Review of facility policy titled Oxygen Medical Gas Use, revised date 02/15/22, revealed oxygen will be ordered by a physician or other authorized provider. The provider order will include the route of administration, liters per minute and frequency of use. This deficiency substantiates Complaint Number OH 305.

Based on medical record review, interviews with staff, observation of residents and meals, interview with the Nurse Practitioner, review of hospital documentation and reports, review of meal tickets, and review of the facility document titled Eating, the facility failed to ensure staff provided adequate supervision during meals for one resident (#08) with a diagnosis of dysphagia oropharyngeal phase, and who was identified to be at risk for aspiration and choking. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #08 choked, requiring staff to perform the [MEDICATION(S)] maneuver, after being served a meal tray without supervision, subsequently went into cardiopulmonary arrest, and passed away at the hospital on [DATE] at 2:46 A.M. This affected one (Resident #08) out of three residents (#08, #14 and #72) reviewed for supervision with meals. The facility identified seven in house residents currently residing in the facility who required supervision with meals (Resident #02, #05, #14, #48, #59, #72, and #93). The facility census was 97. On [DATE] at 5:57 P.M., the Administrator, Regional Nurse Registered Nurse (RN) #107, and Regional Director of Operations #108 were notified Immediate Jeopardy began on [DATE] at approximately 7:15 P.M. when Resident #08, who had a diagnosis of dysphagia oropharyngeal phase and was identified to be at risk for aspiration and choking, was provided his dinner tray and was left unsupervised in his room while eating dinner. At 7:30 P.M., Registered Nurse (RN) #11 (the day shift nurse) went to administer Resident #08's medications and found Resident #08 choking. RN #11 performed the [MEDICATION(S)] maneuver, and a carrot slice was projected. Resident #08 was then able to talk and was breathing at that time. At approximately 7:40 P.M., STNA #76 found Resident #08 was not breathing and appeared gray. RN #11 performed Cardiopulmonary Resuscitation (CPR) and called 911. At approximately 7:55 P.M., Emergency Medical Services (EMS) took over care of the resident. EMS was able to obtain a pulse for Resident #08 and he was transferred to the hospital where he subsequently passed away on [DATE] at 2:46 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Regional Nurse RN #107, Unit Manager #95, the Director of Nursing (DON), and the Administrator began education with all staff regarding provision of adequate supervision of residents during mealtime and monitoring to ensure compliance. The education with all staff was completed on [DATE] at 7:00 P.M. · On [DATE], Registered Dietitian #113 completed a tray accuracy audit of the tray line in order to validate accuracy of the meal served compared to the diet order. · On [DATE], Speech Therapist (ST) #106, ST #110, ST #111, and ST #112, reassessed all residents for risk of choking and/or aspiration and ensured the seven residents identified as at risk for choking and/or aspiration had care plans in place which identified supervision was required during mealtimes. · On [DATE] at 2:00 P.M., Resident Kardex's (the plan of care for the aides) were updated by Regional Nurse RN #107, Minimum Data Set (MDS) Nurse #13, and MDS Nurse #116, with care plan revisions regarding supervision required during mealtimes. The care plans were completed/updated by [DATE] after reassessments were completed by Speech Therapy. · The DON/Designee will identify residents at risk for choking and/or aspiration who require supervision at meals, upon admission, readmission, after a change in condition per hospital paperwork, therapy evaluation, and/or nursing assessment. Any resident identified as requiring supervision with meals will have their care plan updated to reflect their supervision status at meals, and the Kardex will be updated with the current care plan. This will be part of the daily clinical morning meeting and weekly resident at risk meeting. · All new department managers, new nursing staff, and new Agency staff will be educated on providing supervision at meals and how to locate resident specific information on the Kardex in the electronic medical record. The education will occur in orientation with on-going education as needed. A binder will be placed at each nurses' station and will have a copy of all policies received during education, as well as a list of residents who require supervision with dining. · The Interdisciplinary Team (the Administrator, Unit Manager #95, Human Resources Staff #67, Business Office Manager #115, MDS Nurse #13, MDS Nurse #116, Licensed Social Worker #81, Registered Dietitian #113, Registered Dietitian #117, Admissions Staff #118, Admissions Staff #61, Activities Director #104, Medical Records Staff #66, Therapy Manager #119, Environmental Services Director #120, Maintenance Staff #91, and Culinary Director #121) will be assigned a designated unit to monitor for supervision during meal service in order to validate adequate supervision is provided for those residents requiring supervision with meals. Monitoring will occur five times a week for two weeks, then three times a week for six weeks, and then on-going twice a week. Monitoring will occur across all three meal services. · The Dietary Service Manager (DSM) #63/Designee will complete a tray line accuracy audit weekly for one month, then twice for one month, then monthly. · The Administrator/Designee will report all findings to the Quality Assurance and Performance Improvement (QAPI) committee monthly and the QAPI committee will determine when 100 percent compliance is achieved and whether on-going monitoring is required. · Interviews on [DATE] at 4:00 P.M. with State tested Nurse Aide (STNA) #44 and STNA #55, and on [DATE] at 4:10 P.M. with Licensed Practical Nurse (LPN) #88, revealed all staff were educated regarding provision of adequate supervision of residents during mealtime, how to locate resident specific information on the Kardex in the electronic medical record and no concerns were identified. · Observation on [DATE] from approximately 12:10 P.M. to 12:30 P.M. of Resident #59 and Resident #93, who received a mechanically altered diet and required supervision, revealed both received the appropriate diet and supervision. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: Review of Resident #08's medical record revealed an admitted [DATE] and discharge date of [DATE]. Resident #08's diagnoses included [CONDITION(S)], dysphagia oropharyngeal phase, dysarthria and anarthria, and ataxia. Review of the most recent care plan, initiated on [DATE] and revised on [DATE], revealed Resident #08 had a nutritional problem/potential nutritional problem due to Resident #08's disease process, swallowing disorders, and weight loss. The care plan listed interventions which included observing for signs and/or symptoms of aspiration or dysphagia (for example choking, coughing, pocketing food, loss of liquids and/or solids from Resident #08's mouth when eating and/or drinking, and difficulty/pain when swallowing). Additional interventions included to aid with meals as needed and provide meals according to the diet order, and small spoons to aid with self-feeding. Review of Resident #08's physician orders revealed an order with a start date of [DATE] for Resident #08 to receive a regular diet with pureed textures and honey consistency (liquids). Review of Resident #08's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 had moderate cognitive impairment. The assessment further revealed Resident #08 required supervision of one staff for eating. Resident #08 had a functional limitation in range of motion on both sides of his upper and lower extremities. Review of Nurse Practitioner #105's note dated [DATE] at 6:56 A.M., revealed Resident #08 was seen as a follow up for his chronic condition of [CONDITION(S)]. The note revealed staff were to continue with monitoring Resident #08's oral intake and assisting Resident #08 with meals. The note indicated staff were awaiting an appointment for gastrostomy tube (a feeding tube) placement. Resident #08 had current problem history which included dysphagia. The note further revealed Resident #08 was to continue with a pureed diet, and staff was to always feed Resident #08 with the head of the bed greater than 45 degrees. Review of the progress note dated [DATE] at 9:09 P.M. written by RN #11, revealed Resident #08 was found unresponsive at approximately 6:30 P.M. (Interview with RN #11 revealed it was approximately 7:30 P.M. and not 6:30 P.M.) sitting upright in bed with his dinner tray in front of him. RN #11 initiated CPR and called 911. The note documented at 7:45 P.M. the emergency medical technicians (EMTs) arrived and proceeded with CPR, intubation, and defibrillation. The note indicated Resident #08 regained a pulse and was transported to the hospital for further treatment. Review of Resident #08's meal ticket for the dinner tray dated [DATE], printed by Dietary Service Manager #63 on [DATE], revealed Resident #08 was ordered a regular diet with pureed consistency and honey thickened liquids. The meal ticket stated at the top Supervision during Intake. The items to be on the tray included honey thickened water, chicken and dumplings, carrots, a dinner roll, margarine, a Texas gold bar (a dessert brownie), salt, pepper, and sugar. At the bottom of the meal ticket, it indicated Resident #08 Eats in room. Review of the [NAME] Township Fire and Rescue Patient Care Record revealed Resident #08 had an onset of cardiac arrest on [DATE] at 7:30 P.M. At 7:45 P.M., EMS personnel arrived and began CPR. The document indicated Resident #08 was found lying in bed at the facility and the nursing staff were performing CPR. The facility staff stated Resident #08 had been choking on food and staff had to perform the [MEDICATION(S)] maneuver to remove the food. The facility staff stated all food had been spit up and Resident #08 was talking to staff and stated he was fine. Resident #08 went on to continue to eat and facility staff left him in his room. Facility staff returned to find Resident #08 unresponsive, with no pulses, and no respirations. Facility staff began CPR compressions and called 911. Further review of the record revealed Resident #08's airway was full of foreign body food. Suction was attempted by EMS, but they were unable to remove large obstructions with suction. [NAME] Forceps were used to remove large chunks of food. After multiple attempts, Resident #08's pulse returned, and Resident #08 was transferred to the hospital and arrived at the emergency room at 8:24 P.M. Review of the emergency room (ER) report dated [DATE] at 8:27 P.M. revealed Resident #08 presented to the Emergency Department for evaluation of altered mental status and cardiopulmonary arrest. Per EMS, Resident #08 had an episode where he choked at his nursing facility. Reportedly, the [MEDICATION(S)] maneuver was performed, and the patient was able to clear his airway and return to baseline. The report was that Resident #08 was awake and alert and was sent back to his room with his evening medications. At some point, a well check was completed on Resident #08, and he was found unresponsive. EMS reports that he was hypoxic, in cardiac arrest, and CPR was initiated. EMS reported there was copious amounts of what appeared to be food products in the patient's oropharynx. Further review of the ER note revealed Resident #08 presented to the ED as a cardiopulmonary arrest and indicated it appeared to be secondary to possible aspiration and anoxia. Review of a progress note dated [DATE] at 2:55 A.M. revealed Agency RN #114 called the hospital for report on Resident #08 and was informed by the nurse on duty that Resident #08 was pronounced dead on [DATE] at 2:46 A.M. Interview with ST #106 on [DATE] at approximately 11:55 A.M. revealed ST #106 treated Resident #08 most of the time Resident #08 was at the facility. ST #106 revealed when she started Resident #08's most recent treatment in December, Resident #08 had been discharged from a hospital stay due to aspiration. When Resident #08 returned to the facility, Resident #08 completed a modified [MEDICATION(S)] swallow which indicated Resident #08 should receive pureed textures and honey thickened liquids. Before the modified [MEDICATION(S)] swallow, Resident #08 was receiving pureed textures with nectar thickened liquids. The interview revealed Resident #08 used to require staff assistance with feeding due to not having the motor skills to control the amount of food on the utensil; however, Resident #08 regained his ability to feed himself. ST #106 stated Resident #08's meal ticket indicated Resident #08 needed supervision with meals. ST #106 further stated a form was given to the kitchen indicating what kind of assistance Resident #08 needed. ST #106 stated she would have expected that there would have been a staff member present with Resident #08 during his dinner meal on [DATE]. ST #106 indicated education was given to staff informing them that even though he was getting back some of his ability to self-feed, assistance was still needed for safety. ST #106 revealed several weeks ago an aide told her Resident #08 did fine on his own for breakfast and ST #106 let staff know that someone needed to always be with him for meals in order to help feed him. ST #106 stated Resident #08 required supervision at all meals. ST #106 revealed Resident #08 had a feeding tube placed, but staff had not begun utilizing the feeding tube yet. Interview with RN #11 on [DATE] at 12:12 P.M. revealed on [DATE], it was shift change, and another nurse covering night shift, came on duty. RN #11 stated dinner was late and was served past 7:00 P.M. RN #11 revealed that she went into Resident #08's room to give him medications crushed in applesauce. RN #11 stated when she went into the room, Resident #08 was sitting up in his bed with his dinner tray in front of him choking. RN #11 stated she was talking to Resident #08, and he couldn't respond. Resident #08 then started to talk, and RN #11 noticed Resident #08 was choking. RN #11 revealed she went to get a night shift aide to help and attempted to do the [MEDICATION(S)] maneuver on Resident #08. RN #11 stated she got behind Resident #08 to dislodge the obstruction. RN #11 revealed a carrot came out after performing the [MEDICATION(S)] maneuver. RN #11 revealed Resident #08 was breathing and talking to her. RN #11 stated Resident #08's vitals were stable at that time. Resident #08 then had a drink of honey thick water and two small bites of applesauce with medications, which he swallowed and seemed to tolerate fine. RN #11 indicated when she left the room, the tray was moved to the side of Resident #08's bed, out of Resident #08's reach. RN #11 revealed there was no staff in the room when Resident #08 had the tray in front of him and was choking. RN #11 indicated she returned to the hall and was at her medication cart with the computer and was getting ready to text the DON and on call physician. Before RN #11 could text the DON and on call physician, a night shift aid (STNA #76) was walking down the hall, glanced in Resident #08's room, and told RN #11 that Resident #08 did not look right. RN #11 indicated Resident #08 was pale and unresponsive when she went in his room. Resident #08 did not respond to sternal rub, so the night shift agency nurse grabbed the crash cart and put a board under Resident #08. Staff called 911 and completed CPR for about 15 minutes. RN #11 revealed the EMS intubated Resident #08, defibrillated him twice, gave Resident #08 three vials of [MEDICATION(S)] (EPI), did CPR, got a pulse, and transferred him out to the hospital. RN #11 stated the EMS staff said it looked like there was still something orange in Resident #08's throat. RN #11 indicated Resident #08 was supposed to be supervised when eating. RN #11 stated it was shift change when Resident #08 received his meal, and she did not know why there was no staff in his room with him. RN #11 stated she was unsure where the aide was when Resident #08 received his dinner meal on [DATE]. A second interview with RN #11 on [DATE] at 2:12 P.M. revealed it appeared as though Resident #08 had eaten some mashed potatoes (which were chicken and noodles) and carrots on [DATE]. RN #11 said the food was on his clothes and the tray. Interview with Certified Nurse Practitioner (CNP) #105 on [DATE] at 11:39 A.M. revealed Resident #08 had coded and was sent out to the hospital. CNP #105 was not aware Resident #08 had choked. CNP #105 indicated her expectation would be that someone would be supervising Resident #08 when he ate his meal. CNP #105 stated Resident #08 was able to feed himself, but his ability was limited. CNP #105 revealed Resident #08 was a choking risk and that was why staff were pushing for the feeding tube. CNP #105 stated Resident #08 had an order for a pureed diet with thickened liquid. CNP #105 indicated she was afraid Resident #08 would become tired too quickly and would hope staff would be helping him. Interview via telephone with STNA #58 on [DATE] at 5:20 P.M. revealed she was the STNA caring for Resident #08 during the day shift. STNA #58 stated it was 7:00 P.M. on [DATE] and the dinner trays had not arrived yet. STNA #58 indicated she gave report to the oncoming aide and told the aide that Resident #08 needed to be fed and watched carefully. STNA #58 indicated therapy said to try to be with Resident #08 when he ate. STNA #58 revealed she believed therapy fed him breakfast and lunch on [DATE]. STNA #58 stated she was by herself and was caring for two halls and didn't remember feeding Resident #08 on [DATE]. Interview with STNA #05 on [DATE] at 1:46 P.M. revealed she was working with another aide (STNA #76), who was taking care of Resident #08. STNA #05 indicated she was passing the dinner trays on [DATE] and gave a meal tray to Resident #08. STNA #05 remembered Resident #08's dinner tray had a roll, sliced carrots, and chicken and dumplings. STNA #05 revealed the carrots were not pureed. STNA #05 said there was no staff in the room to feed Resident #08. STNA #05 indicated she sat Resident #08 up and put the tray in front of him. STNA #05 indicated STNA #58 told them Resident #08 had been feeding himself and to just set him up and that was what she did. STNA #05 revealed when she started her shift, STNA #58 gave report due to dinner not coming before she left. STNA #05 stated the dinner trays came around 7:10 P.M. to 7:15 P.M. on [DATE]. STNA #05 indicated STNA #58 did not let them know Resident #08 needed to be supervised. STNA #05 revealed after passing trays she was in another resident's room when the day shift nurse came and got her. STNA #05 helped lean Resident #08 forward, while RN #11 performed the [MEDICATION(S)] maneuver. Interview with STNA #76 on [DATE] at 1:56 P.M. revealed she was the one who found Resident #08 unresponsive on [DATE]. STNA #76 revealed when she came in to work on the night shift at 7:00 P.M., she went to another resident's room on another unit. STNA #76 stated she was on the other unit for about 15 minutes. STNA #76 revealed she returned to Resident #08's floor and the meal cart had arrived. STNA #76 indicated she was passing trays on the 300 Hall, and STNA #05 was passing the trays on the 400 Hall. After passing trays on the 300 Hall, STNA #76 walked to the 400 Hall to see what trays needed to be removed after residents had finished eating. STNA #76 stated when she went past Resident #08's room, she noticed Resident #08 was gray, unresponsive, and appeared to be slouched. STNA #76 told the dayshift nurse (RN #11), who was around the corner, she needed to check Resident #08. STNA #76 revealed Resident #08 was not breathing. STNA #76 stated when she walked in Resident #08's room, she sat him up to try to get a response from him. The nurse did CPR and called 911. STNA #76 indicated she was not involved in removing the tray and was not sure what he had eaten. STNA #76 revealed dayshift STNA #58 stated Resident #08 was doing good feeding himself. STNA #76 stated she did not know the diet, and STNA #58 did not say Resident #08 always needed someone in there to supervise him while he was eating. Review of the undated facility document titled Eating, revealed under the section titled ADL Self-Performance Coding Definitions, supervision was defined as oversight, encouragement, or cueing was provided. This deficiency substantiates Complaint Numbers OH 305 and OH 665.

Based on medical record review, staff interview, review of information from the National Pressure Injury Advisory Panel (NPIAP), and policy review the facility failed to complete skin assessments to prevent a pressure ulcer from reoccurring. This resulted in Actual Harm when Resident #105 was admitted to the facility with an open area observed to the sacrum, assessed as a partial thickness wound, the wound healed, and then subsequent skin assessments were not completed as ordered. The wound was found 25 days later and assessed as a full thickness wound. In addition, the facility failed to timely assess Resident #115's skin upon readmission from the hospital. This affected two (Residents #105 and #115) of three residents reviewed for pressure ulcer care. The facility census was 97. Findings included: Review of the closed medical record for Resident #105 revealed an admitted [DATE] and a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE] identified Resident #105 was admitted with a Stage II pressure ulcer to the sacrum. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 had impaired cognition. The resident was dependent on staff for bed mobility and transfers. Resident #105 was incontinent of bowel and bladder. The assessment indicated the resident had a Stage II pressure ulcer. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #105 was at high risk for the development of pressure ulcers Review of the plan of care dated 11/18/21 revealed Resident #105 was at risk for pressure ulcers due to diabetes peripheral vascular disease and impaired mobility. The plan identified she was admitted with a left foot surgical wound and no mention of the pressure area to the sacrum. Interventions included complete weekly skin checks, notify the resident/representative of any declines in wound, provide an off-loading mattress, and provide peri-care as needed to avoid skin breakdown to incontinence. Review of the physician orders dated November 2021 identified orders for an air mattress, daily wound assessments, weekly skin assessments on Wednesday on the day shift. Review of the nurses' notes dated from 12/09/21 through 01/03/22 revealed no documented skin assessments. Review of the physician orders dated 11/17/21 revealed a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weekly skin grid dated 11/24/21 revealed Resident #105 had a stage II pressure ulcer present on the right buttock's sacral region. The wound measured 1.0 centimeter (cm) by 1.5 cm by 0.1 cm. The wound bed was reddened with serous drainage. The weekly skin grid dated 12/01/21 had no measurements or description documented. Review of the wound evaluation note dated 12/08/21 revealed Resident #105's sacrum wound had healed and documented ensure compliance with turning protocol. Review of the weekly skin assessments dated from 12/08/21 through 01/03/22 revealed no weekly skin assessments were completed as ordered for Resident #105. Review of the weekly skin assessment dated [DATE] documented a sacrum wound. No description, measurements or additional information was added about the sacrum wound. Review of the Activities of Daily Living (ADL) tracker dated from 12/09/21 to 01/06/22 revealed Resident #105 had no documented showers/baths. There was one bed bath documented dated 12/22/21. Review of the wound nurse practitioner note dated 01/03/22 documented an unstageable pressure (full-thickness skin and tissue loss wound) re-opened on the sacrum. The wound measured 6.7 cm by 9.1 by 0.0 cm. The wound was 80 percent slough (dead tissue separating from viable tissue) and 20 percent pink, dusky and purple. There was no odor and Venelex (an ointment used to promote wound healing) was ordered to apply three times daily. Interview on 03/08/22 at 12:00 P.M., the Regional Nurse #107 said she had no other documentation to support Resident #105 had received a bath/shower. She said she was not in the facility during this time and there was a lot of agency staff working. Interview on 03/09/22 at 10:24 A.M., the Wound Certified Nurse Practitioner (WCNP) #123, Licensed Practical Nurse (LPN) #126 and the Regional Nurse #107 stated Resident #105 had a stage II pressure ulcer which she observed one time and documented as healed on 12/08/21, which was the first time the wound had been seen by the WCNP #123. WCNP #123 then said she saw her again on 01/03/22 for a re-opened area to the sacrum after she was notified by a staff member. She said the area was an unstageable pressure ulcer which could have developed in three days to one week. She stated it was her practice to start the Venelex ointment three times daily as it enhanced blood flow to the skin and it forced the staff to go in and look at the area. They verified there were no weekly skin assessments completed from 12/09/21 to 01/03/22 and they should have been completed. They also verified someone should have noticed the area before it was found unstageable. Interview on 03/09/22 at 11:35 A.M., Certified Nursing Assistant (CNA) #73 said she had worked with Resident #105, and she went in to change her and saw it on her bottom. The CNA #73 said the area on her bottom was large and someone should have seen it before she did. She immediately went out of the room and reported it to the WCNP #123. Review of the NPIAP Pressure Injury Stages undated revealed an Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Review of the facility policy titled Skin Care & Wound Management review date 05/30/19 revealed each resident/patient is evaluated upon admission and weekly thereafter for changes in skin condition. Resident/patient skin condition is also re-evaluated with change in clinical condition, prior to transfer to the hospital and upon return from the hospital. 2. Review of the closed medical record for Resident #115 revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #115's care plan for impaired skin integrity, dated 12/13/21, revealed to complete a skin risk assessment upon admission, readmission, quarterly and as needed; complete weekly skin checks; monitor meal intake, provide appropriate off loading mattress and provide peri-care as needed to avoid skin breakdown. The Minimum Data Set (MDS) assessment, dated 12/17/21, documented Resident #115 was moderately cognitively impaired. He required supervision for ambulation and the limited assistance of one person for toileting. Review of Resident #115's medical record revealed a physician order dated 12/10/21 for a skin check every Wednesday on night shift. A skin check dated 12/17/21 documented Resident #115's sacrum was pink and blanchable. The resident was ordered a pressure reducing mattress on 12/20/21. A skin check completed on 12/23/21 documented no skin issues. There were no further skin checks documented. The resident was sent to the hospital on 01/06/22 and returned on 01/18/22. Upon readmission from the hospital, there was no initial nursing assessment documented. There was no documentation regarding the condition of Resident #115's skin. There was a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There wasn't any documentation that weekly skin assessments were completed. There was nothing documented in the medical record regarding Resident #115's skin until 02/02/22, when he was seen by the nurse practitioner. Review of the skin/wound note, dated 02/02/22 at 10:57 A.M. revealed the chief complaint was a comprehensive skin and wound evaluation for the buttocks. Certified Nurse Practitioner (CNP) #105 documented an unstageable pressure ulcer on Resident #115's sacrum that measured two centimeters (cm) by three cm by 0.1 cm. CNP #115 debrided the area, removing epidermis, dermis and subcutaneous tissue. The resident was on a low air loss mattress. CNP #105 documented that pressure reduction and turning precautions discussed with staff at the time of the visit. CNP #105 ordered Venelex, a topical medication to heal ulcers, three times a day and as needed. Review of the treatment administration record for February 2022 revealed the treatment was applied as ordered, however Resident #115 discharged on [DATE]. This deficiency substantiates Complaint Numbers OH 305, OH 978 and OH 665.