Every finding on record at Grande Pointe Healthcare Commu

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of the facility's investigation, and facility policy review, the facility failed to provide adequate supervision to ensure a resident with moderately impaired cognition did not leave the facility without staff awareness. This affected one resident (#102) of three residents reviewed for elopements. The facility census was 162. Findings include:Review of the medical record for Resident #102 revealed an admission date of 01/20/25. Medical diagnoses included non-traumatic intracerebral hemorrhage, hypertensive chronic kidney disease, end stage renal disease, dependence on renal dialysis, anxiety, and vascular dementia without behavioral, psychotic, or mood disturbance. Review of a physician order dated 09/25/25 revealed Resident #102 was ordered a wanderguard (a wearable bracelet-like device used to monitor and prevent residents at risk for wandering from leaving designated areas; it is part of a larger system which includes sensors on doors which alarm and lock doors when a resident approaches a monitored exit) bracelet to his ankle. A subsequent order dated 09/26/25 called for staff to check the wanderguard placement and function daily on day shift. Review of a wandering observation tool dated 11/22/25 revealed Resident #102 did not have behaviors of wandering and independently ambulated. Review of Resident #102's care plan dated 01/05/26 revealed the resident was an elopement risk and wandered aimlessly from place to place. A listed goal included Resident #102 would wander without injury. Listed interventions included to maintain the wanderguard to the ankle, check placement and function, provide diversionary tasks/activities as needed, and to redirect when appropriate. Review of Resident #102's Minimum Data Set (MDS) annual assessment dated [DATE] revealed the resident had moderately impaired cognition. He required supervision or touching assistance for all activities of daily living except for eating and oral hygiene. Resident #102 had no functional limitation in range of motion and ambulated independently. The assessment noted the resident had instances of wandering during the seven-day lookback period and had not utilized a wander or elopement alarm.Review of a progress note recorded as a late entry, effective 02/03/26 at 8:30 P.M. revealed while passing evening medications, Resident #102 was noted to not be in his room. Per facility staff, the resident had last been seen between 5:00 P.M. and 5:30 P.M. Resident #102 had previously notified a nurse that he was going to the facility's lobby to meet a friend and remained on an unauthorized leave of absence (LOA). Review of Resident #102's Medication Administration Record (MAR) for 02/03/26 revealed the resident's evening medications including Carvedilol (an oral antihypertensive medication), losartan (an oral antihypertensive medication), calcium carbonate chewable tablet, and ammonium lactate cream (used to treat dry skin) were recorded as not administered. A follow up progress note timed 02/04/26 at 5:30 A.M. revealed Resident #102 remained on an unauthorized LOA. The facility's unit manager and supervisor (unnamed) were notified. The guardian was called and a message was left. Resident #102's son was notified of the unauthorized LOA. Facility staff attempted to call Resident #102's phone but it was disconnected. A subsequent note timed 7:30 A.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident's guardian related to the unauthorized LOA. Continued review of the progress notes revealed on 02/04/26 at 10:30 A.M., the DON received a call from Resident #102 at 9:45 A.M. who reported he stayed the night at his uncle's residence and would be returning shortly. Upon his return he was taken back to his room. A head-to-toe assessment and vital signs were obtained. Resident #102's skin was intact and he had no visible injuries. Resident #102 had no complaints of pain, discomfort, and his mental status was at baseline. The resident was provided breakfast and dialysis as scheduled. Resident #102 was seen by the facility's Nurse Practitioner and the physician was notified. Resident #102 was seen by the facility's social worker and no psychosocial issues were noted. Review of the wandering tool dated 02/04/26 revealed all the questions were negative for wandering except for question six which noted an additional risk factor for wandering was related to an incident of an unauthorized LOA overnight on 02/03/26. Review of the facility's timeline of the incident revealed on 02/04/26 at 5:30 A.M. the charge nurse noted Resident #102 remained missing from the building and a code orange (term used by the facility to indicate a missing resident) was called by the nursing supervisor. The Administrator and DON were notified. A facility-wide search was initiated and included all rooms and the outside grounds. Staff searched the community. The police were notified. A head count was completed with all residents, except Resident #102, accounted for. Resident #102's guardian was contacted by the charge nurse and a message was left. Resident #102's son was additionally notified via phone. Staff attempted to phone Resident #102 but his phone was disconnected. At 5:45 A.M., police arrived at the facility and a report was filed. At 6:00 A.M., all doors and windows were checked for proper function, including function of the wanderguard system, by Maintenance Director #401 and all were found to be in good working order. At 6:00 A.M., the Administrator began collecting witness statements. Resident #102 was last seen by staff (on 02/03/26) between 4:00 P.M. and 5:00 P.M. and had told staff a friend was coming to visit him. Staff reported Resident #102's phone rang, he answered it, and left the unit. Resident #102 was seen by the vending by an unnamed Certified Nursing Assistant (CNA) and told her he was going to the front to visit with a friend. He was fully dressed including jeans, a black jacket, and tennis shoes. At 7:00 A.M., the resident's guardian was notified by the nurse. At 7:30 A.M., the Administrator attempted to call both Resident #102 and his friend via social media with no answer. At 9:45 A.M., a family member of Resident #102 called the facility to notify them that Resident #102 arrived at another family member's home on [DATE] between 9:00 P.M. and 10:00 P.M. and spent the night there. The family member indicated he would return Resident #102 to the facility. At 10:10 A.M., Resident #102 returned to the facility with a family member. The resident reported he left the facility with his friend and later went to his family's home and stayed the night. A head to toe assessment, pain assessment, and skin assessment were completed with no abnormal findings. The facility NP saw Resident #102 on 02/04/26 with no concerns noted. The DON and Administrator began implementing further corrective action once Resident #102 had returned safely. Interview on 02/19/26 at 9:30 A.M. with the Administrator and DON revealed they did not consider Resident #102 to have eloped from the facility but considered his absence an unauthorized LOA. Attempted interview on 02/19/26 at 10:48 A.M. with Resident #102 revealed he did not remember leaving the facility but stated he did not get hurt and will not do it again. Interview on 02/19/26 at 2:33 P.M. with CNA #285 revealed she worked the evening Resident #102 left the facility but was not assigned to care for him. CNA #285 reported she was familiar with Resident #102 and knew he walked around a lot but did not consider him exit seeking. CNA #285 reported Resident #102 had been assigned to CNA #332 on the evening of 02/03/26. Interview on 02/19/26 at 2:39 P.M. with CNA #211 revealed she worked on the night of 02/03/26 but was not assigned to Resident #102. An elopement drill was called early in the morning (on 02/04/26) and staff, including herself, began looking everywhere both inside and outside of the building. CNA #211 reported she got in her car and went down nearby streets looking for Resident #102. She took his picture with her to ask people if they had seen him. She reported Resident #102 ambulated independently but was not known to exit seek. Interview on 02/19/26 at 2:47 P.M. with CNA #332 revealed a few weeks earlier, Resident #102 had eloped. When he began his shift (on 02/03/26 at 7:00 P.M.) he noticed Resident #102 was not in his room. He filled his cart and began rounds and thought Resident #102 might be in the front (of the building). He checked for Resident #102 a second time and the resident was still gone but he had not told the nurse but should have. Later in the shift around 5:00 A.M. (on 02/04/26), he told the nurse when Resident #102 was still not in the building. The nurse initiated an elopement drill. CNA #332 reported Resident #102 ambulated independently but he had not known him to exit seek. An interview on 02/25/26 at 11:13 A.M. with the Administrator and Regional Director of Clinical Operations (RDCO) #410 revealed the presentation of a binder with corrective action the facility had taken after the incident with Resident #102. The Administrator and RDCO #410 reported the facility had implemented corrective action in case the State Agency viewed this as an elopement and not as an unauthorized LOA. Review of the facility policy titled Elopement Prevention and Management Overview, no date, revealed an elopement is defined as when a resident leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at risk for harm or injury. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility was unaware of the resident's departure and/or whereabouts. The deficient practice was corrected on 02/05/26 when the facility implemented the following corrective actions: On 02/04/25 at approximately 5:00 A.M., Resident #102 was identified to be gone from the building and a Code Orange was implemented. A head count was completed by nursing staff on duty and all other residents were accounted for. On 02/04/26 at approximately 10:10 A.M., Resident #102 returned to the facility by means of a family member. Resident #102 was assessed by nursing staff and was found to have no injury, pain, or discomfort and remained at baseline. On 02/04/26, Resident #102's guardian, physician, and NP were notified. On 02/04/26, the DON and Unit Managers completed education to all facility staff on the elopement policy. On 02/04/26, the DON and Unit Managers completed education to all nursing staff on the facility notification policy. The DON audited all residents at risk for elopement and checked the wanderguards for placement and function on 02/04/26. There were no identified concerns. The DON and Unit Managers completed elopement assessments on all residents on 02/04/26. There were no required changes needed. The DON checked the facility's five elopement binders on 02/04/26. There were no required changes. On 02/04/26, the facility's social worker completed a psychosocial visit with Resident #102. The resident remained at his baseline. On 02/04/26, the Administrator placed signage at the front door reminding visitors and staff to ensure residents are not following behind them when they arrive or leave the facility. On 02/04/26, the Administrator educated all receptionists on not leaving the front desk unattended. On 02/04/26, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the incident with Resident #102 and the facility's response. In attendance were the Medical Director, Administrator, and DON. There were no concerns identified. On 02/04/26, an elopement drill was conducted on both day and night shift by the DON. Staff were knowledgeable of the facility's policy and procedure to address missing residents. There were no concerns identified. Beginning on 02/05/26, elopement drills will be conducted by the DON or designee twice weekly for four weeks on various days and shifts. The results of the audits would be reviewed with the Quality Assurance (QA) committee for additional recommendations as warranted. This deficiency represents noncompliance investigated under Master Complaint Number 2784442 and Complaint Number 2745521.

Based on record review, interview, and facility policy review, the facility failed to ensure a physician order for a pressure ulcer treatment was transcribed into the electronic medical records. This affected one resident (#136) of three residents reviewed for physician orders. The facility census was 151.Findings include:Review of Resident #136 ' s medical record revealed an admission date of 02/04/25. Diagnoses included a stage four pressure ulcer (a full thickness wound involving muscle, tendon, and/or bone involvement) to the sacrum (tailbone area), stroke with right sided weakness, and malnutrition.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #136 had intact cognition. Resident #136 was dependent on staff for toileting, bathing, and personal hygiene. Review of the care plan dated 09/18/25 revealed Resident #136 had an actual skin impairment. Interventions included a negative pressure wound vac set at 125 millimeters of mercury (mmHg) of pressure and change the wound vac dressing three times a week on every Tuesday, Thursday, and Saturday, and as needed. Review of Resident #136 ' s physician orders for October 2025 revealed to change wound vac dressing three times a week on Tuesdays, Thursdays and Saturdays and as needed. Physician orders had not included specific information regarding the type of dressing or treatments.Review of a progress note dated 10/17/25 authored by Wound Nurse Practitioner (WNP) #355 revealed orders that included cleanse the sacral area with Dakins (antiseptic) solution, apply skin prep and stoma paste, apply a transparent drape to the area, cut black foam to fit the wound area and apply a transparent dressing over the black foam and set the wound vac to negative 125 mmHg continuously every Tuesday, Thursday, and Saturday.Interview on 10/21/25 at 3:00 P.M. with Registered Nurse (RN) #230, who was the facility's wound nurse, confirmed WNP #355 ' s orders had not been transcribed into his medical records and stated specific wound care orders should have been included in Resident #136 ' s physician orders. Review of the facility policy titled Physician Orders undated revealed physician orders will be transcribed into the electronic medical records.This deficiency represents non-compliance investigated under Complaint Number 2645034.

Based on observation and interview, the facility failed to ensure appropriate infection control techniques were used during incontinence care. This affected one resident (#136) of two residents observed for incontinence care. The facility census was 151.Findings include:Review of Resident #136's medical records revealed an admission date of 02/04/25. Diagnoses included stroke with right sided weakness, muscle weakness, and malnutrition.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #136 had intact cognition. Resident #136 was dependent on staff for toileting and was incontinent of bowel and bladder.Review of the care plan dated 09/18/25 revealed Resident #136 was dependent on staff for toileting. Interventions included to check the resident for incontinence.Observation of incontinence care on 10/20/25 at 10:57 A.M. with Certified Nursing Assistant (CNA) #255 revealed Resident #136 was incontinent of liquid stool. CNA #255 had proceeded to provide Resident #136 with incontinence care while wearing gloves. Upon completion of incontinence care CNA #136 had not removed her soiled gloves and had then proceeded to apply Vaseline to Resident #136's arms and legs using the same soiled gloves she had used to provide incontinence care. Interview with CNA #255 at time of observation revealed she should have removed the soiled gloves after completion of incontinence care. This deficiency represents an incidental finding identified during the complaint investigation.

Based on interview, record review, and facility policy review, the facility failed to timely implement physician orders to insert an indwelling urinary catheter. This affected one resident (#145) of three residents reviewed for urinary tract infection (UTI) prevention. The facility census was 140.Findings include: Review of the medical record for Resident #145 revealed an admission date of 03/20/25 and discharge date of 04/01/25. Diagnoses included orthopedic aftercare, closed fracture of the lower end of left femur, closed fracture of the lateral condyle of left femur, closed fracture of the medial condyle of left femur, fracture of the ninth and tenth thoracic vertebra, and atrial fibrillation. A diagnosis of retention of urine was added upon the date of discharge on [DATE].Review of Resident #145's undated profile sheet revealed the resident was listed as his own responsible party with two children both listed as emergency contacts.Review of the nursing progress notes from 03/20/25 to 03/24/25 revealed Resident #145 was admitted to the facility for skilled therapy services due to a fall which resulted in a left femur fracture. The resident was oriented, able to make needs known, and had no complaints or concerns.Review of Resident #145's physician orders dated 03/25/25 indicated for routine laboratory testing to include a CMP (comprehensive metabolic panel) and for a post-operative orthopedic appointment on 04/01/25.Review of the Nurse Practitioner (NP) progress note dated 03/25/25 revealed Resident #145 had no acute pain and routine laboratory testing was pending. Review of a laboratory test collected on 03/26/25 revealed a high BUN (blood urea nitrogen) level and low GFR (glomerular filtration rate) which both values were used to assess kidney function.Review of the NP progress note dated 03/27/25 revealed Resident #145 denied any changes with bladder function. The laboratory test collected 03/26/25 which resulted in a low GFR indicated stage four chronic kidney disease, so nephrology was to be consulted for evaluation.Review of a laboratory test collected on 03/27/25 again revealed Resident #145 had a high BUN level and low GFR. Review of a nursing progress note dated 03/27/25 revealed the nephrologist was contacted regarding Resident #145's kidney function, and ordered an ultrasound of the kidneys, a bladder scan with PVR (post-void residual) [a measure of the amount of urine remaining in the bladder immediately after urination] and a urinalysis with culture and sensitivity (UA/ CS) [to test for a urinary tract infection] due to the elevated BUN level.Review of Resident #145's physician order dated 03/27/25 revealed to collect a urine specimen for UA/CS, a bladder scan with PVR, and an ultrasound of the kidneys due to the elevated BUN level. The corresponding Treatment Administration Record (TAR) for March 2025 indicated the ultrasound was completed on 03/28/25.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 had moderately impaired cognition and was frequently incontinent of urine. Resident #145 did not have an indwelling urinary catheter.Review of a nursing progress note dated 03/28/25 revealed Resident #145's ultrasound of the bladder and kidneys was completed, including the PVR which resulted in 703 milliliters (mL) of urine left in the bladder after voiding. The nephrologist ordered a Foley catheter (an indwelling urinary catheter) to be inserted.Review of Resident #145's physician order dated 03/28/25 indicated to insert a Foley catheter due to PVR of 703 mL and to change the foley catheter and drainage bag as needed every shift. The corresponding TAR for March 2025 indicated the Foley catheter was inserted on 03/28/25 night shift but no urine specimen had yet been obtained as ordered. Review of the electronic medication administration note dated 03/29/25 at 3:06 P.M. indicated Resident #145 did not have a foley catheter in place as was indicated on the TAR as placed on 03/28/25. There was no indication the physician was contacted.Review of a nursing progress note dated 03/29/25 at 11:02 P.M. revealed Resident #145 was straight catheterized (a urinary catheter used to drain the bladder and not designed to remain in the bladder for extended periods) which drained 1250 mL of urine, and a urine specimen was collected and placed into a refrigerator. There was no documented evidence of urinary discomfort or communication with the physician. The corresponding TAR for March 2025 indicated the urine specimen was collected on 03/29/25 night shift.Review of the electronic medication administration note dated 03/30/25 at 9:27 P.M. indicated Resident #145 continued to have no Foley catheter in place. There was no indication the physician was contacted.Review of a primary care physician progress note dated 03/31/25 revealed Resident #145 denied blood in the urine, difficulty urinating, and had no frequent urination. There was no evidence in the documentation of the physician being aware of the nephrologist's orders for an indwelling urinary catheter to be placed, or that there was a delay in executing those orders. Review of a nursing progress note dated 03/31/25 at 3:09 P.M. revealed Resident #145 had a Foley catheter placed by order of a NP due to retention. The note referenced Resident #145 tolerated the Foley catheter insertion well, having 1500 mL of urine released with some hematuria (blood in the urine) observed. The NP was made aware, and a urine culture was pending.Review of Resident #145's physician orders dated 03/31/25 indicated to insert a Foley catheter to continuous drain for a diagnosis of urinary retention, perform Foley catheter care every shift and as needed, and to change the Foley catheter as needed. The corresponding TAR for March 2025 indicated the Foley catheter was placed on 03/31/25 night shift. Review of the nursing assistant voiding documentation for Resident #145 from 03/27/25 to 03/31/25 revealed the resident was either incontinent using a brief or was continent while using a urinal or the bathroom.Interview on 07/02/25 at 9:32 A.M. with Registered Nurse (RN) #444 who was a Unit Manager confirmed Resident #145's urinalysis ordered on 03/27/25 was not sent to the laboratory until 03/31/25. RN #444 confirmed the urine was not collected until 03/29/25 which was a Saturday, and the laboratory did not pick up specimens on weekends. RN #444 verified Resident #145 had an order for a Foley catheter to be placed on 03/28/25, and although it was signed off as inserted, it was not placed until 03/31/25.Interview on 07/07/25 at 8:39 A.M. with Director of Nursing (DON) verified on 03/28/25, the nurse who received the initial order to place a Foley catheter in Resident #145 had passed the information on to the next shift which was night shift. The night shift nurse indicated the resident voided throughout the night, either by incontinence or use of a urinal, so the physician was contacted to inquire whether the Foley catheter was needed to no avail. The DON confirmed there were no additional attempts to contact the physician recorded in Resident #145's record. From 03/28/25 until the Foley catheter was placed on 03/31/25, staff reported Resident #145 as having no complaints regarding voiding. When RN #444 returned to work, she contacted the NP and inserted Resident #145's Foley catheter. Review of an undated nurse shift report sheet revealed for Resident #145 an order was placed for a foley catheter; however, the resident was using a urinal, and the doctor was called with no answer.Interview on 07/07/25 at 9:20 A.M. with NP #418 revealed Resident #145 was referred to nephrology because of abnormal laboratory values, but denied being aware of the need for a Foley catheter due to urinary retention until 03/31/25.Review of a written witness statement of Licensed Practical Nurse (LPN) #396 undated for 03/28/25 indicated placement of the foley catheter was signed off in error, and Resident #145 was voiding using a urinal, so the physician was contacted to clarify if a foley catheter was needed due to the resident voiding, but there was no answer. It was written onto the nurse report sheet.Review of a written witness statement of RN #433 dated 07/02/25 for 03/27/25 indicated speaking to the nephrologist regarding Resident #145's abnormal laboratory values and new orders received for an ultrasound of the kidneys with a bladder scan for PVR and to obtain a UA/CS. The statement indicated the oncoming shift nurse was notified. Review of a written witness statement of Certified Nursing Assistant (CNA) #337 dated 07/02/25 revealed resident #145 was incontinence and used a brief on 03/28/25.Review of the undated policy, Physician Orders, revealed the provider may write orders in the medical record or may enter an electronic order. A provider may give a medical order over the telephone. A provider may send a signed and dated fax medical order. Verbal orders are accepted but will be input into the electronic medical record by the nurse as soon as practicable. The nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. The policy further explained that outside vendors, including laboratory services, should be contacted to execute the medical order. Review of the undated policy, Notification of Change in Condition, revealed the facility must consult with the resident's medical practitioner when there was a change requiring such notification. Circumstances requiring notification included a significant change in the resident's physical, mental or psychosocial condition, circumstances that required a need to alter treatment which may include a new treatment, or discontinuation of a current treatment. The medical practitioner was to be promptly notified of significant changes in condition, and the medical record must reflect the notification, response and interventions implemented to address the resident's condition. This deficiency represents non-compliance investigated under Complaint Number OH00164261 (1321592).

Based on interview, record review, and facility policy review, the facility failed to complete wound treatments as ordered by the physician. This affected one resident (#114) of three residents reviewed for wound care. The facility census was 140. Findings include:Review of the medical record for Resident #114 revealed an initial admission date of 08/20/24 and re-entry date of 03/18/15. The resident had been hospitalized from [DATE] to 03/18/25 for a wound infection. Diagnoses included polyosteoarthritis, dementia, adult failure to thrive, left-hand and right-hand contractures, left and right shoulder contractures, and severe protein-calorie malnutrition.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #114 had severely impaired cognition and four venous/arterial ulcers. Review of a wound assessment report dated 03/25/25 revealed Resident #114 had a left elbow wound due to end-of-life skin failure, and arterial ulcers to the right hallux (big toe), right heel, left hallux, and left heel.Review of physician orders dated 05/05/25 revealed Resident #114 was admitted to hospice services due to cerebral atherosclerosis with a life expectancy of less than sixth months.Review of a wound assessment report dated 06/02/25 revealed Resident #114 had a sacral/buttocks wound and a left elbow wound due to end-of-life skin failure, and arterial ulcers to the right heel, right hallux, left heel, and left hallux. Review of the physician orders for April 2025 revealed Resident #114 had treatments ordered to the left hallux, left heel, right hallux and right heel arterial ulcers. The left hallux, left heel, and right heel treatments were to cleanse with normal saline solution (NSS), apply betadine (an antiseptic solution), cover with an abdominal (ABD) dressing then wrap with gauze daily on night shift. The right hallux treatment was to cleanse with NSS, apply silver alginate (a dressing used for wounds at risk of or showing signs of infection), cover with an ABD dressing then wrap with gauze daily on night shift. Review of the Treatment Administration Record (TAR) for April 2025 revealed Resident #114's ordered wound treatments were not documented as completed on 04/05/25, 04/17/25, 04/20/25 and 04/25/25. Review of the physician orders for May 2025 revealed Resident #114 had treatments ordered to the left elbow wound and left hallux, left heel, right hallux and right heel arterial ulcers. The left elbow treatment was to cleanse with NSS, apply silver alginate, then cover with a border gauze dressing daily on day shift. The left hallux, left heel, right hallux, and right heel treatments were to cleanse with NSS, apply betadine, cover with an ABD dressing then wrap with gauze three times weekly on night shift. On 05/14/25, the left hallux, left heel, right hallux, and right heel treatments were changed and stated to cleanse with NSS, apply betadine, then leave open to air daily on night shift. Review of the TAR for May 2025 revealed Resident #114's left elbow treatment was not documented as completed on 05/23/25. The treatments to Resident #114's left hallux, left heel, right hallux, and right heel were not documented as completed on 05/03/25 or 05/24/25. Review of the physician orders for June 2025 revealed Resident #114 had treatments ordered to the sacrum/buttocks wound, the left elbow wound, and the left hallux, left heel, right hallux and right heel arterial ulcers. The sacrum/buttocks treatment was to cleanse with NSS, apply silver alginate, cover with a sacral foam dressing, then apply Calmoseptine (a moisture barrier) to the peri-wound (skin surrounding the wound) daily on night shift. The left elbow treatment was to cleanse with NSS, apply silver alginate, then cover with border gauze dressing daily on day shift. The left hallux and left heel treatments were to cleanse with NSS, apply betadine and leave open to air three times weekly on night shift. The right hallux and right heel treatments were to cleanse with NSS, apply betadine, cover with an ABD dressing, and wrap with gauze three times weekly on night shift. On 06/12/25, the right hallux treatment was changed to cleanse with NSS, apply betadine then leave open to air three times weekly on night shift. Review of the TAR for June 2025 revealed Resident #114's sacrum/buttock wound was not documented as completed on 06/12/25, 06/14/25, 06/15/25, 06/21/25 and 06/24/25. Resident #114's left elbow treatment was not documented as completed on 06/06/25. The left hallux treatment was not documented as completed on 06/05/25, 06/12/25, 06/14/25, 06/21/25 and 06/24/25. The left heel treatment was not documented as completed on 06/05/25, 06/14/25, 06/21/25 and 06/24/25. The right heel treatment was not documented as completed on 06/05/25, 06/14/25, 06/21/25 and 06/24/25. The right hallux treatment was not documented as completed on 06/05/25, 06/14/25, 06/21/25 and 06/24/25.Review of nursing progress notes from April 2025 to June 2025 revealed no evidence Resident #114's wound treatments were completed as identified in the above findings. Interview on 07/07/25 at 9:25 A.M. with Director of Nursing verified Resident #114's wound treatments were not completed as ordered by the physician as identified in the above findings.Review of facility policy, Skin Care & Wound Management Overview, undated, revealed completed treatments were to be documented in the electronic treatment administration record.This deficiency represents non-compliance investigated under Complaint Number OH00165152 (1321594) and OH00163754 (1321590).

Based on observation, interview, and review of the facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents except three residents (#68, #75, and #207) who received nothing by mouth and did not receive food from the facility's kitchen. The facility census was 147. Findings include: Observations on 03/03/25 from 10:02 A.M. to 10:23 A.M. during the tour of the kitchen with Mobile Dietary Manager (MDM) #800 revealed on a rack several white dessert plates stacked that had dried brownish, substance and crumbs on several of the plates. Observation of the oven, stove, tilt skillet, and steamer all had various food crumbs and grease on the front and the surfaces on the side of the equipment. The floor in front of the stove, oven, tilt skillet, and steamer and between the stove and the tilt skillet and the tilt skillet and the steamer were dirty with a moderate amount of dark colored debris. Interview on 03/03/25 between 10:02 A.M. and 10:23 A.M. with MDM #800 verified the identified findings and stated they will be taken care of right away. Review of the list of residents with the diet orders provided by facility revealed Resident #68, Resident #75, and Resident #207 had orders to receive nothing by mouth and received no food from the facility's kitchen. Review of the policy Environment, dated September 2017 revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.

Based on observation, interview, and policy review, the facility failed to ensure adequate supervision to prevent accidents related to smoking safety. This had the potential to affect four residents (#62, #85, #98, and #210) of four residents reviewed for smoking. The facility identified 18 current residents who smoked. The facility census was 147. Findings include: Observation on 03/10/25 at 9:15 A.M. of the resident smoke break with Activity Leader #548 revealed Resident #85 and Resident #98 were outside the building, approximately five feet from the glass exit door, smoking cigarettes. Activity Leader #548 was inside the building supervising through the glass door. Resident #210 arrived to smoke break late, and Activity Leader #548 opened the door for her to go out and smoke. Resident #210 wheeled herself out and parked her wheelchair with her back facing the glass door where Activity Leader #548 was supervising. Activity Leader #548 remained inside the building supervising through the door. Resident #85 was observed to pass his lit cigarette to Resident #210 to light her cigarette. Resident #210 then returned the cigarette to Resident #85 and both residents continued to smoke. The approved cigarette disposal receptacle was located approximately thirty feet from the building. Resident #98 smoked his cigarette down to filter and threw it on the ground and motioned Activity Leader #548, who was inside the building, to come out and help him back into the building. Resident #62 then arrived to smoke and the Activity Leader lit her cigarette. Interview with Activity Leader #548 on 03/10/25 at 9:24 A.M. stated she supervised the residents from inside the building. Activity Leader #548 verified that all four residents required supervision with smoking. She stated she did not see Resident #98 throw his cigarette on the ground nor did she see Resident #85 give his cigarette to Resident #210 to light. Activity Leader #548 stated the residents will throw routinely throw their used cigarettes on the ground instead of using the designated receptacle. At the end of the smoking session, Activity Leader #548 stated she typically will retrieve the used cigarettes the residents discard on the ground and disposes of them in the designated receptacle. Interview with the Activity Director on 03/10/25 at 9:30 A.M. stated she would allow staff to supervise residents from inside the building through the glass door if they can visibly see the residents while smoking. Activity Director #559 verified Activity Leader #548 was unable to see Resident #210 smoking. Activity Leader #548 should have walked outside and positioned herself within view of all residents who were outside smoking. Review of the facility policy titled Resident Smoking Guidelines. undated stated a supervised smoker is a resident that is unable to demonstrate safe smoking habits including smoking material management, lighting, controlling cigarette ash, extinguishing smoking materials, and requires staff supervision when smoking. The policy is to promote a resident centered care by providing a safe smoking area for residents that request to smoke and are capable of safe smoking behaviors either independently or with supervision.

Based on interview, record review, and review of facility policy, the facility failed to ensure residents with a diagnosis of Post-Traumatic Stress Disorder (PTSD) were provided culturally competent and trauma-informed care. This affected two residents (#81 and #82) of two residents reviewed for PTSD. The facility census was 147. Findings include: 1. Review of Resident #81's medical record revealed the Resident was admitted to the facility on [DATE]. Her diagnoses included heart disease, burns to her head, face, and neck. Other diagnoses included major depressive disorder, scar conditions and fibrosis, insomnia, Post Traumatic Stress Disorder (PTSD), and restlessness and/or agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had moderately impaired cognition, slight confusion regarding person, place and time. She displayed no signs or symptoms of delirium, and no behaviors were noted. PTSD was noted as an active diagnosis. Review of Resident #81's Social History Assessments, dated 10/19/23 and 11/05/24, completed by Resident #81's nephew and guardian, revealed no information regarding PTSD. Review of Resident 81's care plans revealed nonspecific, generic triggers such as unexpected noises. Interview on 03/05/25 at 10:22 A.M. with Certified Nursing Assistant (CNA) #336, CNA #355, and CNA #542 revealed they were unaware of which residents have PTSD nor where to look for any possible triggers. 2. Review of the medical record for Resident #82 revealed an admitted [DATE] with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, or mood disturbance, hypertensive chronic kidney disease, attention to gastrostomy, dysphagia, malignant neoplasm of the prostate, and benign prostatic hyperplasia with lower urinary tract symptoms. On 01/21/25, a diagnosis was added to the medical diagnoses list for chronic post-traumatic stress disorder (PTSD). Review of the Social History Assessment: Ohio - V8 completed on 11/01/24 revealed Resident #82 had no indication of PTSD, no noted triggers, and listed mental health diagnoses included adjustment disorder with depressed mood, psychotic disturbance, mood disturbance, and anxiety. There were no updated Social History Assessment updates after PTSD was added as an additional diagnosis. Review of the care plan updated on 01/22/25 revealed Resident #82 had the diagnosis of PTSD. Further review of the care plan revealed no etiology, triggers, or resident-specific interventions to mitigate agitation or anxiety related to PTSD. The care plan intervention was to provide quiet areas and comfort item but did not list what items provided Resident #82 comfort. Review of the MDS quarterly assessment dated [DATE] revealed Resident #82 had a severe cognitive impairment with no reported behaviors. Further review of the MDS revealed Resident #82 had non-traumatic brain dysfunction, non-Alzheimer's dementia, and PTSD. Interview on 03/06/25 at 1:51 P.M. with CNA #422 confirmed she was unaware Resident #82 had PTSD and did not know how to find out if he had any specific triggers. CNA #422 suggested the surveyor could probably just ask Resident #82 if he had any triggers. Interview on 03/06/25 at 2:11 P.M. with Licensed Practical Nurse (LPN) #325 confirmed she was not aware Resident #82 had PTSD and was unable to verbalize specific triggers or stressors. Interview on 03/06/25 at 2:15 P.M. with LPN #416 confirmed he had no concerns regarding behaviors and had no encounters where he believed Resident #82 to be triggered. LPN #416 further confirmed staff should be able to find information regarding triggers in the resident charts. At 2:21 P.M., after several minutes of searching Resident #82's electronic medical record, LPN #416 confirmed he was unable to determine anything regarding Resident #82's PTSD-related behaviors or triggers. Interview on 03/05/25 at 2:10 P.M. with the Director of Nursing (DON) reported PTSD triggers are found in the resident's care plan. Interview on 03/06/25 at 11:45 A.M. Regional Registered Nurse (RN) #581 confirmed PTSD triggers are found in the resident's care plan. Review of the list of facility residents who received counseling services in the past six months revealed no counseling services were provided to Resident #81 or Resident #82. Review of facility policy titled Plan of Care Overview, undated, asserted the care plans were written treatment provided for a resident that is resident-focused and provides for optimal personalized care. Review of facility policy titled Behavior Management General, undated, revealed the facility was to identify and safely manage residents who were at risk for displaying behaviors related to psychiatric diagnoses and implement a person-centered plan to help find causes of potential behaviors and de-escalation techniques to mitigate safety risks to self or others.

Based on observation, record review, self-reported incident (SRI) review, review of a police report, facility policy review and interviews, the facility failed to ensure Resident #28, who had dementia, was deemed incompetent, and unable to provide consent, was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm on 11/26/24 at approximately 8:20 P.M. when Resident #18, who had a history of engaging in physical activity (i.e. hand holding and touching behaviors) with Resident #28 without care planned interventions, was observed by Certified Nurse Aide (CNA) #396 engaged in an activity indicative of oral sex on Resident #28. This affected one resident (#28) of three residents reviewed for abuse. The facility census was 158. On 12/10/24 at 4:10 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO)/Registered Nurse (RN) #219 were notified Immediate Jeopardy began on 11/26/24 at approximately 8:20 P.M. when CNA #396 found Resident #28 laying back on her bed with her legs wide open and Resident #18 kneeling with his face between Resident #28's legs. Resident #28, who was cognitively impaired lacked the cognitive ability to consent to the sexual activity. The facility failed to address Resident #18's prior physical aggression towards Resident #28 and a known relationship formed with Resident #28 prior to this sexual abuse incident. In addition, there was no evidence of any further behavioral assessments addressing the capacity to consent to sexual activity in addition to no documented monitoring or consistent interventions being initiated following the observed sexual encounter. The Immediate Jeopardy was removed on 12/11/24 when the facility implemented the following corrective actions: On 11/26/24 at 8:20 P.M. CNA #396 knocked on Resident #28's door, walked in and noticed Resident #28 laying on her back on her bed with her legs open and Resident #18 on his knees with his face in between the resident's legs. Residents #18 and #28 were immediately separated by CNA #396 and Resident #18 was placed on one-on-one (1:1) supervision with CNA #396. The 1:1 supervision ended on 12/03/24 at 7:00 A.M. On 11/26/24 At 8:29 P.M. CNA #396 notified the Administrator of an allegation of resident-to-resident sexual abuse. On 11/26/24 At 8:32 P.M. the Administrator notified the DON of an allegation of resident-to-resident sexual abuse. On 11/26/24 At 8:34 P.M. the DON notified RDCO/RN #219 and Regional Director of Operations (RDO) #410 of an allegation of resident-to-resident sexual abuse. On 11/26/24 at 9:00 P.M. the DON and RDCO/RN #219 interviewed Resident #18 and Resident #28 by phone as the staff members were not in the facility at that time. On 11/26/24 at 10:00 P.M. the Administrator submitted a SRI report with the State Agency. On 11/26/24 at 10:20 P.M. the families of Resident #18 and Resident #28 were made aware of the allegation of resident-to-resident sexual abuse. On 11/26/24 at 10:20 P.M. Licensed Practical Nurse (LPN) #310 called the police to report the allegation of resident-to-resident sexual abuse. On 11/26/24 at 11:00 P.M. LPN #310 notified On-call Physician #196 of the allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. No new orders were given and he recommended to follow up with in-house provider and DON. On 11/26/24 at 11:27 P.M. LPN #310 attempted to check Resident #28's skin but she refused. On 11/26/24 at 11:52 P.M. LPN #310 attempted to check Resident #18's skin but he refused. On 11/27/24 Unit Manager (UM)/LPN #368 completed skin checks on all residents on the Connections (dementia) unit. On 11/27/24 the DON/designee provided education throughout the day to the Connections unit staff by on sexual abuse and sexual behaviors including behavior to look for such as holding hands, kissing and spending a lot of time together. Education to staff included reporting behaviors to the Administrator, DON, and/or UM/LPN #368. Any staff not there were educated their next scheduled day of work. On 11/27/24, UM/LPN #368 placed a note at the nurses' station informing staff Resident #18 and Resident #28 were not permitted to be left alone behind closed doors due to the allegation of sexual abuse. This was communicated to staff via shift-to-shift report. Any staff not there were educated their next scheduled day of work. On 11/27/24 at 5:30 P.M. Nurse Practitioner (NP) #195 assessed Resident #18 and Resident #28 with no new orders provided at that time. On 12/09/24 at 10:20 A.M. Licensed Social Worker (LSW) #245 made a referral to another facility for Resident #18 per family request as the family talked about him residing on an all-male unit. On 12/10/24 and 12/11/24 the DON/Designee interviewed all residents on the Connections unit to determine their capacity to consent to sexual behavior with the questionnaire from the facility's policy, Process for Consensual Sexual Behavior. It was determined no residents had the capacity to consent on the Connections unit including both Resident #18 and Resident #28. If a resident would have the capacity to consent to sexual activity, the facility would involve the physician, interdisciplinary team (IDT) and resident's guardian/representative and the team will discuss the risks/benefits of sexual behavior and develop a plan of care. On 12/10/24 at 4:51 P.M. Resident #18 was immediately placed on 1:1 supervision with physician's order written by UM/LPN #368 and care plan updated by Minimum Data Set (MDS)/LPN #309 to reflect resident required 1:1. Resident #18's Kardex (care card) was also updated so staff were aware. Resident #18 would remain on 1:1 supervision until discharged from the facility. MDS/LPN #309 also reviewed Resident #28's care plan and no additional changes were made. On 12/10/24 and 12/11/24 the DON/Designee interviewed staff working on the Connections unit regarding knowledge of any residents that have a sexual relationship who lack the capacity to consent. Any resident found to be having sexual relations with other residents who lack the capacity to consent would be reviewed by the physician and IDT team to discuss the risks/benefits of sexual behavior and this would be discussed with the resident's guardian/representative and a plan of care would be developed. There were no other residents that were identified to be having a sexual relationship and there were no additional resident-to-resident sexual occurrences found. DON/Designee reviewed all charts on the unit as well with no findings. On 12/10/24 and 12/11/24 the DON/Designee educated all staff on the facility's abuse and neglect policy which included: (a) What constitutes abuse and types of abuse and neglect; (b) Identification of signs and symptoms in residents and staff of potential abuse and abusers; (c) Actions to take when abuse is witnessed, suspected, or alleged; (d) Timely and appropriate reporting of witnessed, suspected, or alleged abuse to all responsible parties per facility policy; (e) Protection of resident while conducting a thorough investigation of alleged abuse; (f) Proper assessment of residents who have been or suspected to be abused; (g) Prevention of future incidents of abuse from occurring; (h) Sexual activity between residents including what constitutes sexual abuse per Centers for Medicare and Medicaid Services (CMS) guidelines and what to do when you identify inappropriate sexual behaviors including reporting to your supervisor, DON, or Administrator and holding a meeting with physicians, IDT and family to develop a plan of care for the resident. Staff were also educated on the facility's dementia policy as the allegation of resident-to-resident sexual abuse occurred on the Connections (dementia) unit. Additionally, staff were educated on behaviors and what to look for with residents that lack the capacity to consent to sexual behaviors. Staff on leave to be educated upon return and prior to working the floor. On 12/11/24 from 9:30 A.M. to 2:00 P.M. the DON/Designee started additional skin checks on all residents on the Connections unit. On 12/11/24 at 10:00 A.M. Medical Director (MD)/Physician #406 completed medication reviews for Resident #18 and Resident #28. On 12/11/24 at 11:00 A.M. LSW #245 completed psychosocial reviews for Resident #18 and Resident #28. On 12/11/24 at 11:00 A.M. the Administrator/designee had an ad hoc Quality Assurance/Performance Improvement (QAPI) meeting to discuss the Immediate Jeopardy and abatement plan, the facility's abuse policy and the resident-to-resident sexual abuse involving Resident #18 and Resident #28. Staff present included the Administrator, the DON, Infection Preventionist (IP)/RN #370, (MD)/Physician #406, UM/LPN #240, UM/LPN #368, LPN/UM #349, UM/RN #395, RDCO/RN #219, Regional Resident Care Coordinator (RRCC)/RN #411 and Divisional Director of Clinical Operations (DDCO)/RN #199. Beginning 12/11/24, LSW #245 would continue offering support to Resident #18 and Resident #28 by weekly visits for four weeks then as needed. Beginning 12/11/24 all facility-reported incidents would be reviewed by DON/Designee immediately to ensure no other residents were affected. DON/Designee to address issues with reported incidents immediately upon identification. This would be ongoing. Beginning 12/11/24 all allegations of abuse would be reported to the RDCO/RN #219 by the DON or Administrator as soon as the allegation was made. This would be ongoing. Beginning on 12/11/24 the DON/Designee would educate all new staff on Abuse, Dementia and Behavioral Health management. This would be ongoing as part of new hire orientation. Beginning on 12/11/24 the DON/Designee would observe five residents weekly for four weeks, then three residents weekly for four weeks, then two residents weekly for four weeks to look for any inappropriate sexual behaviors between residents. This would continue until compliance was achieved. Beginning on 12/11/24, the Administrator/Designee would interview five staff members weekly for four weeks, then three staff members weekly for four weeks, then two staff members weekly for four weeks to determine if there have been any inappropriate sexual behaviors between residents. This would continue until compliance was achieved. The Administrator or DON would monitor compliance with the above during monthly QAPI meetings for three months, then as needed for one year. The RDCO/RN #219 would monitor compliance with the above during monthly visits times for three months then on an as needed basis. Interviews on 12/16/24 from 7:55 A.M. to 9:07 A.M. with LPN/Medical Records #307, UM/RN/Assistant Director of Nursing (ADON) #307, CNA #390, CNA #365, CNA #382, Activities Aide (AA) #232 and RN #351 confirmed they received education on sexual abuse, dementia, sexual behaviors between residents and sexual consent. Although the Immediate Jeopardy was removed on 12/11/24 the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of Resident #28's medical record revealed an admitted [DATE] with diagnoses including heart disease, vascular dementia with other behavioral disturbance, depression, cognitive communication deficit, insomnia, post-traumatic stress disorder (PTSD), dysphagia, burn of unspecified degree of head, face and neck restlessness and agitation. Review of Resident #28's guardianship documentation revealed she was deemed incompetent and had a guardian of person effective 03/13/20. Review of Resident #28's care plans revealed a plan of care dated 08/23/21 and revised 03/24/22 for impaired cognitive function related to dementia with listed interventions including observe/document report to medical provider any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. Review of a plan of care dated 05/02/23 revealed Resident #28 required placement on a secured unit with listed interventions including notify medical provider/resident representative of behavior changes and provide diversionary activities as needed and redirect when appropriate. Review of Resident #28's physician's orders revealed an order dated 06/16/23 for behavior monitoring which included: 1. Withdrawn 2. Tearful. 3. Refusal of Care. 4. Poor appetite. Non-pharmacological intervention: 1. Redirect. 2: One-on-one. Every shift for behaviors. Review of Resident #28's progress notes revealed a telehealth note dated 03/21/24 at 1:13 A.M. with the following information: Resident #28 was jumped on by another resident (on dementia unit). No fall to ground, unwitnessed. Noted to have small, very superficial abrasion to nose. No tenderness to palpitation. Residents are separated. Police are on site. Review of a nurse's note dated 03/21/24 at 1:53 A.M. revealed the following information: At approximately 12:35 A.M. Resident #28 alerted this nurse that another resident jumped on her. Upon assessment resident noted to have small abrasion to nose, scratch. Resident immediately separated for safety. Vitals obtained, appropriate notifications made, and supervisor noted. Police called and on-site talking with resident. This nurse instructed resident to call for help and use call light if any residents attempted to enter room. Review of a facility SRI dated 03/21/24 at 12:35 A.M. revealed an allegation of resident-to-resident physical abuse between Resident #18 and Resident #28. Resident #28 alleged Resident #18 hit her and/or jumped on her. Resident #18's cognition was listed as oriented times one and Resident #28's cognition was listed as oriented times one. Staff statements were included from CNA #400, the police were called, and skin sweeps were completed on like residents. The facility determined the allegation of abuse was unsubstantiated due to no witnesses. Review of an IDT follow up note dated 03/22/24 at 11:40 A.M. revealed the following information: Resident to Resident incident. Resident #28 reported other male resident jumped on her in her room. The resident has a small, reddened area to her nose, no further injuries or complaints. Root cause: dementia. Interventions put into place: residents immediately separated, one on one with male resident and treatment given to injured area. Review of Resident #28's medical record revealed there was no further follow up with additional interventions to address the 03/21/24 incident. Review of a plan of care dated 04/24/24 revealed Resident #28 had a communication problem related to dementia with listed interventions including observe for declines in communication and anticipate and meet needs. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a brief interview for mental status (BIMS) score of nine, indicating moderate cognitive impairment and had no behaviors coded on the assessment. Review of a plan of care dated 09/30/24 revealed Resident #28 had diagnosis of PTSD with listed interventions including observe for increased agitation, anxiety and offer quiet areas and comfort items, observe resident in group situations and prevent resident from becoming overstimulated and assist resident in identifying what triggers PTSD episodes. Review of a nurses' note dated 11/26/24 at 11:28 P.M. and authored by LPN #310 revealed the following information: Around 10:00 P.M. while doing rounds, CNA entered Resident #28's room and saw the resident laying in her bed with pants down with a male resident kneeling in front of her with his head within proximity of her vagina. Residents were immediately separated. Resident #28 was interviewed, stated she consented, not forced and felt safe. Guardian notified. Physician notified. Police notified. Resident #28 resting in room, will continue to monitor. Review of a facility SRI dated 11/26/24 revealed an allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. Resident #18 was allegedly found to be performing oral sex on Resident #28 on 11/26/24 at approximately 8:30 P.M. CNA #396 found Resident #18 kneeling with his head in proximity of Resident #28's vagina. Both residents were separated and interviewed and reported consenting to the behavior and understanding what they were engaged in. Resident #28 also stated she was in a relationship with Resident #18. The facility determined the allegation of sexual abuse to be unsubstantiated as both residents consented to the sexual interaction. Review of a telehealth note dated 11/27/24 at 12:00 A.M. and authored by Physician #196 revealed the following information: Resident #28 was seen with another resident appearing to have intimate contact. Both residents have dementia, and acts were consensual per the residents. Follow with in house provider and DON. Review of a nurse practitioner note dated 11/27/24 at 1:00 A.M. and authored by NP #195 revealed the following information: Met with Resident #28 today to follow-up for nursing reports of patient having physical interaction of a sexual nature. Per nursing report and chart review, Resident #28 was seen laying in her bed with another resident/male between her legs. It is important to know that the patient is currently a resident on a locked dementia unit. Resident #28 does have a diagnosis of vascular dementia. Resident #28 is alert and oriented times one to two at baseline. Resident #28 reports she is angry she is being questioned repeatedly and repeatedly states the other resident is her boyfriend. Resident #28 denies being forced to do anything and denied wanting to press charges or file a complaint on the other resident. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was moderately cognitively impaired, required set up for eating, supervision for toileting, dressing and personal hygiene and most ambulatory tasks. Review of a plan of care dated 12/09/24 and revised 12/09/24 revealed Resident #28 had a behavior problem with listed interventions including '11/26/24 not to be in room with male with door closed,' communicate with resident/resident representative regarding behaviors and treatment, intervene as necessary to protect the rights and safety of others and notify medical provider of increased episodes of behaviors. Record review as of 12/09/24 revealed the facility had not assessed or developed a comprehensive or individualized plan care for Resident #28 related to human sexuality needs or preferences or the resident's capacity to consent to sexual activity. Review of Resident #28's Kardex as of 12/10/24 had a notation under 'Monitoring' on 11/26/24 for not being in room with male with door closed. Review of Resident #18's medical record revealed an admitted [DATE] with diagnoses including depression, anxiety, dementia with agitation, cognitive communication deficit and history of transient ischemic attack (TIA). Review of Resident #18's care plans revealed a plan of care dated 11/23/22 for impaired cognitive function [related to] dementia and listed interventions including communicate with resident/family/caregivers regarding resident's capabilities and needs, discuss concerns about confusion, disease process and nursing home placement with resident/family/caregiver and keep routine as consistent as possible in order to decrease confusion. Review of a plan of care dated 11/23/22 revealed Resident #18 required a secured unit due to dementia and listed interventions included notify medical provider/resident representative of behavior changes and provide diversionary activities as needed. Redirect when appropriate. Review of a plan of care dated 11/25/22 revealed Resident #18 wandered aimlessly from place to place, and listed interventions included notify medical provider, resident representative of behavior changes and notify staff of wandering risk. Review of a plan of care dated 11/30/22 and revised 10/16/24 revealed Resident #18 had a behavior problem [related to] disease process, nursing home admission, refusal of medication, banging on exit doors, history of refusing labs, screaming at others, cursing at others, layers clothing, refuses to change daily including socks/underwear, refuses shower feels doesn't needs it and hoards personal care items (personal/private bought) with listed interventions including '11/26/24 not be in room with female with door closed (initiated 12/09/24),' behavioral health consults as needed, communicate with resident/resident representative regarding behaviors and treatment, intervene as necessary to protect the rights and safety of others, monitor behavioral episodes and attempt to determine underlying causes and notify medical provider of increased episodes of behaviors. Review of a plan of care dated 11/30/22 and revised 10/16/24 revealed Resident #18 had a communication problem due to other disease process/condition usually understands and is usually understood with listed interventions including observe for declines in communication and anticipate and meet needs. Review of Resident #18's physician's orders revealed an order dated of 06/16/23 for behavior monitoring which included: 1. Withdrawn 2. Tearful. 3. Resists Care. 4. Agitation. Non-pharmacological intervention: 1. One-on-one. 2: Calm quiet environment. 3. Activity. 4. Meet Needs Every shift for behaviors as well as an order dated 12/05/24 for monitor resident for exit-seeking behaviors and document each shift twice a day. Resident #18's guardianship documentation revealed he was deemed incompetent and had a guardian of person and estate effective 07/17/23. Review of Resident #18's progress notes revealed a telehealth note dated 03/21/24 at 1:49 A.M. revealed the following information: 'Patient on dementia unit, allegedly hit another resident. Police were on site. Reports have been filed. Residents immediately separated. Resident #18 now calm. No change in behavior from baseline. Review of a nurse's note dated 03/21/24 at 2:16 A.M. revealed the following information: At approximately 12:35 A.M. this shift another resident alleged Resident #18 jumped on her. Residents immediately separated for safety and Resident #18 instructed to stay in his room. Vitals obtained, abrasion noted to right hand, appears to be a scratch. Appropriate notifications were made, and the police were called and were onsite taking statement. Review of a facility SRI dated 03/21/24 at 12:35 A.M. revealed an allegation of resident-to-resident physical abuse between Resident #18 and Resident #28. Resident #28 alleged Resident #18 hit her and/or jumped on her. Resident #18's cognition was listed as 'oriented times one' and Resident #28's cognition was listed as 'oriented times one.' Staff statements were included from CNA #400, the police were called, and skin sweeps were completed on like residents. The facility determined the allegation of abuse was unsubstantiated due to no witnesses. Review of a nurse practitioner note dated 03/22/24 at 1:00 A.M. and authored by NP #194 revealed the following information: Resident #18 resides on the dementia unit due to the condition. It was reported he was involved in an altercation with another female resident yesterday and the female member sustained a small scratch to the nose. Resident #18 denies any such incident occurring. Today, Resident #18 was observed acting well with the other resident. He is alert and oriented times one to two and ambulates independently. Review of an IDT follow-up note dated 03/22/24 at 11:44 A.M. revealed the following information: Resident to Resident incident. It was reported by female resident; Resident #18 jumped on her in her room causing a small abrasion to his hand. No further injuries or complaints. Root cause: dementia. Interventions put into place: residents immediately separated, one on one with male resident and treatment given to injured area. Review of Resident #18's medical record revealed no evidence of the one-on-one supervision or additional interventions adding to his comprehensive care plan to address the incident. Review of Resident #18's annual MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, had no behaviors coded on the assessment and required set up for meals, dressing and toileting. Resident #18 required supervision for ambulation and was independent with most mobility. Review of a nurses' note dated 11/26/24 at 11:43 P.M. and authored by LPN #310 revealed the following information: Around 10:00 P.M. during rounds CNA walked into female resident room and saw Resident #18 kneeling in front of her with his head within proximity of her vagina. Residents were immediately separated. Resident #18 was interviewed and stated it was consensual, not forced and he felt safe. Guardian and physician notified as well as police. Review of a telehealth note dated 11/27/24 at 12:02 A.M. and authored by Physician #196 revealed the following information: Resident #18 was seen with another resident appearing to have intimate contact. Both residents have dementia and acts were consensual per the residents. Follow with in house provider and DON. Review of a nurse practitioner note dated 11/27/24 at 1:00 A.M. and authored by NP #195 revealed the following information: Nursing reports that patient was observed in an alleged sexual encounter with another resident. Per nursing report and chart review Resident #18 was found in another resident's room. The other patient was laying on the bed and Resident #18 was between her legs. It is important to understand that Resident #18 is on a locked dementia unit and has a diagnosis of dementia. Nursing reports that Resident #18 has a history of developing relationships, girlfriend/boyfriend intermittently with other residents since his stay at the facility. Resident #18 has been seen socializing more closely with this resident as opposed to others. There have been no other inappropriate behaviors observed or reported before this incident. Resident #18 reports he is very angry with questioning he has had to answer regarding the incident. Resident #18 was initially dismissive and would not talk but after some encouragement he reports he did nothing wrong and was with his girlfriend. Resident #18 declines being forced to do anything and declines having to force the other resident. Resident #18 reports it has been a consensual relationship. Review of Resident #18's nurse's notes from March 2024 through November 2024 did not contain any documentation regarding Resident #18 holding hands with other residents, putting his arm around other residents or developing a relationship with other residents. Review of a facility SRI dated 11/26/24 revealed an allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. Resident #18 was allegedly found to be performing oral sex on Resident #28 on 11/26/24 at approximately 8:30 P.M. CNA #396 found Resident #18 kneeling with his head in proximity of Resident #28's vagina. Both residents were separated and interviewed and reported consenting to the behavior and understanding what they were engaged in. Resident #28 also stated she was in a relationship with Resident #18. The facility determined the allegation of sexual abuse to be unsubstantiated as both residents consented to the sexual interaction. Review of a witness statement dated 11/26/24 and authored by LPN #310 revealed the following information: Since beginning of shift on 11/26/24 both residents (#18, #28) were acting normal, at their baseline, in a good mood, no change in condition, no behaviors, no issues or complaints. Review of a witness statement dated 11/26/24 and authored by CNA #396 revealed the following information: I was doing rounds and noticed Resident #24 was not in her room so I knocked on Resident #28's door and walked in and saw Resident #28 laying back on her bed with her legs wide open and Resident #18 on his knees with his face in between her legs. Review of a staff schedule for 11/26/24 7:00 P.M. to 7:00 A.M. identified three staff working on the Connections secured unit: LPN #310, CNA #396 and CNA #358. No witness statement was available for CNA #358. Review of a typed, unauthored interview dated 11/27/24 with Resident #28 revealed the following information: Resident #28 shared she and the gentleman were in an average relationship and that no sexual contact occurred. Resident #28 stated she is not married, just an average relationship and reported other patient did not have a spouse. Resident #28 stated sexual intimacy occurred between people that care for one another and that she was not taken advantage of. Resident #28 indicated she could say no to sexual contact. Resident #28 stated she was aware one of them may move but that did not mean their relationship will end. Review of a typed, unauthored interview dated 11/27/24 with Resident #18 revealed the social worker read the questions and Resident #18 responded 'no' to the first four questions relating to who initiated the sexual contact, did the patient believe the other person was a spouse, what level of sexual intimacy was he comfortable with and if the behavior was consistent with formerly held beliefs/values. Resident #18 stated he could say no to sexual contact. Resident #18 said he would be fine when the relationship ends, and he would just not see her anymore. Review of a typed interview completed by the DON and RDCO/RN #219 on 11/26/24 at 9:00 P.M. with Resident #28 revealed she knew what was happening in her room with Resident #18 and thought they were alone in here. Resident #18 stated she was not forced during this episode, no one put a gun to my head, stated she felt safe and was not hurt. Review of a typed interview completed by the DON and RDCO/RN #219 on 11/26/24 at 9:00 P.M. with Resident #18 revealed he understood what was happening in his room with Resident #28, he was not forced, felt safe and was not hurt, and leave me alone. Review of a police report dated 11/26/24 at 10:11 P.M. revealed LPN #310 placed a call for a sex offense at the facility. Comments on the report read: Needs to report sexual abuse between two patients on the dementia unit. Both parties say it was consensual but because it is the dementia unit staff was advised they need to make a report. Parties involved: Resident #18 and Resident #28. Record review as of 12/09/24 revealed the facility had not assessed or developed a comprehensive or individualized plan care for Resident #18 related to human sexuality needs or preferences or the resident's capacity to consent to sexual activity. Review of Resident #18's Kardex as of 12/10/24 had a notation under 'Monitoring' on 11/26/24 for not being in room with female with door closed. Observation on 12/09/24 at 9:19 A.M. with Resident #28 revealed she was sitting in bed in her room eating breakfast without issue. When the surveyor introduced herself to attempt an interview, Resident #28 nodded when her name was said and said I don't know as several questions were asked about how long she had lived at the facility and if she had friends or boyfriends at the facility. The interview was terminated due to Resident #28's decreased cognitive ability. Interview on 12/09/24 at 9:30 A.M. with Resident #18 revealed he had been at the facility for one month and was going home soon. Resident #18 denied having any female friends at the facility, denied any intimate relationships with any of the female residents on the unit and denied sexual interactions with Resident #28 as he did not spend time with her. Resident #18 then voi [TRUNCATED]

Based on personnel file review, interview, review of facility policies and review of the Ohio Revised Code (ORC), the facility failed to hire staff free of disqualifying offenses. This affected one out of seven personnel files reviewed and had the potential to affect all 158 residents residing in the facility. Findings include: Review of personnel files on 12/11/24 starting at 2:20 P.M. with Employee Lifecycle Manager (ELM) #246 and Regional Employee Engagement Specialist ([NAME]) #197 revealed the following area of concern: Review of Maintenance Staff (MS) #385's personnel file revealed a date of hire of 04/28/23. MS #385 was on the Bureau of Criminal Investigation (BCI) log as having a background check sent on 04/27/23 and the results returning on 05/11/23 with no findings. ELM #246 and [NAME] #197 were asked to provide the background check report. Further review of MS #385's background check report dated 05/12/23 revealed charges for domestic violence (2919.25) on 12/28/95. No personal care standards were located within MS #385's personnel file. Interview with [NAME] #197 verified the above findings at the time of discovery and confirmed MS #385 did not have personal care standards completed within his personnel file or background check reports. Review of the facility policy, Background Checks/Abuse Checks Under Ohio Law, effective 10/01/00 revealed if an individual had convictions you will see a printout that will list all convictions for that individual not just convictions for disqualifying crimes. You will need to review the printout to determine whether any of the convictions are disqualifying. The printout will also include arrests for which the Bureau of Criminal Investigation (BCII) or the Federal Bureau of Investigation (FBI) has no record of disposition (i.e. they do not know how the matter turned out in the courts). If a job applicant has been arrested for what would be a disqualifying crime but there is no disposition listed, you will have to investigate yourself to find out what the result was. You may put the burden on the applicant to provide you with evidence of what the disposition of the offense was you are not required to hire someone with a prohibited offense regardless of whether they can meet personal care standards or not Any individual found not eligible to work may not be employed. Review of the policy, Ohio Prohibited Offenses, dated 10/01/19 revealed applicants coming under final consideration for employment with the facility's corporation may not have been convicted of, plead guilty to or plead no contest to the listed offenses including 2919.25 domestic violence. Review of ORC Rule 3701-13-05, Disqualifying Offenses, dated 12/08/23 revealed except as set forth in the personal character standards established in rule 3701-13-06 of the Administrative Code, no Direct Care Provider is allowed to employ a person in a position that involves providing direct care to an older adult if the person has been convicted of or pleaded guilty to a violation of any of the following sections of the Revised Code . including 2919.25 domestic violence.

Based on personnel record review, facility policy review, and interview, the facility failed to implement their abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry (NAR) prior to working with residents as well as completing background checks as required. This affected six out of seven personnel files reviewed and had the potential to affect all 158 residents who resided in the facility. Findings include: Review of personnel files on 12/11/24 starting at 2:20 P.M. with Employee Lifecycle Manager (ELM) #246 and Regional Employee Engagement Specialist ([NAME]) #197 revealed the following areas of concern: Review of Certified Nurse Aide (CNA) #365's personnel file revealed a date of hire of 11/29/23. CNA #365 was checked against the NAR on 12/19/23, after she had already been working with residents. CNA #365 was not on the facility's background check log and her file contained no envelope with background checks available for further review. Review of Dietary Aide (DA) #338's personnel file revealed a date of hire of 08/08/24. DA #338's file lacked evidence she was checked against the NAR. DA #338 was not on the background check log and a copy of her background checks was present dated 12/11/24. Review of CNA #384's personnel file revealed a date of hire of 08/14/24. CNA #384 was checked against the NAR on 09/03/24, after she had already been working with residents. Review of Licensed Practical Nurse (LPN) #324's personnel file revealed a date of hire of 04/03/24. LPN #324's file lacked evidence she was checked against the NAR. Review of Maintenance Staff (MS) #385's personnel file revealed a date of hire of 04/28/23. MS #385's personnel file lacked evidence he was checked against the NAR. Review of Receptionist #224's personnel file revealed a date of hire of 06/16/23. Receptionist #224's personnel file lacked evidence she was checked against the NAR. Receptionist #224 was on the facility's background check log, however, her file contained no envelope with background checks available for further review. Interview with [NAME] #197 verified the above findings at the time of discovery and confirmed the NAR was to be checked and background checks were to be run for all potential employees before they were hired to ensure no applicant had a finding of abuse, neglect, misappropriation or other disqualifying offenses. Review of the policy, Background Checks/Abuse Checks Under Ohio Law, dated 10/01/00 revealed it was policy of the facility's corporation to assure a check of the Ohio NAR registry was completed on all candidates for employment prior to a job offer being made. When hiring or rehiring any employee, including contract employees, to any position within an Ohio facility, you must conduct an Ohio Bureau of Criminal Identification and Investigation (BCII) and Federal Bureau of Investigation (FBI) check prior to date of hire. Review of the facility policy, Ohio Abuse, Neglect and Misappropriation, no date revealed following the personal interview and upon recommendation of the interviewer, background checks will be performed. A pre-hire criminal background check will be performed for all potential Ohio staff. Licensure/registry checks will be performed after the interview to verify the NAR. All checks will be managed by the facility Human Resources manager/designee and results will be reviewed with the appropriate department head and administration.

Based on record review, review of the facility assessment, self-reported incident (SRI) review and interview the facility failed to maintain sufficient levels of staff on the secured care unit to meet the supervisory needs of all residents. This affected two residents (#18 and #28) and had the potential to affect the 41 residents residing on the facility's secured memory care unit. Facility census was 158. Findings include: Review of the facility assessment dated [DATE] revealed based on the facility resident population and their needs for care and support, our approach to staffing is to ensure that each of our nursing facility residents has the minimum direct care staff to meet the needs of the residents at any given time. We work to assure necessary staff based on the model shown. For the Connections (secured) unit on night shift, there were to be one to two licensed nurses and two to three nurse aides. The facility assessment did not delineate what would determine more or less nurses or aides or at what point staffing would change on the Connections unit. Review of a staff schedule for 11/26/24 from 7:00 P.M. to 7:00 A.M. identified three staff working on the Connections secured unit: Licensed Practical Nurse (LPN) #310, Certified Nurse Aide (CNA) #396 and CNA #358. In addition, concerns for Resident #18 and Resident #28 were identified which correlated to a lack of staffing and resident supervision on 11/26/24: Review of a facility SRI dated 11/26/24 revealed an allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. Resident #18 was allegedly found to be performing oral sex on Resident #28 on 11/26/24 at approximately 8:30 P.M. CNA #396 found Resident #18 kneeling with his head in proximity of Resident #28's vagina. Both residents were separated and interviewed and reported consenting to the behavior and understanding what they were engaged in. Resident #28 also stated she was in a relationship with Resident #18. The facility determined the allegation of sexual abuse to be unsubstantiated as both residents consented to the sexual interaction. Review of a witness statement dated 11/26/24 and authored by LPN #310 revealed the following information: Since beginning of shift on 11/26/24 both residents (#18, #28) were acting normal, at their baseline, in a good mood, no change in condition, no behaviors, no issues or complaints. Review of a witness statement dated 11/26/24 and authored by CNA #396 revealed the following information: I was doing rounds and noticed Resident #24 was not in her room so I knocked on Resident #28's door and walked in and saw Resident #28 laying back on her bed with her legs wide open and Resident #18 on his knees with his face in between her legs. No witness statement was available for CNA #358. A telephone interview on 12/10/24 at 8:33 A.M. and 2:09 P.M. with CNA #396 revealed on 11/26/24 around 8:30 P.M. she had identified Resident #24 was not in her bed so she went to her (Resident #24's old room (which was Resident #28's current room) to look for the resident. When she arrived to this room, she witnessed Resident #18 giving Resident #28 oral sex. CNA #396 stated both residents did not have pants on and Resident #18 was on his knees and his head was between Resident #28's legs. CNA #396 called LPN #310 down and reported what she saw to the Administrator. CNA #396 stated they separated both residents at that time. CNA #396 shared the night of the incident, a staff member had called off, so it was only her, LPN #310 and CNA #358 on the dementia unit from 7:00 P.M. to 7:00 A.M. When asked about when both residents had been last seen (as her witness statement did not contain this information), CNA #396 stated 15 minutes prior, both residents were sitting at the table together on the unit. A telephone interview on 12/10/24 at 9:31 A.M. and 2:11 P.M. with CNA #358 revealed she was aware of the sexual interaction that had occurred between Resident #18 and Resident #28 but was providing patient care to other residents at the time it was discovered. CNA #358 stated the nurse and the other CNA were the only other staff on the unit at the time. When asked when she last saw Resident #18, CNA #358 stated he had been upset at his roommate and was sitting in the dining room before 12:00 A.M. but did not recall further. When asked when she last saw Resident #28, CNA #358 stated she put her roommate to bed before 8:00 P.M. An interview was attempted with LPN #310 on 12/10/24 at 8:32 A.M. but was not successful. Interview on 12/16/24 at 2:09 P.M. with the Administrator revealed for staffing schedules, the facility's corporation utilized an outside company based in Dubai that made the schedules and she, the Director of Nursing (DON) and Human Resources (HR) got on daily calls with their point person to discuss the schedule. The Administrator stated since she had starting working at this facility in January 2024, the facility did not utilize staffing agencies to meet staffing needs. The Administrator explained they had a dedicated call-off specialist that would help to fill holes in the schedule 72 hours out, but the DON and Unit Managers would help to fill scheduling needs when changes occurred more last minute. The on-call manager would call staff to try to get the call-off replaced and if it could not be covered, staff could be pulled from a unit with less acuity and if the situation was really bad the on-call manager would have to come in to work. The Administrator was asked regarding the facility assessment and what determined two versus three aides on the Connections unit on night shift as the facility assessment did not specify and she indicated that census as well as resident behaviors or need to have a one-on-one staff would impact how many staff were needed on the unit at any given time. The Administrator explained that there was a staffing ladder for the whole building which was based on census number and would give how many total CNAs could be in the building but confirmed this did not break down further into units, including the Connections unit. The Administrator confirmed the schedule provided for 11/26/24 was accurate and as-worked with one LPN and two CNAs working at the time the sexual abuse between Resident #18 and Resident #28 occurred.

Based on record review, review of a self-reported incident (SRI), review of facility policies and interview, the facility failed to timely inform residents' attending physicians of an instance of resident-to-resident sexual abuse. This affected two residents (Resident #18 and Resident #28) out of three residents reviewed for abuse. Facility census was 158. Findings include: 1. Review of Resident #28's medical record revealed an admitted [DATE] and diagnoses including heart disease, vascular dementia with other behavioral disturbance, depression, cognitive communication deficit, insomnia, post-traumatic stress disorder (PTSD), dysphagia, burn of unspecified degree of head, face and neck restlessness and agitation. Review of Resident #28's guardianship documentation revealed she was deemed incompetent and had a guardian of person effective 03/13/20. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a brief interview for mental status (BIMS) score of nine, indicating moderate cognitive impairment and had no behaviors coded on the assessment. Review of Resident #28's plans of care revealed a plan of care dated 08/23/21 and revised 03/24/22 for impaired cognitive function related to dementia with listed interventions including observe/document report to medical provider any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. Review of a plan of care dated 05/02/23 revealed Resident #28 required placement on a secured unit with listed interventions including notify medical provider/resident representative of behavior changes and provide diversionary activities as needed and redirect when appropriate. Review of a SRI dated 11/26/24 revealed an allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. Resident #18 was allegedly found to be performing oral sex on Resident #28 on 11/26/24 at approximately 8:30 P.M. Certified Nurse Aide (CNA) #396 found Resident #18 kneeling with his head in proximity of Resident #28's vagina. Both residents were separated and interviewed and reported consenting to the behavior and understanding what they were engaged in. Resident #28 also stated she was in a relationship with Resident #18. The facility determined the allegation of sexual abuse to be unsubstantiated as both residents consented to the sexual interaction. Review of a telehealth note dated 11/27/24 at 12:00 A.M. and authored by Physician #196 revealed the following information: 'Resident #28 was seen with another resident appearing to have intimate contact. Both residents have dementia and acts were consensual per the residents. Follow with in house provider and Director of Nursing (DON).' Review of a nurse practitioner (NP) note dated 11/27/24 at 1:00 A.M. and authored by NP #195 revealed the following information: 'Met with Resident #28 today to follow-up for nursing reports of patient having physical interaction of a sexual nature. Per nursing report and chart review, Resident #28 was seen laying in her bed with another resident/male between her legs. It is important to know that the patient is currently a resident on a locked dementia unit. Resident #28 does have a diagnosis of vascular dementia. Resident #28 is alert and oriented times one to two at baseline. Resident #28 reports she is angry she is being questioned repeatedly and repeatedly states the other resident is her boyfriend. Resident #28 denies being forced to do anything and denied wanting to press charges or file a complaint on the other resident.' Phone interview on 12/09/24 at 3:42 P.M. with Physician #405 revealed he was the attending physician for Resident #28. Physician #405 was unaware of Resident #28 having a sexual encounter with another resident on the dementia unit. Interview on 12/10/24 at 12:54 P.M. with the DON revealed if it was not documented, it was not done regarding physician notifications. The DON confirmed there was not evidence in Resident #28's record that her attending physician, Physician #405 had been made aware of the allegation of sexual abuse involving Resident #28. 2. Review of Resident #18's medical record revealed an admitted [DATE] and diagnoses including depression, anxiety, dementia with agitation, cognitive communication deficit and history of transient ischemic attack (TIA). Resident #18's guardianship documentation revealed he was deemed incompetent and had a guardian of person and estate effective 07/17/23. Review of Resident #18's annual MDS dated [DATE] revealed he was severely cognitively impaired, had no behaviors coded on the assessment and required set up for meals, dressing and toileting. Resident #18 required supervision for ambulation and was independent with most mobility. Review of Resident #18's plans of care revealed a plan of care dated 11/23/22 for impaired cognitive function [related to] dementia and listed interventions including communicate with resident/family/caregivers regarding resident's capabilities and needs, discuss concerns about confusion, disease process and nursing home placement with resident/family/caregiver and keep routine as consistent as possible in order to decrease confusion. Review of a plan of care dated 11/23/22 revealed Resident #18 required a secured unit due to dementia and listed interventions included notify medical provider/resident representative of behavior changes and provide diversionary activities as needed. Redirect when appropriate. Review of a SRI dated 11/26/24 revealed an allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. Resident #18 was allegedly found to be performing oral sex on Resident #28 on 11/26/24 at approximately 8:30 P.M. CNA #396 found Resident #18 kneeling with his head in proximity of Resident #28's vagina. Both residents were separated and interviewed and reported consenting to the behavior and understanding what they were engaged in. Resident #28 also stated she was in a relationship with Resident #18. The facility determined the allegation of sexual abuse to be unsubstantiated as both residents consented to the sexual interaction. Review of a nurses' note dated 11/26/24 at 11:43 P.M. and authored by Licensed Practical Nurse (LPN) #310 revealed the following information: 'Around 10:00 P.M. during rounds CNA walked into female resident room and saw Resident #18 kneeling in front of her with his head within proximity of her vagina. Residents were immediately separated. Resident #18 was interviewed and stated it was consensual, not forced and he felt safe. Guardian and physician notified as well as police.' Review of a telehealth note dated 11/27/24 at 12:02 A.M. and authored by Physician #196 revealed the following information: 'Resident #18 was seen with another resident appearing to have intimate contact. Both residents have dementia and acts were consensual per the residents. Follow with in house provider and DON.' Review of a nurse practitioner note dated 11/27/24 at 1:00 A.M. and authored by NP #195 revealed the following information: 'Nursing reports that patient was observed in an alleged sexual encounter with another resident. Per nursing report and chart review Resident #18 was found in another resident's room. The other patient was laying on the bed and Resident #18 was between her legs. It is important to understand that Resident #18 is on a locked dementia unit and has a diagnosis of dementia. Nursing reports that Resident #18 has a history of developing relationships, girlfriend/boyfriend intermittently with other residents since his stay at the facility. Resident #18 has been seen socializing more closely with this resident as opposed to others. There have been no other inappropriate behaviors observed or reported before this incident. Resident #18 reports he is very angry with questioning he has had to answer regarding the incident. Resident #18 was initially dismissive and would not talk but after some encouragement he reports he did nothing wrong and was with his girlfriend. Resident #18 declines being forced to do anything and declines having to force the other resident. Resident #18 reports it has been a consensual relationship.' Phone interview on 12/09/24 at 3:57 P.M. with Physician #406 revealed he was the attending physician for Resident #18. Physician #406 stated he had heard about inappropriate behavior on the secured unit last month but indicated they did not tell me if it was consensual. Physician #406 did not have additional information to add regarding timely notification of Resident #18 having a sexual encounter with another resident on the dementia unit. Interview on 12/10/24 at 12:54 P.M. with the Director of Nursing (DON) revealed if it was not documented, it was not done regarding physician notifications. The DON confirmed there was not evidence in Resident #18's record that his attending physician, Physician #406 had been made aware of the allegation of sexual abuse involving Resident #18. Review of the facility policy, Notification of Change in Condition, no date revealed the center must inform the resident, consult with the resident's physician and/or notify the residents' representative, authorized family member or legal power of attorney/guardian when there is a change requiring such notification. The practitioner is promptly notified of significant changes in condition and the medical record must reflect the notification, response and interventions implemented to address the resident's condition. Review of the facility policy, Telehealth Services, no date revealed telehealth services will be utilized under the following guidelines: after hours on weekdays (5:00 P.M. to 8:30 A.M.) and weekends at all times for changes in condition. Telehealth services do not need to be utilized by the facility when the primary physician or licensed nurse practitioner is in-house to physically assess the resident and during weekdays (8:30 A.M. to 5:00 P.M.) the facility will directly contact the primary care physician or licensed nurse practitioner assigned to the resident during this timeframe for all resident care needs. The policy did not address how significant changes in resident condition, such as allegations of resident-to-resident abuse, would be communicated from the off-hours personnel to the residents' attending providers.

Based on interview, review of a self-reported incident (SRI), review of the facility investigation and review of the facility policy, the facility failed to thoroughly investigate allegations of resident-to-resident sexual abuse. This affected one resident (#28) of three residents reviewed for abuse. Facility census was 158. Findings include: Review of Resident #28's medical record revealed an admitted [DATE] with diagnoses including heart disease, vascular dementia with other behavioral disturbance, depression, cognitive communication deficit, insomnia, post-traumatic stress disorder (PTSD), dysphagia, burn of unspecified degree of head, face and neck restlessness and agitation. Review of Resident #28's guardianship documentation revealed she was deemed incompetent and had a guardian of person effective 03/13/20. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a brief interview for mental status (BIMS) score of nine, indicating moderate cognitive impairment and had no behaviors coded on the assessment. Review of Resident #28's care plans revealed a plan of care dated 08/23/21 and revised 03/24/22 for impaired cognitive function related to dementia with listed interventions including observe/document report to medical provider any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. Review of a plan of care dated 05/02/23 revealed Resident #28 required placement on a secured unit with listed interventions including notify medical provider/resident representative of behavior changes and provide diversionary activities as needed and redirect when appropriate. Review of a nurses' note dated 11/26/24 at 11:28 P.M. and authored by Licensed Practical Nurse (LPN) #310 revealed the following information: Around 10:00 P.M. while doing rounds, Certified Nurse Aide (CNA) entered Resident #28's room and saw the resident laying in her bed with pants down with a male resident kneeling in front of her with his head within proximity of her vagina. Residents were immediately separated. Resident #28 was interviewed, stated she consented, not forced and felt safe. Guardian notified. Physician notified. Police notified. Resident #28 resting in room, will continue to monitor. Review of Resident #18's medical record revealed an admitted [DATE] with diagnoses including depression, anxiety, dementia with agitation, cognitive communication deficit and history of transient ischemic attack (TIA). Resident #18's guardianship documentation revealed he was deemed incompetent and had a guardian of person and estate effective 07/17/23. Review of Resident #18's annual MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, had no behaviors coded on the assessment and required set up for meals, dressing and toileting. Resident #18 required supervision for ambulation and was independent with most mobility. Review of Resident #18's care plans revealed a plan of care dated 11/23/22 for impaired cognitive function [related to] dementia and listed interventions including communicate with resident/family/caregivers regarding resident's capabilities and needs, discuss concerns about confusion, disease process and nursing home placement with resident/family/caregiver and keep routine as consistent as possible in order to decrease confusion. Review of a plan of care dated 11/23/22 revealed Resident #18 required a secured unit due to dementia and listed interventions included notify medical provider/resident representative of behavior changes and provide diversionary activities as needed. Redirect when appropriate. Review of a nurses' note dated 11/26/24 at 11:43 P.M. and authored by LPN #310 revealed the following information: Around 10:00 P.M. during rounds CNA walked into female resident room and saw Resident #18 kneeling in front of her with his head within proximity of her vagina. Residents were immediately separated. Resident #18 was interviewed and stated it was consensual, not forced and he felt safe. Guardian and physician notified as well as police. Review of a facility SRI dated 11/26/24 revealed an allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. Resident #18 was allegedly found to be performing oral sex on Resident #28 on 11/26/24 at approximately 8:30 P.M. CNA #396 found Resident #18 kneeling with his head in proximity of Resident #28's vagina. Both residents were separated and interviewed and reported consenting to the behavior and understanding what they were engaged in. Resident #28 also stated she was in a relationship with Resident #18. The facility determined the allegation of sexual abuse to be unsubstantiated as both residents consented to the sexual interaction. Review of a witness statement dated 11/26/24 and authored by LPN #310 revealed the following information: Since beginning of shift on 11/26/24 both residents (#18, #28) were acting normal, at their baseline, in a good mood, no change in condition, no behaviors, no issues or complaints. Review of a witness statement dated 11/26/24 and authored by CNA #396 revealed the following information: I was doing rounds and noticed Resident #24 was not in her room so I knocked on Resident #28's door and walked in and saw Resident #28 laying back on her bed with her legs wide open and Resident #18 on his knees with his face in between her legs. Review of a staff schedule for 11/26/24 7:00 P.M. to 7:00 A.M. identified three staff working on the Connections secured unit: LPN #310, CNA #396 and CNA #358. No witness statement was available for CNA #358. Review of a typed, unauthored interview dated 11/27/24 with Resident #28 revealed the following information: Resident #28 shared she and the gentleman were in an average relationship and that no sexual contact occurred. Resident #28 stated she is not married, just an average relationship and reported other patient did not have a spouse. Resident #28 stated sexual intimacy occurred between people that care for one another and that she was not taken advantage of. Resident #28 indicated she could say no to sexual contact. Resident #28 stated she was aware one of them may move but that did not mean their relationship will end. Review of a typed, unauthored interview dated 11/27/24 with Resident #18 revealed the social worker read the questions and Resident #18 responded 'no' to the first four questions relating to who initiated the sexual contact, did the patient believe the other person was a spouse, what level of sexual intimacy was he comfortable with and if the behavior was consistent with formerly held beliefs/values. Resident #18 stated he could say no to sexual contact. Resident #18 said he would be fine when the relationship ends, and he would just not see her anymore. Review of a typed interview completed by the Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO)/Registered Nurse (RN) #219 on 11/26/24 at 9:00 P.M. with Resident #28 revealed she knew what was happening in her room with Resident #18 and thought they were alone in here. Resident #18 stated she was not forced during this episode, no one put a gun to my head, stated she felt safe and was not hurt. Review of a typed interview completed by the DON and RDCO/RN #219 on 11/26/24 at 9:00 P.M. with Resident #18 revealed he understood what was happening in his room with Resident #28, he was not forced, felt safe and was not hurt, and leave me alone. A telephone interview on 12/10/24 at 8:33 A.M. and 2:09 P.M. with CNA #396 revealed on 11/26/24 around 8:30 P.M. she had identified Resident #24 was not in her bed so she went to her (Resident #24's old room (which was Resident #28's current room) to look for the resident. When she arrived to this room, she witnessed Resident #18 giving Resident #28 oral sex. CNA #396 stated both residents did not have pants on and Resident #18 was on his knees and his head was between Resident #28's legs. CNA #396 called LPN #310 down and reported what she saw to the Administrator. CNA #396 stated they separated both residents at that time. CNA #396 explained both Resident #18 and Resident #28 felt they were boyfriend and girlfriend and would put their arms around each other and sit next to each other and this had been going on for maybe nine months to one year. CNA #396 stated Family Member (FM) #192 saw them often sitting at the table together and Resident #18 would introduce Resident #28 as his girlfriend. CNA #396 shared the night of the incident, a staff member had called off, so it was her, LPN #310 and CNA #358 on the dementia unit from 7:00 P.M. to 7:00 A.M. When asked about when both residents had been last seen (as her witness statement did not contain this information), CNA #396 stated 15 minutes prior, both residents were sitting at the table together on the unit. A telephone interview on 12/10/24 at 9:31 A.M. and 2:11 P.M. with CNA #358 revealed she was aware of the sexual interaction that had occurred between Resident #18 and Resident #28 but was providing patient care to other residents at the time it was discovered. CNA #358 stated the nurse, and the other CNA were communicating with administration. CNA #358 stated she was present when Resident #28 was being questioned by staff (not named) and Resident #28 was aggravated, said she consented to the activity and was asking why people were in her business. When asked when she last saw Resident #18, CNA #358 stated he had been upset at his roommate and was sitting in the dining room before 12:00 A.M. but did not recall further. When asked when she last saw Resident #28, CNA #358 stated she put her roommate to bed before 8:00 P.M. An interview was attempted with LPN #310 on 12/10/24 at 8:32 A.M. but was not successful. Interview on 12/10/24 at 11:56 P.M. with Licensed Social Worker (LSW) #245 revealed FM #192 had left her a voicemail about the sexual encounter between Resident #18 and Resident #28. Resident #18 was in Resident #28's room during rounds the evening of 11/26/24 and was found in a sexual position kneeling in front of Resident #28. LSW #245 confirmed she completed the typed, unauthored interviews as part of the facility's SRI and related investigation and shared Resident #18 said nothing and Resident #28 felt she was in a relationship with Resident #18. Interview on 12/10/24 at 12:41 P.M. with the DON and RDCO/RN #219 revealed the DON indicated she was not sure how long Resident #18 and Resident #28 had been friends and was made aware of multiple staff reports Resident #18 and Resident #28 were holding hands on the unit and were quite close which was not documented in either resident's medical record. The DON indicated she had learned from staff interviews during the SRI investigation that both residents would walk together and hold hands but this was not documented within the SRI. The DON was questioned regarding the lack of detail in both staff statements for the SRI on 11/26/24 including times and she indicated both residents were last seen not much before the time of the encounter walking together and did not have further documentation to provide on the matter. A follow up interview on 12/11/24 at 8:24 A.M. with the DON, the Administrator and Divisional Director of Clinical Operations (DDCO)/RN #199 revealed no statement was collected from CNA #358 even though she was working on the unit at the time of the sexual encounter with Resident #18 and Resident #28, as the DON and the Administrator indicated they could not get ahold of her. When asked about establishing a timeline, including interviewing staff from the shift before an incident occurred to see if there were any precursors to this behavior, the Administrator stated they did not obtain a timeline as they got a first-hand account from CNA #396 and they would only establish a timeline if the incident was not witnessed. When asked why LPN #310's statement lacked information regarding this incident including times, the DON stated that it reflected that LPN #310 saw the residents at the beginning of the shift but to determine when LPN #310 last saw both residents, they would have to interview her again. Follow-up interview on 12/11/24 at 8:40 A.M. with DDCO/RN #199 during a review of the sexual abuse SRI with the surveyor confirmed the SRI lacked a timeline and the two available staff statements were not clear, complete and did not contain time details to help with establishing a timeline. Review of the undated facility policy, Ohio Abuse, Neglect and Misappropriation, revealed the accurate and timely identification of any event which would place our residents at risk is a primary concern of the facility. Each occurrence of alleged abuse will be identified and reported to the supervisor and investigated timely. The DON and Administrator receive reports of resident incidents. The Administrator determines when an investigation is required and directs the investigation. Statements will be obtained from the resident or from the reporter of the incident in writing whenever possible by the Administrator or Designee. Statements will be obtained from staff related to the incident including victim, person reporting incident, accused perpetrator and witnesses. The statement should be in writing, signed and dated at the time it is written. Statements should include the following: first-hand knowledge of the incident and a description of what was witnessed, seen or heard. Following the initial report of the alleged violation, the facility will complete a thorough investigation and put measures in place to prevent other incidents from occurring during the course of the investigation.

Based on record review, fall investigation review, interview and review of the facility policy, the facility failed to thoroughly investigate falls to ensure appropriate safety interventions were in place for Resident #160. This affected one resident (#160) of three residents reviewed for falls. Facility census was 158. Findings include: Review of Resident #160's closed medical record revealed an admitted [DATE] and diagnoses including type two diabetes, repeated falls, hypertension, obesity, aphasia following cerebral infarction and hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side. Resident #160 discharged to the hospital on 09/06/24 and did not return to the facility. Review of Resident #160's physician's orders revealed an order dated 09/04/24 for low bed with bilateral mats to floor every shift and an order dated 09/04/24 for physical therapy (PT) and occupational therapy (OT) to evaluate. Review of Resident #160's admission nursing evaluation dated 09/04/24 revealed Resident #160's fall history was unknown prior to admission but Resident #160 had poor recall and judgement and required a wheelchair and/or ambulation assistance. The assessment indicated Resident #160 was at risk for falls. Review of a discharge-return anticipated Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #160 had intact memory, no behaviors documented, required substantial/maximal assistance for bed mobility and transfers and was dependent on staff for toileting. Resident #160 had one fall with minor injury and one fall with major injury coded on the assessment. Review of Resident #160's care plans revealed a plan of care dated 09/04/24 for risk of falls due to cerebrovascular accident with left hemiparesis and diabetes mellitus with listed interventions including physical therapy evaluation; move closer to nursing station when returns; assess for risk for falls on admission/readmission, quarterly and as needed; educate resident or resident representative how to operate bed controls/call light/television; ensure resident is wearing appropriate non-skid footwear; ensure resident's room is free of potential visible hazards; ensure the bed locks are engaged; initiate neurological checks if a fall is unwitnessed or if the head is involved; low bed with bilateral mats to floor; observe medication for side effects that may increase risk for falls; place call bell within reach and remind resident to call for assistance. Review of Resident #160's progress note dated 09/06/24 at 6:33 A.M. and was authored by Licensed Practical Nurse (LPN) #356 and contained the following information: 'Resident #160 was found on the floor next to bed at approximately 4:10 A.M. by laboratory technician. Resident #160 was assessed for pain and injury, Resident #160 complained of headache and stated that he hit his head upon landing on the floor. Resident #160's bed was found in high position and Resident #160 stated he had lifted the bed up for reasons he did not know. Nurse practitioner contacted and recommended sending Resident #160 [to the hospital] due to hitting his head and being on blood thinners. Vitals were obtained and emergency contact informed of incident.' The progress note did not indicate when LPN #356 last saw Resident #160 prior to the fall and in what capacity. Review of a progress note dated 09/06/24 at 6:43 A.M. and authored by LPN #356 revealed Resident #160 was picked up [by emergency medical services] at 6:00 A.M. headed to Euclid Hospital. Review of a progress note dated 09/06/24 at 7:56 A.M. and authored by Unit Manager (UM)/RN #395 revealed Resident #160 was transferring to University Hospitals main campus with diagnosis intracranial hemorrhage. Review of a post-fall investigation dated 09/06/24 revealed Resident #160 fell from the bed to the floor at 4:10 A.M. Resident #160 was found sitting on the floor next to bed unable to verbalize how he came to be on the floor. A new intervention was listed as move Resident #160 closer to the nurses' station upon return from hospital. Follow-up was listed as 'sent to hospital via 9-1-1.' Appropriate notifications were made. Staff on duty were identified at LPN #356, Certified Nurse Aide (CNA)#198 and CNA #383. Review of an incident report for Resident #160's fall on 09/06/24 reported by LPN #356 timed the fall at 4:10 A.M. revealed Resident #160's emergency contact was notified on 09/06/24 at 4:30 A.M., the telehealth physician was notified on 09/06/24 at 4:31 A.M., an ambulance was called on 09/06/24 at 5:00 A.M. and Resident #160 was sent to the hospital on 09/06/24 at 6:00 A.M. Notes on the incident report were added by UM/RN #396 on 12/09/24 to include what happened: 'Per nurse, Resident #160 found on the floor by laboratory technician and did not witness fall;' and resident statement of what happened: 'Per patient, raised bed for unknown reasons and fell , states that he hit his head.' The incident report section, Care Prior to Fall, listed a visually observed time of 09/06/24 at 4:10 A.M. with no further information provided as to who saw Resident #160 and in what capacity prior to his fall. The report indicated mattresses were on the floor and the call light was off at the time of discovery. Review of a witness statement dated 09/06/24 for CNA #198 revealed the following information: 'Verbal- did not witness incident.' The statement did not indicate when CNA #198 last saw Resident #160. Review of a witness statement dated 09/06/24 for CNA #383 revealed the following information: 'Verbal- did not witness incident.' The statement did not indicate when CNA #383 last saw Resident #160. Review of bowel and bladder tracking for 09/06/24 revealed Resident #160 was checked for incontinence at 2:17 A.M. by CNA #383 but this information was not within the facility investigation. Interview on 12/11/24 at 11:12 A.M. with UM/RN #395 revealed Resident #160's fall on 09/06/24 was unwitnessed. When asked when Resident #160 was seen prior to falling as it was not stated in the facility's fall investigation, UM/RN #395 stated staff should have seen him at the 2:00 A.M. checks. UM/RN #395 confirmed the time of 4:10 A.M. on the fall investigation is when the laboratory technician found Resident #160, not the actual time he fell or was seen last by staff. The floor nurse was supposed to do an incident report when a resident fell and gather witness statements; these witness statements would tell what staff were doing at the time of the fall and when they last observed the resident which UM/RN #395 confirmed was not done in this case. UM/RN #395 also confirmed the incident report was not done at the time of the fall and this was the reason why she placed notes in the incident report on 12/09/24. Interview on 12/11/24 at 12:11 P.M. with the Director of Nursing (DON) revealed she had no further information regarding Resident #160's fall on 09/06/24 aside from the content of the fall investigation and incident report provided other than he was found by the laboratory technician at 4:10 A.M. The DON confirmed witness statements and fall investigations were to include more details including the last time a staff member saw the resident and the last time the resident was toileted or cared for. The DON explained the facility's unit managers were to complete the post-fall investigation with a completed incident report and witness statements within seven days following the fall for discussion at the weekly risk meeting. The DON indicated in this case, LPN #356 was responsible for obtaining complete and accurate witness statements post-fall and UM/RN #395 should have asked further questions about the witness statements that did not provide adequate information as required. The DON acknowledged she did not like how these witness statements were done and confirmed she needed to continue to educate staff. Phone interview on 12/11/24 at 1:56 P.M. with CNA #198 revealed she no longer worked for the facility and did not recall Resident #160's fall. Phone interview on 12/11/24 at 1:58 P.M. with LPN #356 revealed on 09/06/24 during night shift, the lab staff found Resident #160 on the floor. When asked when she last saw Resident #160 as the progress notes and report did not contain this information, LPN #356 stated she saw Resident #160 an hour prior, maybe under an hour prior to his fall and she and CNA #383 had repositioned him at that time in a low bed. When asked if staff had entered the room after she had prior to Resident #160's fall, LPN #356 claimed she and CNA #383 had just been in there. Phone interview on 12/11/24 at 2:04 P.M. with CNA #383 revealed he did not recall Resident #160's fall. Review of the facility policy, Fall Prevention and Management, no date revealed once the resident is safely transferred a fall investigation should begin. Ask the resident what they were doing when the fell . Identify if there were witnesses to the fall. Ask them what they saw, have them write a statement if possible. Immediately written statements provide much more detail than asking later. This deficiency represents noncompliance investigated under Complaint Number OH00159828.

Based on closed medical record review, review of skin and wound notes, facility policy review and interview, the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #165 from developing in-house pressure ulcers within 30 days of admission and failed to ensure the pressure ulcer was properly treated, and interventions were initiated to promote healing and to prevent Resident #165 from developing an additional full thickness wound to the left buttock from incontinence associated dermatitis. Actual Harm occurred on 09/12/24 when Resident #165, who was at risk for developing pressure ulcers, was dependent on staff for bed mobility and incontinence care, and had in-house acquired Stage III pressure ulcers (full-thickness loss of skin that extended to the subcutaneous tissue, but did not cross the fascia beneath it) on her sacral area, developed a new new full thickness (extend deeper than the skin's epidermis and dermis layers and can reach the subcutaneous tissue, muscle, bone or tendons) wound to the left buttock with a primary etiology of incontinence associated dermatitis (a combination of chemical and physical irritation to the skin from prolonged exposure to urine and/or feces). Resident #165's family voiced concerns staff did not provide timely assistance with turning and repositioning, off-loading and timely incontinence care believed to be a contributing factor to the development. The facility census was 160. Findings include Review of Resident #165's closed medical record revealed an admitted [DATE] with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, and cognitive communication deficit. Resident #165 was discharged from the facility on 09/16/24. Review of Resident #165's Nursing Admission Evaluation, Braden Scale for Predicting Pressure Sore Risk dated 08/03/24 revealed Resident #165 was at high risk for developing a pressure ulcer/injury. Review of Resident #165's care plan dated 08/03/24 and revised on 09/24/24 included Resident #165 had impaired skin integrity or was at risk for altered skin integrity. Revision on 09/24/24 (Resident #165 was discharged from the facility on 09/16/24) revealed Resident #165 had a bilateral buttock, coccyx pressure injury and on 09/12/24 developed a pressure injury to her left buttock. The goal developed was for Resident #165 to have improved or maintain current skin status through the next review date. Interventions included to complete weekly skin checks; intervention initiated on 08/03/24 was encourage Resident #165 to turn and reposition or assist as needed as resident allowed; intervention initiated on 08/05/24 was encourage Resident #165 to turn and reposition every two hours and as needed as tolerated; provide peri care as needed to avoid skin breakdown due to incontinence. Review of Resident #165's medical record including physician orders, progress notes and Treatment Administration Record (TAR) from 08/03/24 through 08/17/24 did not reveal evidence Resident #165 was turned and repositioned every two hours and as needed or encouraged to turn and reposition. Review of Resident #165's Admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #165 had severe cognitive impairment. Resident #165 was dependent for toileting, personal hygiene, bathing, dressing, rolling left and right from lying on her back, sit to lying, and lying to sitting. Resident #165 was frequently incontinent of urine and bowel. Resident #165 was at risk for developing pressure ulcers/injuries, and Resident #165 did not have a pressure ulcer/injury at this time. Review of Resident #165's progress notes dated 08/11/24 at 10:00 P.M. and written by Registered Nurse (RN) #809 revealed she was called into Resident #165's room by an unidentified State tested Nursing Assistant (STNA) and RN #809 identified several skin tears on Resident #165's right and left buttock. The area was cleansed with normal saline and covered with a foam dressing. Telehealth was contacted and asked to follow up with wound care. Review of Resident #165's progress notes dated 08/11/24 at 10:07 P.M. and written by a Telehealth Provider revealed the Telehealth Provider was notified Resident #165 had a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer. Resident #165 did not ambulate, and off load to prevent worsening. The progress note did not include treatment orders being implemented and to have the wound care nurse evaluate the area. Review of Resident #165's physician orders on 08/11/24 did not reveal treatment orders for Resident #165's pressure ulcer at this time. Review of Resident #165's Skin Grid Pressure dated 08/11/24 at 11:38 P.M. included Resident #165 had a new pressure area, in-house acquired, risk factors were impaired and the resident had decreased mobility. Resident #165's right buttock had a Stage II pressure injury and measurements were length 1.0 cm, width 1.0 cm and depth 0. The edges were distinct, outlined clearly visible, attached and even with the wound base. The wound bed had granulation tissue present, the wound bed was pink, reddened and had no drainage. There were no measurements for Resident #165's left buttock or evaluation of the wound appearance at this time. Review of Resident #165's progress notes dated 08/12/24 revealed her sister (guardian) was aware of skin areas and new orders and Resident #165 was evaluated by Wound Nurse Practitioner (WNP) #815. Review of Resident #165's skin and wound progress notes dated 08/12/24 at 4:42 P.M. written by WNP #815 included Resident #165 was seen for a new Stage III pressure injury of the sacrum (investigation noted this to be the same area previously identified by facility staff on 08/11/24) and measurements included length 3.0 cm, width 5.0 cm and depth 0.1 cm. The wound edges were attached, exposed tissue was subcutaneous, wound base 90 percent granulation, 10 percent epithelial and a moderate amount of serosanguineous drainage was noted. A sharp debridement was not performed due to patient, family refusal. Treatment recommendations were cleanse with normal saline, apply silver alginate to base of the wound, secure with bordered foam dressing, and change twice a day (BID) and as needed (PRN). Recommend ongoing pressure reduction and turning/repositioning per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. Use appropriate moisture barrier creams per approved list, to provide thorough skin care for each incontinent episode. Resident #165 was recommended for a nutritional consult for presence of a wound, and reevaluation of current supplementation. Discussed with Unit Manager and would follow up in one week and as needed. Review of Resident #165's physician orders dated 08/12/24 revealed an order to cleanse areas to bilateral buttocks, coccyx with normal saline, pat dry, apply silver alginate and border foam, change twice daily and as needed until resolved. Review of Resident #165's progress notes and evaluations dated 08/12/24 through 08/27/24 did not reveal an evaluation of Resident #165's Stage III sacral pressure injury including appearance and measurements during this time period. Review of Resident #165's medical record including evaluations and progress notes from 08/12/24 through 09/09/24 did not reveal a nutritional consult for the presence of a Stage III pressure ulcer or reevaluation of Resident #165's current supplementation. Review of Resident #165's physician orders dated 08/16/24 at 3:30 P.M. (was ordered on 08/12/24) revealed turn and reposition every two hours and as needed as tolerated, every shift. Review of Resident #165's Treatment Administration Record (TAR) dated 08/16/24 at night did not reveal documentation Resident #165 was turned and repositioned every two hours as ordered. Review of Resident #165's medical record including progress notes did not indicate a reason why turning and repositioning was not completed. Review of Resident #165 TAR dated 08/16/24, 08/17/24, 09/01/24, 09/02/24, 09/08/24 at night and 09/09/24 in the morning revealed Resident #165's treatment orders to cleanse her buttocks, coccyx with normal saline, pat dry, apply silver alginate and border foam were not completed as ordered. Review of Resident #165's medical record including progress notes, physician orders did not indicate a reason why the treatment was not completed on these dates. Review of Resident #165's progress notes dated 08/20/24 at 6:13 P.M. revealed Resident #165 was unavailable and wound care would follow up in one week. There was no reason given why Resident #165 was unavailable for her wound evaluation. Review of Resident #165's skin and wound noted dated 08/27/24 at 1:41 P.M. written by WNP #815 included Resident #165 had a Stage III sacral pressure injury and measurements were length 4.5 cm, width, 8.0 cm and depth 0.1 cm. Wound status was improving despite measurements (the wound base on 08/12/24 and 08/27/24 was 10 percent epithelial and 90 percent granulation). The wound base was 10 percent epithelial and 90 percent granulation, exposed tissue subcutaneous, wound edges attached, and a moderate amount of serosanguineous drainage was noted. Treatment recommendations were cleanse with normal saline, apply silver alginate to the base of the wound, secure with bordered foam and change twice a day and as needed. Resident #165 was recommended for a nutritional consult for the presence of a wound and reevaluation of current supplementation. This was discussed with the Unit Manager. Review of Resident #165's dietary progress notes dated 08/28/24 and 08/30/24 did not reveal evidence Resident #165 had a nutritional consult for her sacral Stage III pressure ulcer or reevaluation of current supplementation. Review of Resident #165's aide charting of skin observation in the electronic record from 08/27/24 through 09/16/24 did not reveal evidence skin areas were noted. Review of Resident #165's skin and wound note dated 09/03/24 at 4:23 P.M. written by WNP #815 included Resident #165 had a surgical sacral wound debridement of her Stage III pressure ulcer, it was improving without complications, and pre-debridement measurements were length 4.5 cm, width 7.0 cm and depth 0.1 cm and 100 percent of the wound was debrided and indications for the debridement were removal of biofilm (bacteria form aggregates, or communities of slow-growing cells) causing delayed wound closure, stimulate acute healing response. A surgical excisional debridement of devitalized subcutaneous (tissue that was no longer living or was weak and could be detrimental to healing) was performed. Tissue removal including but not limited to biofilm was performed to keep the wound in an active state of healing. Post debridement measurements were length 4.5 cm, width 7.0 cm and depth 0.2 cm. Treatment was cleanse with normal saline, apply silver alginate to the base of the wound, secure with bordered foam and change twice a day and as needed. Resident #165 was recommended for a nutritional consult for the presence of a wound and reevaluation of current supplementation. Review of Resident #165's weight change progress notes dated 09/09/24 at 5:15 P.M. included meals and supplements meet re-estimated needs of 2032 to 2370 kcal (kilocalories) and 88 to 95 gm (gram) of protein for Stage III sacrum pressure ulcer (this was 28 days after the nutritional consult was ordered). Review of Resident #165's skin and wound note dated 09/12/24 at 2:40 A.M. written by WNP #816 revealed the date of service was 09/12/24 at 6:40 A.M. included Resident #165's Stage III sacrum pressure ulcer measurements included length 4.5 cm, width 7.0 cm, depth 0.1 cm and the area was improving without complications, wound base was 100 percent granulation soft, unhealthy, the wound edges were unattached, the peri wound was macerated, and exudate indicated stool contamination. New treatment was cleanse with normal saline, apply bacitracin ointment, apply Triad over bacitracin wound and over bilateral buttock and ischium to the base of the wound, cover with ABD (abdominal pad) twice a day and as needed. Further review of Resident #165's skin and wound note dated 09/12/24 at 2:40 A.M. revealed the date of service was 09/12/24 at 6:40 A.M. and included Resident #165 had a new full thickness (extend deeper than the skin's epidermis and dermis layers and can reach the subcutaneous tissue, muscle, bone or tendons) wound to the left buttock and stated the primary etiology was incontinence associated dermatitis (a combination of chemical and physical irritation to the skin from prolonged exposure to urine and/or feces). Resident #165 had diaper dermatitis. Measurements included length 6.0 cm, width 5.0 cm and depth 0 cm., peri wound was macerated, the wound base indicated scar tissue with scattered opened areas of epithelial tissue, exudate indicated contaminates with stool. Treatment was cleanse with wound cleanser, apply bacitracin ointment, apply Triad over the bacitracin ointment to the base of the wound and cover with ABD pad twice a day and as needed. Review of Resident #165's medical record from 08/27/24 through 09/12/24 including progress notes, physician orders, TAR did not reveal evidence Resident #165 had a new wound area to her left buttock. Review of Resident #165's physician orders dated 09/12/24 through 09/16/24 did not reveal new treatment orders for Resident #165's sacral Stage III pressure ulcer to cleanse with normal saline, apply bacitracin ointment, apply Triad over bacitracin wound and over bilateral buttock and ischium to the base of the wound, cover with ABD twice a day and as needed. Further review did not reveal treatment orders for left buttock to cleanse with wound cleanser, apply bacitracin ointment, apply Triad over the bacitracin ointment to the base of the wound and cover with ABD pad twice a day and as needed. Review of Resident #165's TAR dated 09/12/24 through 09/16/24 did not reveal evidence treatments for Resident #165's sacral Stage III pressure ulcer and full thickness wound of her left buttock were completed as ordered. Interview on 09/25/24 at 11:01 A.M. with Guardian #818 revealed Resident #165 was admitted to the facility and did not have any open areas on her skin. Guardian #818 stated sometime between 08/03/24 and 08/10/24 Resident #165 developed bedsores on her bottom, and she knew this because on 08/10/24 Resident #165 was soaking wet and was lying on soaking wet, brown stained sheets and she saw wounds on Resident #165's sacral area when the aides changed her. Guardian #818 stated she was really upset, was crying and talked to the Director of Nursing (DON) about the aides not changing Resident #165 timely. Guardian #818 stated Resident #165 was mildly retarded and she sat in a wheelchair all day long in the same position without taking the pressure off her bottom and did not get changed by staff (related to incontinence). Guardian #818 indicated Resident #165 told her that her butt hurt from bedsores. Guardian #818 stated Resident #165 was neglected at the facility. Interview on 09/25/24 at 5:03 P.M. with WNP #815 and the DON confirmed Resident #165's sacral Stage III pressure ulcer was not evaluated on 08/20/24. WNP #815 stated Resident #165 was not available, she did not know why she was not available and did not have to document why Resident #165 was not available for wound rounds even though Resident #165 was in the facility at the time of wound rounds. WNP #815 stated Resident #165 could have been at therapy or eating or with her family and it happened sometimes. WNP #815 stated she was not aware Resident #165's nutritional consult was not completed until 09/09/24 (although it was documented a nutritional consult needed completed on 08/12/24, 08/27/24 and 09/03/24 in the skin and wound notes). Interview on 09/26/24 at 7:45 A.M. with Registered Nurse (RN) #809 revealed an STNA initially told her about Resident #165's buttocks and when she looked at the areas it looked like she had skin tears. RN #809 stated there was what looked like a skin tear on both the right and left buttock, she called the Telehealth provider, and the provider thought the areas looked like pressure injuries. RN #809 indicated she measured the right and left buttock areas, documented them in Resident #165's nurses notes; the wounds were pink and there was no drainage (record review revealed only the right buttock had measurements and appearance documented). Interview on 09/26/24 at 3:01 P.M. with Licensed Practical Nurse/Unit Manager/Infection Preventionist (LPN/UM/IP) #800 confirmed Resident #165 did not have her sacral Stage III pressure ulcer evaluated on 08/20/24. LPN/UM/IP #800 stated the Unit Manager should have evaluated the wound if WNP #815 did not evaluate it and should have completed a pressure skin grid and documented measurements and appearance of the wound. LPN/UM/IP #800 stated each Unit Manager was responsible for the residents with wounds who resided on their nursing units, and not all Unit Managers did the same thing. LPN/UM/IP #800 stated the nurse's cleansed the new area with normal saline, put a foam dressing on, completed a skin grid and notified the Unit Managers, WNP #815 or a facility Nurse Practitioner, and if it was after hours the Telehealth provider was contacted for treatment orders. Interview on 09/27/24 at 2:06 P.M. with the DON and Registered Dietician (RD) #817 revealed RD #817 stated he worked on site at the facility Monday through Friday and all his documentation for the residents could be found in their electronic records. RD #817 stated he was familiar with Resident #165 and met with her a few times after she was admitted on [DATE]. RD #817 stated when he was notified a resident had a pressure ulcer, he would complete a nutritional evaluation with in about a week of the notification. RD #817 confirmed Resident #165's Stage III pressure ulcer was identified on 08/12/24 and the first time he documented a nutritional evaluation for the Stage III pressure ulcer was on 09/09/24. RD #817 stated he could not remember when he first found out Resident #165 had a Stage III sacral pressure ulcer, but stated it was probably in the daily morning meeting. Interview on 09/29/24 at 9:08 A.M. with the DON revealed she was not aware of Guardian #818's concerns regarding Resident #165's care including incontinence care and pressure ulcer concerns. The DON confirmed Resident #165's treatment orders written on 09/12/24 were not placed by WNP #816. The DON stated on 09/12/24 WNP #816 was filling in for WNP #815 and should have put the orders in if they were new orders. The DON indicated the Unit Manager should have reviewed the skin and wound notes, and she was not sure what happened with Resident #165's orders. The DON confirmed treatments were not completed as ordered from 09/12/24 through 09/16/24 as noted above for Resident #165's sacral Stage III pressure ulcer and full thickness wound to the left buttock. Review of the facility undated policy titled Skin Care and Wound Management Overview included facility staff strived to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team worked with the resident and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluated and documented identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment. Each resident was evaluated upon admission and weekly thereafter for changes in skin condition. Resident skin condition was also re-evaluated with change in clinical condition, prior to transfer to the hospital and upon return from the hospital. Skin care and wound management program included implementation of prevention strategies to decrease the potential for developing pressure ulcers. Develop a care plan with individualized interventions to address risk factors, communicate risk factors and interventions to the care giving team. For treatment select and complete the appropriate form, pressure ulcer documentation, complete for all pressure ulcers, review and select the appropriate treatment for the identified skin impairment, obtain a physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00157677.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #28 and Resident#127 were provided incontinence care timely. This affected two residents (Resident's #28 and #127) out of four residents reviewed for incontinence care. The facility census was 160. Findings include: 1. Review of Resident #28's medical record revealed an admitted [DATE] and diagnoses included Alzheimer's Disease, vascular dementia, and other speech and language deficits following unspecified cerebrovascular disease. Review of Resident #28's care plan dated 10/20/21 and revised on 08/07/24 included Resident #28 was incontinent of bowel and bladder related to impaired cognition, impaired mobility. Resident #28 would remain free of skin break down due to incontinence. Interventions included to check Resident #28 for incontinence and wash, rinse and dry perineum, and changed clothing as needed after incontinence episodes; Resident #28 used disposable briefs, change as needed. Review of Resident #28's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had severe cognitive impairment. Resident #28 was dependent for personal and toileting hygiene, dressing, and the ability to roll left and right from lying on back, chair, bed-to-chair transfer, and to return to lying on back on the bed. Resident #28 was always incontinent of urine and bowel. Observation on 09/25/24 at 4:16 P.M. of State tested Nursing Assistant (STNA) #819 revealed she was providing incontinence care for Resident #28. Observation of Resident #28 revealed she was lying on her bed and her gown was soaked with urine, her bed was soaked with urine, there was a dried urine ring around the wet urine, the sheet also had some greenish brown material that looked like bowel movement, and she was wearing two incontinence briefs which were soaked with urine and bowel. STNA #819 stated she did not put two incontinence briefs on Resident #28, the night shift did it. STNA #819 indicated she checked Resident #28 when she arrived for work at 7:00 A.M., had not changed her incontinence brief since she arrived for work, and this was the first time Resident #28's incontinence brief was changed today. Resident #28's buttocks, sacral area and perineum were reddened. STNA #819 stated she was too busy until now to provide incontinence care. STNA #819 continued with the incontinence care and removed Resident #28's gown and top sheet and left her lying naked and uncovered. Resident #28 repeatedly said cover me, please cover me but STNA #819 did not acknowledge Resident #28's request and did not find a sheet or blanket to cover Resident #28. Licensed Practical Nurse (LPN) #820 entered Resident #28's room, Resident #28 said cover me, and LPN #820 did not acknowledge Resident #28 said anything, did not cover her, and left the room. When asked why Resident #28 was not provided a sheet or blanket to cover her as requested STNA #819 stated there were no sheets in the room she could use. 2. Review of Resident #127's medical record revealed an admitted [DATE] and diagnoses included polyosteoarthritis, dementia without behavioral, psychotic, mood disturbance, and anxiety, and cognitive communication deficit. Review of Resident #127's Admission MDS 3.0 assessment dated [DATE] revealed Resident #127 had severe cognitive impairment. Resident #127 was dependent for toileting and personal hygiene, bathing, and was frequently incontinent of urine and bowel. Review of Resident #127's care plan dated 08/30/24 included Resident #127 was incontinent of urine. Resident #127 would remain free of skin breakdown due to incontinence. Interventions included to check resident for incontinence, wash, rinse, dry perineum and change clothing as needed after incontinence episodes. Observation on 09/25/24 at 4:16 P.M. of STNA #819 revealed she was finished providing incontinence care for Resident #127 but held up a bag with two incontinence briefs which were soaked with urine and a large bowel movement. STNA #819 stated she had to completely change Resident #127's gown and bed because they were soaked with urine and stool. STNA #819 confirmed Resident #127 was wearing two incontinence briefs which were put on her by the night shift aides. STNA #819 stated I am not going to lie, the night shift put two briefs on, indicated she arrived for work at 7:00 A.M. and she had not changed Resident #127's incontinence brief because she was too busy to provide Resident #127's incontinence care until now. Review of the facility policy titled Routine Resident Care undated included licensed staff would include the following services based upon their scope of practice, but not limited to maintaining nursing skills for appropriate areas of care management including but not limited to bowel and bladder management. Provide routine daily care by a certified nursing assistant with specialized training in rehabilitation, restorative care under the supervision of a licensed nurse including but not limited to implementing and maintaining a program for skin care, toileting, providing care for incontinence with dignity and maintaining skin integrity. This deficiency represents non-compliance investigated under Complaint Number OH00157677 and Complaint Number OH00157217.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure a medication error rate of less than 5 percent (%). A Total of two errors out of 26 opportunities were observed resulting in a 7.69% medication error rate. This affected two residents (Resident's #98 and #139) out of six residents reviewed for medication administration. The facility census was 160. Findings include: 1. Review of Resident #98's medical record revealed an admitted [DATE] and a re-entry date of 09/10/24. Resident #98's diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, and dependence on renal dialysis. Review of Resident #98's physician orders dated 09/11/24 at 12:17 A.M. revealed orders for Spiriva Respimat 2.5 mcg/ACT Aerosol, solution, two puffs inhale orally in the morning for COPD (chronic obstructive pulmonary disease). Observation on 09/25/24 at 8:38 A.M. of Licensed Practical Nurse (LPN) #821 revealed she was standing at the medication cart preparing medications for Resident #98. LPN #821 prepared Guaifenisen 1200 ER (extended release) tablet and placed it in a small plastic cup, took Breo Ellipta inhaler 200 mcg/25 mcg (not the ordered Spiriva inhaler) out of the medication cart and laid it on top of the cart while she finished preparing the medications. LPN #821 was unable to find Resident #98's Potassium Chloride 10 millequivalents packet in the medication cart and locked the guaifenesin tablet and the Ellipta inhaler in the medication cart while she searched for the medication. LPN #821 could not find the Potassium Chloride packet and unlocked the cart and took the plastic cup with the guaifenesin tablet in it, but did not take the Ellipta inhaler out of the cart, and walked in Resident #98's room and administered the medication. LPN #821 walked back to the medication cart and signed off in the electronic record she administered Resident #98's guaifenesin and Breo Ellipta inhaler. LPN #821 was preparing to administer the next residents medication when she was asked about Resident #98's inhaler. LPN #821 confirmed she did not administer the Breo Ellipta inhaler, and signed off in Resident #98's electronic record she administered it. LPN #821 took the Breo Ellipta inhaler out of the medication cart and walked in Resident 98's room and had her take two puffs orally. This was identified as one medication error. 2. Review of Resident #139's medical record revealed an admitted [DATE] and diagnoses included anxiety disorder, chronic obstructive pulmonary disease, and polyneuropathy. Review of Resident #139's physician orders dated 09/19/24 revealed Anoro Ellipta (Umexlidinium-Vilanterol), inhalation aerosol powder breath activated 62.5-25 mcg/ACT, one inhalation, inhale orally one time a day for SOB (shortness of breath). Observation on 09/25/24 at 9:12 A.M. of LPN #804 revealed she was standing at the medication cart preparing to administer medications for Resident #139. LPN #804 took Resident #139's Anoro Ellipta inhaler out of the medication cart and walked into Resident #139's room. LPN #804 handed the Anoro Ellipta inhaler to Resident #139 without giving any instructions on how many inhalations were ordered, and Resident #139 proceeded to rapidly inhale four times. When asked how many inhalations were ordered, LPN #804 confirmed Resident #139 took four inhalation and stated Resident #139 was supposed to inhale two times (the order was for one inhalation), not four, and Resident #139 knew that. Resident #139 stated she did not know how many inhalations she was supposed to take. This was identified as one medication error. Review of the medication administration revealed two nurses were observed to have 26 opportunities for error while administering medications to six residents. Two errors were observed and the medication error rate was 7.69 percent. Review of the facility policy titled Medication Administration undated included to only administer medication as prescribed by the provider. Observe the five rights in giving each medication the right resident, the right time, the right medication, the right dose and the right route. This deficiency represents non-compliance investigated under Complaint Number OH00156479.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of a facility self-reported incident (SRI) investigation, observation, staff and resident interviews, and review of the facility Abuse, Neglect and Misappropriation policy, the facility failed to ensure controlled substances were stored and discarded properly to prevent misappropriation. This affected seven residents (#256, #257, #258, #259, #260, #261, and #262) of seven residents reviewed for misappropriation. The facility census was 156. Findings include: Review of the closed medical record for Resident #256 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to sepsis, type II diabetes with polyneuropathy and chronic kidney disease. Review of Resident #256's physician orders dated 04/26/24 revealed an order for Percocet (oxycodone) oral tablet 5-325 milligrams (mg). Give one tablet by mouth every morning and at bedtime for moderate pain. Review of the closed medical record for Resident #257 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to fracture of the neck of the left femur, chronic kidney disease, alcohol dependence, generalized anxiety disorder. Review of Resident #257's physician orders dated 12/09/23 revealed an order for Morphine Sulfate Solution 10 mg per five milliliters (ml). Give 3.75 ml by mouth every four hours as needed for pain for three days. Review of the physician orders dated 12/01/24 revealed an order for Fentanyl Transdermal Patch 25 microgram/hour. Apply one patch in the morning every three days for pain. Review of the closed medical record for Resident #258 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to displaced fracture of base of left femur, aftercare following explanation of hip joint prosthesis, and neuropathy. Review of Resident #258's physician orders dated 05/07/24 revealed an order for hydrocodone-acetaminophen (APAP) oral table 5-325 mg. Give one tablet by mouth every four hours as needed for pain. Review of physician orders dated 05/07/24 revealed an order for hydrocodone-acetaminophen oral table 5-325 mg. Give one tablet by mouth every six hours as needed for pain. Review of the closed medical record for Resident #259 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to palliative care, stage III chronic kidney disease and senile degeneration of brain. Review of Resident #259's physician order dated 11/19/23 revealed an order for lorazepam (Ativan) oral table 0.5 mg. Give one table orally every four hours as needed for anxiety. Review of the closed medical record for Resident #260 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to end stage renal disease, malignant neoplasm of prostrate and unspecified severe protein-calorie malnutrition. Review of Resident #260's physician orders revealed an order dated 05/23/24 for oxycodone HCL oral capsule five mg. Give one table by mouth every six hours for pain. Review of the closed medical record for Resident #261 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to metabolic syndrome, cirrhosis of the liver, and depression. Review of Resident #261's physician order dated 05/10/24 revealed an order for oxycodone HCl oral tablet 10 mg. Give one tablet by mouth every six hours as needed for pain. Review of the closed medical record for Resident #262 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included but were not limited to emphysema, end stage renal disease and osteoarthritis. Review of Resident #262's physician order dated 01/30/24 revealed an order for as needed (prn) Tramadol HCl oral tablet 50 mg. Give one table by mouth every 12 hours as needed for pain for seven days. Review of Self-Reported Incident (SRI) Number 249080 with an initiation date of 06/26/24 revealed a suspicion of misappropriation. The SRI indicated there was potential misappropriation of medications of discharged residents. The SRI identified Residents #256, #257, #258, #259, #260, #261, and #262 as being the residents involved. The summary of missing medications indicated regarding Resident #256, no narcotic sheet was found, no medications were found nor listed on the destruction list. Resident #256 was noted to be missing 27 oxycodone pills. Regarding Resident #257, four Fentanyl patches were found in the drawer, no Fentanyl narcotic sheets were found. A Morphine bottle with 16 ml was found with no narcotic sheet. Regarding Resident #258, oxycodone narcotic sheet was found with no medication or destruction log. Thirty tablets were noted to be missing. Hydrocodone narcotic sheet was found, no destruction log and two pills were noted to be missing. Regarding Resident #259, an Ativan as needed narcotic form was found. Medications were missing and not listed on the destruction log. Twenty pills were noted to be missing. Regarding Resident #260, an oxycodone narcotic form was found, no medications or destruction log was found. Twenty pills were noted to be missing. Regarding Resident #261, an oxycodone narcotic form was found, no medications were found nor destruction log. Twenty-seven pills were noted to be missing. Regarding Resident #262, a Tramadol narcotic sheet was found, no medications were found nor a destruction log. Twenty-three pills were noted to be missing. Interview on 07/08/24 at 10:39 A.M. with the Director of Nursing (DON) revealed she found multiple narcotic sheets for seven discharged residents (Residents # 256, 257, #258, #259, #260, #261 and #262) and the medications were missing from Unit Manager (UM) #7's desk. UM #7 was immediately suspended pending investigation. The DON stated when interviewed, UM #7 did not have an explanation of the whereabouts of the missing medications. The missing narcotics could not be located, and the DON was unsure what happened to them. Observation and interview on 07/09/24 between 12:07 P.M. and 12:32 P.M. with the DON revealed there were no narcotic sheets found for Resident #256 and no medications were found nor listed on the destruction list. Resident #256 was missing 27 oxycodone pills; Resident #257's narcotic sheets were missing and unable to be reviewed. Resident #258's narcotic sheets dated 05/27/24 revealed no medications were signed off for hydrocodone (oxycodone-APAP) and the narcotic sheet dated 05/21/24 for oxycodone-APAP revealed no medications were signed off. The DON stated they found the medication card for the oxycodone-APAP which had 10 left so there were two missing from the medication card that were unaccounted for; Resident #259's narcotic sheet dated 11/14/22 revealed no Ativan was signed out. The DON confirmed no Ativan was signed off as having been administered and 20 pills were missing; Resident #260's narcotic log for oxycodone dated 05/23/24 revealed 20 pills were missing; the oxycodone narcotic sheet for Resident #261 dated 01/31/24 revealed all doses were given and matched the medication administration record indicating the oxycodone was administered. The DON confirmed Resident #261's oxycodone medication card dated 02/07/24 revealed no doses were given but the oxycodone dispensed by the pharmacy was missing, and the Tramadol 50 mg narcotic sheet for Resident #262 dated 01/31/24 indicated 23 pills were missing. Review of the witness statement for UM #7 dated 06/26/24 confirmed narcotic sheets were found in her office during her vacation and medications were identified as missing. UM #7 indicated she had recently been sloppy with her job duties and had misplaced several narcotics and took full responsibility for her actions. Review of the police report dated 06/26/24 timed at 4:17 P.M. revealed the DON filed a theft of narcotics report concerning Unit Manager #7. The stolen medications included Percocet, oxycodone, and Ativan. The report was forwarded to the Ohio Board of Health and the Pharmacy Board. Phone interview on 07/08/24 at 3:54 P.M. with UM #7 confirmed she had pulled medications for the identified discharged residents and had not properly stored or disposed of them but denied stealing them. Review of the employee file UM #7 revealed an employee termination letter was mailed to her on 07/02/24 after attempts to reach her by phone and text on 07/01/24 and 07/02/24 were not responded to. Review of the facility policy Discontinued Medications with a revision date of August 2020 revealed when medications were discontinued by the prescriber or the resident was discharged and medications were not sent with the resident, the medications were to be marked as discontinued and stored in a secured and separate area from the active medications until destroyed per facility policy or returned to the pharmacy when permissible by state regulations. Residents whose medications were sent home on discharge would be provided medications in accordance with state laws and regulations, and according to discharge medication policies. Review of the facility policy Controlled Substance Disposal with a revision date of August 2020 revealed the DON, in collaboration with the consultant pharmacist, was responsible for the facility's compliance with federal and state laws and regulation in the handling of controlled medications. All controlled substances remaining in the facility after a resident was discharged or an order was discontinued were to be disposed of in the facility by the DON and consultant pharmacist or other licensed personnel or returned to the Drug Enforcement Administration (DEA) or by sending to the appropriate state agency, as directed by state laws, regulations, and/or by the DEA. Disposition was to be documented on the facility's drug Destruction log. The witnessing licensed nurse would ensure that at a minimum, the following information was entered on the facility's Drug Destruction log or similar form: date of destruction, resident's name, name and strength of medication, prescription umber, amount of medication destroyed and signature of witness. Review of the facility policy OHIO Abuse, Neglect and Misappropriation with a revision date of 04/01/19 revealed misappropriation of resident property was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The deficient practice was corrected on 07/02/24 when the facility implemented the following corrective actions: On 06/26/24 the facility's corporation, police, pharmacy, and medical director were notified, and an investigation was started. An SRI was filed on 06/26/24 at 2:56 P.M. Unit Manager #7 was suspended pending investigation on 06/26/24. All residents had pain assessments completed on 06/27/24 by the DON and Unit Managers with no negative findings. All nursing staff interviews were conducted from 06/26/24 through 07/01/24 by the DON. The DON/designee completed a 30 day look back of any delivered narcotics and validated narcotic sheets and medications on 06/27/24 with no negative findings. The DON provided one on one in-service with clinical management team on chain of custody and Pathway to Narcotic Management on 07/01/24. The DON provided one on one education to all licensed nurses and Certified Medication Technicians between 06/26/24 and 07/01/24. This one-on-one education included education and expectations as it related to chain of custody and Pathway to narcotic management to ensure proper procedures followed Beginning on 06/27/24 the facility implemented a plan for the DON/designee to check medication carts in facility one time per week for four weeks or until compliance was maintained to ensure recognition and proper reporting process was being followed for any potential misappropriation instances. Beginning 06/27/24, all narcotic destruction to be completed by the DON weekly along with another member of management until further notice. Beginning on 06/27/24 the DON and another nurse would collect discontinued narcotics weekly from each medication cart. UM #7 was terminated on 07/01/24; the termination letter was mailed on 07/02/24. The Ohio Board of Nursing was notified on 07/10/24 that there was a narcotic discrepancy, and the Unit manager could not account for the location of those medications belonging to the narcotic sheets that she was in possession of. The Administrator/designee to present the results of the audits monthly to the Quality Assurance Performance Improvement (QAPI) committees for no less than three months. Any patterns that identified would have an action plan initiated. The QAPI committee to determine when 100 percent compliance is achieved, or if ongoing monitoring was required. This deficiency represents non-compliance investigated under Self -Reported Incident Control Number OH00155404.

Based on record review, review of facility policy and interview the facility failed to develop and implement a comprehensive and effective pain management program for Resident #156, including a comprehensive pain assessment and effective interventions to timely treat the resident's pain. This affected one resident (#156) of three residents reviewed for pain. The facility census was 154. Actual Harm occurred on 04/21/24 when Resident #156, who was admitted to the facility with an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the sacrum, experienced moderate to severe/unbearable pain, difficulty with seated positioning, difficulty sleeping at night and pain that interfered with therapy activities and ability to complete hemodialysis treatments due to the lack of effective pain management interventions (including the administration of pain medication). Pain medication was not ordered for the resident until 04/24/24, and Resident #156 was not administered any pain medication until 04/26/24 at bedtime. Findings include: Review of Resident #156's closed medical record revealed an admitted [DATE] with diagnoses including sepsis, pneumonia, type two diabetes mellitus with diabetic chronic kidney disease, and diabetic polyneuropathy. Resident #156 had dependence on renal dialysis. Resident #156 was discharged from the facility to another skilled nursing facility on 05/01/24. Review of Resident #156's After Visit Summary and Clinical Summary dated 04/06/24 through 04/21/24 included Resident #156 was admitted to the hospital with diabetic ketoacidosis without coma associated with other specified diabetes mellitus, end stage renal disease, Influenza A, pneumonia of both lungs due to infectious organism, unspecified part of lung, and bacteremia due to gram-negative bacteria. There were no orders for pain medication. Review of Resident #156's progress note dated 04/21/24 at 7:01 P.M. revealed Resident #156 arrived at the facility via stretcher from the local hospital, and his daughter and sister-in-law were at the bedside. Licensed Practical Nurse (LPN) #379 noted she did not receive report on Resident #156. Review of Resident #156's progress note dated 04/21/24 at 11:36 P.M. revealed Telehealth Notification notes including Resident #156 was a new admission, alert and oriented times three (person, place, time), and medications were reviewed with the nurse. Review of Resident #156's progress note dated 04/21/24 at 11:46 P.M. included Licensed LPN #425 verified Resident #156's medications with Telehealth on call and okay to continue discharge orders, all orders were entered in the electronic system at this time. Review of Resident #156's Medication Administration Record (MAR) dated 04/22/24 through 05/01/24 revealed to monitor for pain every shift. There were check marks for each shift, but there was no pain rating using a scale of one to ten, zero indicating no pain, and ten indicating the worst pain, and it was unable to be determined if Resident #156 had pain based on the review of the MAR. Review of Resident #156's care plan dated 04/22/24 revealed Resident #156 had complaints of acute, chronic pain or was at risk for pain due to polyneuropathy. The care plan revealed Resident #156 would be able to verbalize relief of pain through the target date of 07/21/24. Interventions included to administer non-pharmacological interventions such as repositioning, relaxation techniques; to complete a pain assessment as needed; to follow physician orders for complaints of pain; to observe for pain every shift; provide medication per orders and monitor for signs and symptoms of side effects and evaluate the effectiveness of the medication. Review of Resident #156's physician encounter notes dated 04/22/24 at 1:00 A.M. and written by Certified Nurse Practitioner (CNP) #320 included this was a new patient visit, Resident #156 was a full code, and was admitted to the facility on [DATE] (he was admitted to the facility on [DATE]). Resident #156 had a past medical history of sepsis, pneumonia, type two diabetes mellitus, and end-stage renal disease with hemodialysis. Resident #156 was lying in his bed upon arrival, he was pleasant and appropriate and reported having pain to his buttocks. Resident #156 stated he was living at home, was independent, developed pneumonia and sepsis, became extremely weak and was unable to ambulate. Resident #156 reported he became incontinent of both bowel and bladder and often sat in his stool which led to breakdown of the skin on his buttocks. Further review of Resident #156's encounter notes plan did not reveal orders for pain medication. Review of Resident #156's progress notes dated 04/22/24 at 8:42 A.M. included Resident #156 arrived at the facility on 04/21/24 at 6:55 P.M. and was accompanied by his family. Resident #156 had an open pressure wound to the coccyx. Resident #156's medications were verified. Review of Resident #156's Physical Therapy note dated 04/23/24 and signed at 2:36 P.M. by Physical Therapist (PT) #361 included Resident #156 tolerated functional mobility poorly this date stating dizziness and generalized pain. Resident #156 complained of buttock pain while in the w/c (wheelchair) and a two-inch cushion was added. Resident #156 reported mild relief. There was no evidence Resident #156's nurse was notified of Resident #156's pain. Record review revealed there was no care plan for pain related to Resident #156's unstageable sacral pressure ulcer. Review of Resident #156's skin and wound progress note dated 04/23/24 at 5:35 P.M. and written by Certified Nurse Practitioner (CNP) #491 included the reason for the visit was Resident #156 was a new admission to the facility and needed a skin and wound assessment. Resident #156 presented upon admission with an unstageable pressure ulcer to the sacrum with a length of 2.0 centimeters (cm), width of 1.5 cm and depth was 0 cm. The wound base was 1 to 24 percent granulation tissue and 75 to 99 percent slough. Resident #156's wound pain at rest was a 3. Resident #156's Skin and Wound Plan did not include orders for pain medication. Review of Resident #156's physician encounter notes dated 04/24/24 at 1:00 A.M. written by CNP #320 included Resident #156 was sitting in his room upon arrival and continued to report he was having unbearable pain to his sacral area. Resident #156 had an unstageable wound to the sacral area. Discussed medication options with Resident #156 and he stated he was willing to try anything. Further review revealed a plan for Tramadol HCl oral tablet 50 milligrams (mg), give one tablet by mouth every six hours as needed for mild pain. Review of Resident #156's physician orders dated 04/24/24 at 9:30 A.M. revealed the order for Tramadol HCl oral tablet 50 mg, give one tablet by mouth every six hours as needed for mild pain was written. Review of Resident #156's MAR did not reveal evidence Resident #156 received Tramadol 50 mg by mouth for pain from 04/24/24 through 04/28/24 at 12:25 P.M. Review of Resident #156's Occupation Therapy notes written by OT (Occupational Therapist) #357 and signed on 04/24/24 at 5:09 P.M. included Resident #156 was seated in a dialysis chair at the start of the session and stating he had pain everywhere. There was no evidence Resident #156's nurse was notified Resident #156 had pain. Review of Resident #156's Care Conference note dated 04/26/24 at 11:11 A.M. included physiotherapy barriers to Resident #156's improvement were dizziness and pain. Attendees to Resident #156's care conference included Resident #156's sister, Licensed Independent Social Worker (LISW) #485, Physician #492 and PT #361. Review of Resident #156's Speech Therapy notes dated 04/26/24 and signed at 1:21 P.M. by SLP (Speech Language Pathologist) #348 included Resident #156 struggled to maintain positioning due to wound on bottom which was causing significant pain. Resident #156's sister reported the physician was in and had plans to better address pain going forward. Review of Resident #156's MDS note dated 04/26/24 at 2:55 P.M. revealed Resident #156 reported having pain of nine out of ten during the MDS look-back period. The nurse on duty was notified of Resident #156's complaints of pain. Review of Resident #156's nursing progress note dated 04/26/24 at 2:55 P.M. did not reveal evidence Resident #156's pain was evaluated by a nurse or pain medication was administered. Review of Resident #156's physician orders dated 04/26/24 at 5:22 P.M. revealed an order for Percocet (oxycodone with acetaminophen) oral tablet 5-325 mg, give one tablet every morning and at bedtime for moderate pain. Review of Resident #156's MAR did not reveal evidence he received pain medication (acetaminophen, Tramadol or Percocet) for reports of pain of nine out of a ten on a pain scale of zero to ten, zero being no pain and ten indicating the worst pain, until 04/26/24 at HS (bedtime). On 04/26/24 between 8:00 P.M. and 10:00 P.M. Resident #156 received Percocet oral tablet 5-325 mg. Resident #156's pain rating was marked as zero when Percocet was administered. Review of Resident #156's progress notes dated 04/27/24 at 11:16 A.M. revealed the nurse spoke with MD #494. Pharmacy was contacted and would be contacting MD #494 for verbal prescription. The note did not specify what the verbal prescription was. Resident #156 notified. Review of Resident #156's 5-day MDS 3.0 assessment dated [DATE] revealed Resident #156 was cognitively intact. The assessment revealed Resident #156 received a scheduled pain medication regimen. Resident #156 had pain or was hurting in the last five days, the pain almost constantly made it hard for him to sleep at night, and the pain occasionally interfered with therapy activities. Resident #156 rated the worst pain he experienced over the last five days as a nine on a scale of zero to ten, zero being no pain and ten being the worst pain he could imagine. Review of Resident #156's physician encounter note dated 04/29/24 at 1:00 A.M. included Resident #156 shortened his hemodialysis session today as his sacral pain was unbearable while sitting in the dialysis chair. Resident #156 had an unstageable sacral wound and was followed by wound care and the wound nurse practitioner. Resident #156 and his sister reported that Resident #156 had better managed pain with topical treatments as opposed to the systemic medication that he had. Resident #156 was scheduled Percocet with Tramadol as needed. Resident #156 reported that he got no relief from the Tramadol and minimal relief from the Percocet. Resident #156 was open to having a referral to pain management. Resident #156's pain level was a seven, and he was lying on his left side with a furrowed brown with intermittent moaning and rocking. Resident #156's plan was to coordinate care with physiatrist and continue Percocet oral tablet 5-325 mg (oxycodone with acetaminophen), give one tablet by mouth every morning and at bedtime for moderate pain. Continue to encourage Resident #156 to lay on alternating sides and consult pain management. The goal was Resident #156 would not report unmanageable pain. Review of Resident #156's OT notes written by OT #357 and signed on 04/29/24 at 4:15 P.M. included Resident #156 was lying supine at the start of the session, no noted pain, but had increased dizziness and fatigue. During therapy Resident #156 suddenly threw himself down onto the bed yelling I am just too dizzy! I hurt! There was no evidence in the notes Resident #156's nurse was notified he was in pain. Review of Resident #156's MAR dated 04/29/24 revealed Resident #156's bedtime Percocet tablet was not given. Resident #156's pain level was documented as a zero. Review of Resident #156's progress notes dated 04/29/24 at 10:52 P.M. revealed Resident #156's Percocet tablet was not given due to it being on order. Further review did not reveal evidence Resident #156's physician was notified he did not receive the Percocet per physician order. Review of Resident #156's MAR dated 04/29/24 at 10:52 P.M. revealed Tramadol 50 mg oral tablet was administered, and Resident #156's pain level was marked as zero. Review of Resident #156's Grievance Form dated 04/29/24 included Resident #156's family stated Resident #156 was not receiving his pain medication. Unit Manager (UM) #386 followed up on the grievance, and wrote the nurse was educated that when a substance order was taken, a prescription must be initiated, but did not state what the substance was. Review of Resident #156's MAR dated 04/30/24 revealed Resident #156's Percocet was not given as ordered in the morning, and there was no pain level documented. Review of Resident #156's MAR dated 04/30/24 at 8:01 A.M. revealed Tramadol 50 mg oral tablet was administered, and Resident #156's pain level was rated at an eight on a scale of zero to ten, ten being the worst pain. Review of Resident #156's progress note dated 04/30/24 at 9:55 A.M. revealed Percocet tablet was not given due to awaiting written prescription to be faxed to pharmacy. There was no evidence Resident #156's physician was contacted regarding the need for a written prescription. Further review did not reveal evidence Resident #156's physician was notified he did not receive the Percocet per physician order. Review of Resident #156's PT notes written by PT #361 and signed on 04/30/24 at 1:31 P.M. included Resident #156 was originally not agreeable to therapy stating he did not receive his Percocet today, and he remained dizzy with mobility. Review of Resident #156's physician encounter notes written by CNP #320 dated 05/01/24 at 1:00 A.M. included Resident #156 was being discharged from the facility today (05/01/24) and nursing reported Resident #156 declined going to dialysis today. Resident #156 was lying on his bed upon arrival and his sister was present. Resident #156 reported he was unable to tolerate his pain and would wait until he was transferred to resume dialysis. Resident #156's pain level was a five. Review of Resident #156's physician progress note dated 05/01/24 at 5:59 A.M. and written by Physician #492 revealed the service date was 04/26/24 and it was an initial encounter for physical medicine and rehabilitation. The notes included Physiatry, Physical Medicine and Rehabilitation consult was requested for management of decline in function with impaired mobility and self-care. Resident #156 was seen in room for interdisciplinary meeting and then individually with Resident #156 and his sister following the meeting. Resident #156's main concern today was the pain from his sacral ulcer that prevented him from being able to sit up for long periods of time or fully participate in therapies. Resident #156 also expressed that he was unable to complete full sessions of HD (hemodialysis) due to the pain and even expressed his desire to potentially discontinue dialysis. Resident #156's pain was severe sacral pain without radiation and was a deep ache with occasional sharpness. Resident #156 reported minimal relief with current pain regimen of Percocet 5-325 mg (Resident #156 did not have Percocet ordered until 04/26/24 at 5:22 P.M.) and tramadol (ordered on 04/24/24 and first dose of Tramadol was not administered until 04/28/24 at 12:25 P.M.) every six hours as needed. Resident #156 reported insomnia and sleeping difficulty mainly due to his pain. Pain and opioid management evaluation was continuing to monitor Resident #156's pain closely. Percocet 5-325 mg two times a day for pain control. Monitor for pain and effect on therapy progress and tolerance. Review of Resident #156's progress note dated 05/01/24 at 8:37 A.M. and written by Physician #492 revealed the service date was 04/29/24 included Resident #156 was seen in room briefly while working with therapy and then later in the morning with Resident #156's sister present. Resident #156's sister expressed significant concern for Resident #156's care during his stay. Resident #156 continued to have significant pain in his sacrum that was severe today. Attempted trials with donut pillow brought to facility by the family were unsuccessful, and he was still unable to tolerate any sitting. Resident #156's pain medication was discussed, and the plan was to increase Percocet to 10-650 mg. Updates for 04/29/24 included Resident #156's sacral pain was still uncontrolled, and Percocet would be increased to 10-650 mg twice a day. Discussed need for slow titration of medication as Resident #156 was on HD (hemodialysis) and was at higher risk for adverse reactions such as somnolence and respiratory depression. Monitor for pain and effect on therapy progress and tolerance. Monitor closely for side effects and discontinue medication immediately if any signs and symptoms are present. Review of Resident #156's physician orders, MAR, and nursing progress notes dated 04/29/24 through 05/01/24 did not reveal orders for Percocet 10-650 mg to be administered twice a day. Review of Resident #156's OT Discharge Summary dated 05/02/24 at 4:36 P.M. included no progress was made while on therapy services due to short treatment duration. Resident #156 met no goals at this time with barriers due to decreased activity tolerance and limited ability to participate in treatment sessions due to increased pain and fatigue. Review of Resident #156's nursing progress notes dated 04/21/24 through 05/01/24 did not reveal non-pharmacological interventions for pain control such as turning to relieve pain. Interview on 06/20/24 at 11:42 A.M. of the Director of Nursing (DON) revealed when a resident was admitted to the facility, orders should be verified by the physician. The DON stated orders should be verified as soon as possible because the sooner the resident's medications were in the system the sooner pharmacy could send them. The DON indicated if a resident had a medication ordered and it was available in the on hand medications in the automated medication dispensing system, the medication should be given, and the nurses should not wait until pharmacy delivered the medications. Interview on 06/20/24 at 5:23 P.M. of UM #386 revealed she did not know anything about Resident #156's pain or not having pain medication ordered. Interview on 06/21/24 at 10:24 A.M. of CNP #320 confirmed Resident #156 did not have pain medications ordered when he was admitted to the facility. CNP #320 stated it was absolutely a miss on my part. CNP #320 stated for renal residents she usually started with Tylenol and worked up to tramadol or stronger pain medications as needed. CNP #320 confirmed she wrote a progress note on 04/22/24 and it stated Resident #156 had pain in the buttocks and a note on 04/24/24 stating Resident #156 had unbearable pain. CNP #320 revealed she remembered Resident #156, he had difficulty moving due to pain, could not tolerate dialysis, and there was talk of getting a donut for him to sit on during dialysis. Interview on 06/24/24 at 6:50 A.M. of LPN #433 revealed when Resident #156 was admitted to the facility on [DATE] it was a very busy and chaotic night, and she was the only nurse on the nursing unit Resident #156 resided on. LPN #433 stated she did not remember many details about Resident #156, but she always checked newly admitted resident's admission orders for narcotics and if narcotics were ordered she called the resident's physician right away so the residents could receive pain medications as needed. LPN #433 stated another nurse verified Resident #156's medications with the physician and she did not know what medications were ordered. LPN #433 indicated it was very time consuming to admit a resident, verify the medications, and have all the paperwork and forms completed, and she often had to choose between finishing the admitting information or passing medications to the residents residing on the nursing unit she was assigned to. Interview on 06/24/24 at 9:15 A.M. of LISW #485 revealed Resident #156 had a grievance filed on 04/29/24 and included in the grievance was Resident #156 and his family were upset the resident did not receive his pain medications. DSS #485 stated Resident #156's family wanted him transferred (to another facility) because of concerns with his care. Interview on 06/24/24 at 9:57 A.M. with CNP #320 revealed she missed ordering Resident #156's pain medication, but the nurses did not tell her Resident #156 had pain. CNP #320 stated Resident #156 did not want to go to dialysis because of the pain from his sacral wound. CNP #320 stated Physician #492 was a physiatrist and helped manage Resident #156's pain, but she was not sure if he ordered anything for pain. CNP #320 indicated MD #494 ordered Percocet, but there was no documentation in Resident #156's progress notes how we got to the Percocet. CNP #320 stated she told the nurses about the pain referral, they did not do it, and she could not remember which nurse she told. Interview on 06/24/24 at 11:41 A.M. of Physician #492 revealed his first visit with Resident #156 was on 04/26/24. Physician #492 stated Resident #156 was admitted with sepsis, pneumonia, and he had a sacral pressure ulcer which was causing him a lot of pain. Physician #492 stated Resident #156's pain was stable pretty much his whole admission. Physician #492 stated his main objective was to control Resident #156's pain, and he was having dizziness as well. Physician #492 stated on 04/29/24 Resident #156's pain was uncontrolled, and he increased the Percocet from 5-325 mg to 10-650 mg. Physician #492 stated he did not have electronic access to write orders and wrote the orders for the Percocet increase on paper orders, and flagged Resident #156's chart and told a nurse he wrote orders. Physician #492 stated he did not remember which nurse he told, but the orders did not get taken off the chart and started. Interview on 06/24/24 at 12:04 P.M. with MD #494 revealed he did not remember details regarding Resident #156, but he remembered Resident #156 was in pain and he ordered Percocet. Review of the facility on hand medications located in the automated medication dispensing system revealed oxycodone-acetaminophen 5-325 mg tablets (Percocet) were available in the system. Review of the undated facility policy titled Pain Management and Assessment included to the extent possible and in consideration of cognitive abilities, the nurse would provide a thorough assessment by observation of activities and treatment, relief for detection of pain and to attempt to identify location and any limitations imposed by the pain. Clues might include facial grimaces during care, guarding or protecting a body limb or part. Additionally, the basis for the pain management included source, type, and intensity of pain, the use of the appropriate pain management scale for the resident's ability to express pain, to include non-pharmacological and pharmacological treatment and whether each treatment was effective. Impact of pain on quality of life including sleep loss, function abilities and mood. Use of the 1 to 10 pain scale for residents with intact cognition abilities who can and are willing to determine their worst pain ever (10) and no pain (1) range using numbers. This deficiency represents non-compliance investigated under Master Complaint Number OH00154408.

THE FOLLOWING SURVEY FINDING PERTAINS TO AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure residents were transferred in a manner to prevent injury. This affected one of three residents reviewed for falls. Facility census was 147. Actual harm occurred when Resident #152, who lacked coordination and had reduced mobility, sustained a laceration requiring transfer to an emergency room for evaluation and treatment, 14 sutures, and prophylactic antibiotics while being transferred from a wheelchair to bed. Findings include: Review of the medical record for Resident #152 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included osteoarthritis, lack of coordination, dependence on wheelchair, reduced mobility, need for assistance with personal care, diabetes mellitus, congestive heart failure, and schizophrenia. Review of the telehealth progress note dated 07/21/22 timed 10:30 P.M. revealed Resident #152 sustained a long laceration to right leg during transfer when leg was caught on metal railing of bed. Wound estimated to be 12 centimeter (cm) long by nursing with exposed tissue. There was noted bleeding and order to transfer to hospital for wound care and possible stitches. Review of the nursing progress note dated 07/21/22 timed 11:00 P.M. revealed a State tested Nurse Aide (STNA) notified nurse that Resident #152 sustained injury during care. The STNA indicated Resident #152 cut leg against bed frame during transfer. Resident #152 was treated for bleeding and assessed. Resident #152 reported no pain. The Director of Nursing (DON), telehealth physician, unit manager, and family were notified. Review of the facility Transfer Form dated 07/21/22 revealed Resident #152 was transferred to hospital for leg laceration. Review of telehealth physician post transfer note dated 07/22/22 timed 3:39 A.M. revealed sutures placed, started on prophylactic antibiotic. Review of nursing progress note dated 07/22/22 timed 10:57 A.M. revealed Resident #152 returned from hospital with 14 stitches to right leg. Review of the Skin Grid Non-Pressure document dated 07/22/22 revealed Resident #152 had new skin impairment on 07/21/22. Resident #152 sustained right lower extremity laceration measuring 12.0 cm x 1.5 cm x less than 0.1 cm. Skin treatment included cleanse with normal saline, pat dry, cover with ABD (large padded gauze) and wrap with Kerlix (absorbent gauze wrap) daily and as needed. Review of the facility Skin Alteration Investigation dated 07/22/22 revealed Resident #152 sustained right lower extremity laceration and was sent to hospital for treatment. Resident #152 returned to facility with sutures. Family and physician were notified. Investigation indicated STNA was transferring Resident #152 from wheelchair to bed for incontinence care. During transfer Resident #152 was noted to scrape leg on bed causing skin tear. Review of a statement from maintenance dated 07/22/22 revealed nursing asked for a pool noodle to be placed around bed. Maintenance checked bed for correct functioning and pool noodle was placed as requested. Maintenance indicated there was no damage to bed and there was no metal sticking out or around the bed. Review of the Staff Education form dated 07/22/22 revealed the STNA was educated on appropriate technique for transfers. Review of the plan of care dated 07/25/22 revealed Resident #152 was at risk for altered skin integrity. Interventions included complete weekly skin checks, monitor stitches to right leg for infection, noodle foam on bed frame, monitor vital signs, and lab testing as needed. Review of the Medicare Discharge Minimum Data Set (MDS) assessment, dated 10/21/22, revealed Resident #152 had intact cognition. Resident #152 required extensive assistance with bed mobility and transfers. Interview with the Director of Nursing (DON) on 12/07/22 at 4:00 P.M. confirmed Resident #152 sustained a laceration to the right lower extremity while being transferred back to bed. The laceration was deep, pressure was applied, and telehealth was called. Telehealth provided instruction to send Resident #152 to emergency room for evaluation. The laceration required sutures and Resident #152 was placed on a prophylactic antibiotic. The DON said the unit manager looked at the bed frame and could not identify where the injury occurred. Maintenance also looked at the bed and did not see where the injury occurred. The DON further indicated Resident #157 had contracted legs and she thought when the STNA turned the resident her leg caught on the bed. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 07/25/22. No residents sustained injuries during transfer since 07/21/22. On 07/21/22, Resident #152 was transferred to the hospital for treatment in a timely manner and family notification was completed. On 07/22/22, the facility completed a thorough investigation to determine how the injury occurred; the STNA involved received education on appropriate transfer techniques; maintenance assessed the bed frame and determined there were no sharp edges, and a foam pool noodle was placed on the bed frame. On 07/25/22, Resident #152's care plan was updated. On 08/04/22, Resident #152 had stitches removed without difficulty. There were no signs or symptoms of infection. Observations on 12/06/22 from 7:40 A.M. to 8:15 A.M. and subsequent observations throughout the day revealed staff transferring residents using appropriate technique. No environmental safety hazards were noted. This deficiency represents non-compliance investigated under Complaint Number OH00137537.

Based on observation, record review and interview, the facility failed to ensure interventions were in place to prevent or treat pressure wounds for three residents (Residents #157, #115 and #[AGE]). This affected three of four residents reviewed for pressure wounds Actual harm occurred when Resident #157's sacrum pressure wound treatment was not initiated timely and the wound progressed in severity from a Stage 2 pressure ulcer to a Stage 4 pressure ulcer. Findings include: 1. Review of Resident #157's medical record revealed the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #157's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident #157's Skin Grid Pressure form dated 01/14/20 revealed a Stage 2 (partial-thickness skin loss with exposed dermis) sacrum pressure wound measuring 6 centimeters (cm) in length by 5 cm width by 0 cm depth which was community acquired and first observed on 01/14/20. Review of Resident #157's medication administration records (MARS) and treatment administration records (TARS) from 01/14/20 to 01/18/20 revealed no documentation wound care was initiated or completed from 01/14/20 to 01/18/20. Review of Resident #157's physician orders [REDACTED]. Review of Resident #157's Skin Grid Pressure form dated 01/22/20 indicated the resident had an unstageable (cannot stage because wound covered by slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead tissue)) sacrum pressure wound measuring 6.5 cm by 8.5 cm with no depth indicated. The area was first observed on 01/14/20. Review of the wound nurse practitioner (NP) progress note dated 01/22/20 indicated Resident #157's sacrum pressure wound was 100 percent slough with serosanguinous (watery pinkish red) drainage measuring 6.5 cm by 8.5 cm with an undetermined depth. Review of a physician order [REDACTED]. Review of Resident #157's Skin Grid Pressure form dated 01/29/20 indicated the resident had an unstageable sacrum pressure wound measuring 8.5 cm by 9.5 cm with an undetermined depth. The area was first observed on 01/14/20. Review of a physician order [REDACTED]. Review of Resident #157's NP wound progress note dated 02/05/20 revealed the resident had a Stage 4 (full thickness skin loss with extensive destruction, tissue necrosis (death) or damage to muscle, bone or supportive structures) sacrum pressure wound with 50 percent granular tissue and 50 percent slough measuring 9.5 cm by 10.3 cm by 3.4 cm. Necrotic tissue was debrided (removed) from the wound to reduce risk of infection and improve wound healing. Review of Resident #157's Skin Grid Pressure form dated [DATE] indicated the resident had a Stage 4 sacrum pressure wound measuring 9.5 cm by 10.3 cm by 3.4 cm. The area was first observed on 01/14/20. Review of an order dated [DATE] to cleanse the wound with normal saline, pad dry, apply [MED] (enzymatic [MEDICATION NAME] agent) and calcium alginate and cover with a foam dressing daily and as needed. Review of Resident #157's Skin Grid Pressure form dated 02/12/20 indicated the resident had a Stage 4 sacrum pressure wound measuring 10 cm by 7.2 cm by 2 cm. The area was first observed on 01/14/20. Review of Resident #157's wound NP progress note dated 02/12/20 indicated the resident's sacrum pressure wound was a Stage 4 measuring 10 cm by 7.2 cm by 2 cm depth and the wound continued to get bigger as the slough shed. Interview on 0[DATE] at 3:43 P.M. with the Director of Nursing (DON) confirmed Resident #157 was readmitted from the hospital to the facility on [DATE] with a Stage 2 pressure wound to the sacrum. The DON verified Resident #157's medical record did not contain evidence wound care was initiated for the Stage 2 pressure wound until 01/19/20. Interview on 0[DATE] at 5:58 P.M. with NP #999 revealed she first observed the pressure wound to Resident #157's sacrum on 01/19/20 and the wound was unstageable at that point. NP #999 indicated the treatment for [REDACTED]. 2. Review of Resident #115's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 0[DATE] at 9:16 A.M. with State tested Nursing Assistant (STNA) #[AGE]4 revealed Resident #115's control box for the alternating pressure reduction mattress that was on her bed was hanging at the end of the bed and was not plugged into the wall and not working correctly. Interview on 0[DATE] at 12:38 P.M. with the DON revealed hospice services brought Resident #115's bed in for the resident at some point and was unaware the bed was not functioning correctly. Interview on 0[DATE] at 3:07 P.M. with Hospice Registered Nurse (RN) #961 revealed she ordered an alternating pressure mattress for Resident #115 on 0[DATE]. The alternating pressure mattress was delivered to the facility on [DATE] but she was unaware the mattress was not plugged in and functioning properly. 3. Review of Resident #[AGE]'s medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #[AGE]'s physician orders [REDACTED]. Observation on 0[DATE] at 7:44 A.M. with Licensed Practical Nurse (LPN) #918 confirmed Resident #[AGE]'s Prevalon boots for pressure were not on the resident at the time of the observation. The resident's heels were lying on the bed and were not elevated as ordered Interview on 0[DATE] at 8:03 A.M. with LPN #918 confirmed Resident #[AGE]'s pressure boots were not on the resident as ordered, not in the resident's room and must be in laundry. Interview on 0[DATE] at 12:38 P.M. with the DON revealed she interviewed staff and Resident #[AGE]'s night STNA took the resident's Prevalon boots to the laundry at some point and did not place a new pair on the resident's lower extremities or elevate the resident's heels. This deficiency substantiates Complaint Number OH 201.

Based on observation, record review, witness statements, policy review, temperature history and interview, the facility failed to ensure Resident #134's environment remained free from accident hazards. This affected one (Resident #134) of three residents reviewed for falls. Actual harm occurred when Resident #134 fell out of bed on to the baseboard heating unit while it was warm to touch and received injuries consistant with a burn to his right flank, right chest, right elbow and right hip. Findings include: Review of the medical record for Resident #134 indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 06/02/19 Minimum Data Set (MDS) 3.0 quarterly assessment indicated Resident #134 was severely cognitively impaired, had two or more falls since admission or prior assessment with no injuries and was not steady with walking (only able to stabilize with staff assistance). Review of the 06/01/19 fall risk assessment indicated Resident #134's potential interventions included toileting assistance and monitoring the resident. Review of the 06/04/19 post fall assessment indicated Resident #134 fell out of bed at 5:00 A.M., was lying on his right side with his arms to his side and legs straight out, he had pain in his back and had last been seen at 4:40 A.M. Review of the 06/04/19 physician progress notes [REDACTED]., indicated Resident #134 was found on floor near the baseboard heater and complained of pain in right arm and hip. Obtain an x-ray of the right hip and arm. He had an abrasion with blisters on his back; please clean and cover. Review of the 06/04/19 hospital emergency department triage nursing assessment, timed 6:57 A.M., indicated Resident #134 had a chief complaint of a fall. Resident #134's symptoms were positive for an abrasion, confusion and pain in the right arm, right leg and back. Resident #134 had blisters to his back. Review of the 06/04/19 nurses note, timed 9:29 A.M., indicated State-tested Nurse Aide (STNA) called the nurse to the resident's room. Resident #134 was on the floor between his bed and the wall. He was on his right side touching the baseboard heating unit. He was assessed for injury which indicated a skin tear and abrasions to the right mid-back. Resident #134 was unable to tell the nurse how it happened. The resident complained the abrasions were stinging. Telehealth (physician) called with new orders for X-ray's and cleanse area with water and cover. Resident #134 was not cooperative and began yelling, ambulance. Resident #134's daughter wanted him sent to the emergency department. Review of the nursing hospital triage assessment dated [DATE] indicated Resident #134 had constant pain of a ten out of ten on the pain scale. Review of the 06/04/19 nurses note, timed 8:00 P.M. indicated Resident #134 returned back from the emergency department at 10:28 A.M. Resident #134 had abrasions to his right flank and right elbow and was seen by the wound team at the facility. Resident #134 had an order from the hospital for [MEDICATION NAME] topical ointment (a medication used to prevent and treat minor skin infections caused by small cuts, scrapes or burns) to be applied to the affected area two times a day. Review of the 06/04/19 initial physician wound assessment indicated Resident #134 had a blister (non-pressure) on his right chest measuring 27.5 centimeters (cm) length by 6.2 cm width by 0.1 cm depth with scant exudate. Resident #134 apparently fell and was laying on his right side. Resident #134 had a blister (non-pressure) on his right flank measuring 5.5 cm length by 2.0 cm width by 0 cm depth with scant exudate. Resident #134 had a blister (non-pressure) on his right hip measuring 8.5 cm length, 7.0 cm width, 0.1 cm depth with scant exudate. The treatment order was to cleanse wounds with normal saline or sterile water, apply an oil [MEDICATION NAME] to the wound bed and cover with dry clean foam dressing. Resident #134 had an intact blister (non-pressure) to his right elbow measuring 5.0 cm length by 3.0 cm width by 0 cm depth. The treatment order was for a barrier wipe/spray daily and as needed. Review of the 06/04/19 witness statement, written by STNA #25, indicated about 5:00 A.M., STNA #25 heard someone moaning from the hall, went to Resident #134's room and Resident #134 was on the floor by the other side of the bed, the left side, by the heater. Resident #134 was lying on the heater and got skin tears [MEDICAL CONDITION] the heater. STNA #25 called for help and informed the nurse. Review of the 06/04/19 witness statement, written by LPN #24, indicated LPN #24 was on the way back from another unit when she was told to come to Resident #134's room. Resident #134 was on the floor between his bed and the wall on his right side. There was no cover on the baseboard heating unit. He was scraped on his right back and blisters were forming Resident #134 was complaining of burning. Telehealth (physician) was called, and a new order was given for x-ray's and to rinse the blisters with cool water. At this time, Resident #134 was yelling, ambulance. Resident #134's daughter wanted him sent to the emergency department. This nurse touched the baseboard heating unit with her barehand and unit felt warm to the touch; unit did not feel burning hot. Review of the 06/04/19 witness statement, written by STNA #28, indicated STNA #28, two other STNA's and a nurse assisted Resident #134 in bed. STNA #28 witnessed the wounds from Resident #134 falling on the heater vent on right side. Review of the National Weather Service Forecast data (www.weather.gov) indicated the minimum temperature on 06/04/19 was 50 degrees Fahrenheit. Review of the fall care plan, updated on 06/06/19, indicated Resident #134 was at risk for falls related to weakness, unaware of safety needs, impulsive, impaired cognition, [DIAGNOSES REDACTED]. Observation on 06/25/19 at 9:40 A.M. of Resident #134's prior bedroom revealed there wasn't a bed where Resident #134's would have been. Resident #134's bed would have been near the wall with the window; there would be a space between Resident #134's bed and the wall with the window. There was baseboard heating unit attached to the wall, near the floor, approximately six-inches in height and the heating unit ran the entire length of the wall. The baseboard heating unit cover wasn't fully attached to the unit and approximately two inches of the heating unit coils were exposed. Interview on 06/25/19 at 3:30 P.M. with Director of Maintenance #23 revealed the baseboard heating unit coils would be hot but the baseboard heating unit cover would not be hot when the unit was on. The heater automatically turns on when the outside temperature was 55 degrees F or lower. Interview on 06/26/19 at 7:37 A.M. with LPN #24 revealed the heating unit coils were exposed and the heating unit cover was not attached to the unit while Resident #134 was lying on the floor after the fall. LPN #24 touched the heating coils which were warm to the touch at the time of the fall then touched them again later on and the coils were still warm. LPN #24 couldn't get through to call in a nurse-to-nurse report to the emergency department. LPN #24 reported to the emergency medical technicians (EMT's) that Resident #134 fell on the baseboard and the baseboard cover was off. Interview on 06/26/19 at 8:23 A.M. with STNA #25 revealed she couldn't remember the last time she observed Resident #134. STNA #25 touched the baseboard heating unit coils which were warm to the touch, and the baseboard cover was not attached to the unit. Observation on 06/26/19 at 10:00 A.M. of Resident #134 with Registered Nurse (RN) #26 and LPN #27, and another surveyor present, revealed Resident #134 had an area on his right flank, approximately from his shoulder blade to hip bone covered by three dressings. Within the area, there was pink tissue on the outer edge and yellow and black tissue in the center. Resident #26 had five linear, horizontal areas approximately from his right hip to his upper thigh. Resident #26 had an area on his right elbow approximately the size of a quarter-dollar coin. The area's on Resident #26 appeared to be consisted with a burn. Review of the fall risk assessment, revised on 03/16/16, indicated the facility would institute appropriate precautions that are individualized to the residents needs. This deficiency substantiates Complaint Number OH 970.

Based on observation, interview and record review the facility failed to ensure the proper amount of staff were provided to Resident #17 during incontinence care resulting in a fall with injury and failed to ensure Resident #423 was transferred properly using a mechanical lift. This effected two residents (Residents #17 and #423) of three residents reviewed for accidents. Actual harm occurred to Resident #17 when a State tested Nurse Aide (STNA) #115 attempted to provide incontinence care to Resident #17 by herself, instead of waiting for a second STNA to help. Resident #17 rolled out of the bed, onto the floor, and sustained a laceration to the forehead that required transfer to the emergency room and five sutures to the forehead wound. Finding include: 1. Resident #17 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was nonverbal and received nutrition via a feeding tube. A Minimum Data Set 3.0 assessment ((MDS) dated [DATE] revealed Resident #17 was severely impaired with limited range of motion of the upper and lower extremities, and required the assistance of two persons for bed mobility, toileting and transfers. Review of Resident #17's Fall Detail Report for a fall that occurred on 03/22/18 at 1:18 A.M. included a conclusion statement written by the Director of Nursing (DON). The statement revealed STNA #115 was in the room providing care to Resident #17. STNA #115 came out of the room and notified Licensed Practical Nurse (LPN) #46 that Resident #17 accidentally rolled out of bed while being positioned for cleaning. STNA #115 was unable to stop Resident #17 from rolling out of the bed onto the floor. LPN #46 observed Resident #17 laying on her back next to the bed and appeared to have hit her forehead on the base of a pole used to hold her tube feeding solution. Resident #17 had a laceration to the left forehead and bruising to the right eye. Resident #17 was sent to the emergency room for evaluation. The statement indicated the root cause of the accident was that staff did not follow the care plan. Review of the nurses note dated 03/22/18 at 1:18 A.M. revealed STNA #115 came out of Resident #17's room and notified LPN #46 that the resident was on the floor. LPN #46 observed Resident #17 laying on her back on the floor with a laceration to left side of her forehead with a moderate amount of red drainage. Resident #17 was sent to the emergency room . Review of the Patient Care Summary dated 03/22/28 revealed Resident #17 sustained a laceration with swelling to the left frontal scalp with instructions for suture care. A nurses note dated 03/22/18 at 5:05 A.M. revealed Resident #17 returned from the emergency room with five sutures to the forehead. Interview on 04/05/18 at 11:55 A.M. with STNA #115 revealed on 03/22/18 at about 1:00 A.M. Resident #17 was incontinent of urine and stool. STNA #115 knew Resident #17 required two staff members for care but believed she would be able to clean and change the resident by herself. However, when STNA #115 attempted to position the resident on her side so she could clean her, the resident rolled off the bed, onto the floor, and hit her head. STNA #115 was suspended from her job and was required to attend training on safe transfers and two person assist technique prior to returning to work. On 04/05/18 at 1:25 P.M. the DON verified on 03/22/18 Resident #17 fell out of bed during care and sustained a [MEDICAL CONDITION], that required transfer to the emergency room and five sutures to the forehead. STNA #115 was aware the resident required the assistance of two persons for incontinence care and should not have attempted to do it by herself. 2. Resident #423 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required the use of a mechanical lift for transfers. Review of the admission MDS 3.0 revealed the resident was cognitively intact and was totally dependent on two or more staff for transfers. On 04/04/18 at 10:40 A.M., observation of the mechanical lift transfer, with the Drive # lift, from the bed into the wheelchair by STNAs #92 and #149 revealed STNA #92 placed the lift legs under the bed in the closed position. The STNAs then hooked the sling to the lift, elevated Resident #423 in the lift sling off the bed, then moved the lift from under the bed about four feet with the legs still in the closed position. STNA #92 stopped moving the lift and then opened the legs with resident's head and body facing away from the lift operator. STNA #149 operated the lift as STNA #92 moved the wheelchair with the left leg rest attached under the resident. STNA #92 tilted the wheelchair back using the handles. With the wheelchair wheels unlocked the resident was lowered into the wheelchair while it was tilted back with the front wheels about two feet off the floor. STNA #92 verified he always tilted the wheelchair back without locking the wheels so Resident #423 could be positioned better in the wheelchair and they would not have to be adjusted after lowering him in the chair. STNA #92 verified it depended on the size of the bed and room if the lift legs were able to be opened while under the bed or during moving in the room. He also verified at no time were the lift casters locked, the resident did not face the lift operator during transfer and the wheelchair was tipped backward with the brakes unlocked when the resident was lowered into it. On 04/04/18 at 3:40 P.M., observation of the mechanical lift transfer, with the Invacare Reliant 450 lift, from the wheelchair into bed by STNAs #98 and #120 revealed STNA #120 widened the legs of the lift to get it under the wheelchair, then lifted Resident #423 out of the wheelchair. During the lifting neither the casters of the lift nor the wheels of the wheelchair were locked. As the resident was lifted out of the wheelchair he was facing 180 degrees away from the lift operator. The lift was moved towards the bed and when approaching the bed the legs of the lift were closed. Once over the bed the resident was facing 180 degrees away from the lift operator and the STNAs tried to turn the resident to the left so he would be positioned correctly with his head at the head of the bed. However, the lift would not allow the resident to be turned that way, so the resident had to be turned 270 degrees to the right in order to be able to lower him into the bed with his head at the head of the bed. When the resident was about two inches from the bed, STNA #98 locked the right caster and informed STNA #120 to lock the left caster and they finished lowering the resident into the bed. STNAs #98 and #120 verified the above observation. On 04/06/18 at 7:50 A.M., during interview with the DON related to the above findings the DON verified STNAs #92, #149, #98 and #120 had not used the mechanical lifts properly. Review of the mechanical lifts transfer policy and procedure dated 06/05/14 revealed to make sure the base was at the widest position and the wheels were locked. Position the resident over the wheelchair and lock the lift wheels. Review of the manufacturer's instructions for the Drive # mechanical lift revealed to spread the base legs to the widest position before lifting the resident. Keep the resident centered between the base legs and have the resident face the attendant. Lock the rear casters and lift the resident facing the attendant. Unlock the rear casters and transfer the resident to the wheelchair. Lock brakes of both the lift and the wheelchair. Review of the manufacturer's instructions for the Invacare reliant 450 mechanical lift revealed when using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the resident. Invacare does not recommend locking the rear casters of the lift when lifting the resident. Doing so could cause the lift to tip and endanger the resident. The wheelchair wheel locks must be in a locked position before lowering the resident into the wheelchair. The legs of the lift must be in the maximum open position for optimum stability and safety.

The following deficiency finding pertains to an incident of Past Non-Compliance that was subsequently corrected prior to this survey. Based on observation,interview and record review, the facility failed to ensure Resident #43 was transferred and repositioned in a safe manner. Actual harm occurred when staff transferred Resident #43 by her arms and legs instead of with a gait belt, resulting in a left humerus fracture and hospitalization . This affected one of four residents reviewed for falls. The facility census was 174. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired, she had no mood or behavior issues and required the extensive assistance of one staff member for bed mobility, transfers and other activities of daily living. Review of her care plan for falls updated through 04/05/18 revealed she was at risk for falls due to problems with vision, gait, balance, incontinence and muscle weakness. Review of the listed staff interventions revealed she was to wear appropriate foot wear, be reminded to call for assistance with the call light kept within reach and to provide a safe environment. Review of an intervention dated 11/29/17 revealed she was to have mats to the floor along both sides of her bed when she was in bed. Review of her physician orders [REDACTED]. Review of her nursing notes from 08/01/17 revealed Resident #43 had some concerns related to pain, [MEDICAL CONDITION]/swelling and weakness at times of both of her lower legs/feet with treatments and interventions appropriately attempted. She had an X-ray of her left foot and ankle on 10/04/17 showing deformity due to a bunion, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of a nursing note dated 11/29/17 at 1:32 A.M. revealed Resident #43 was found on the floor by the nursing assistant. She was assessed by the nurse and no injuries were found. She stated she was trying to get to her wheelchair and fell . She was educated to use the call light for assistance and the floor mats were placed along both sides of her bed to prevent injury. Review of a nursing progress note dated 01/15/18 at 11:37 P.M. revealed around 3:45 P.M. on 01/15/18, the nurse was alerted to the resident's room to assist a staff member. The note indicated when the nurse entered the resident's room, Resident #43 was observed halfway sliding out of the wheelchair. The nurse attempted to reposition the resident to sit back up in the chair with the other staff person, but as they attempted this, staff heard a noise and patient immediately screamed in pain, stating OOW, my left arm hurts!!!. The nurse assessed the resident's arm and applied ice. Resident #43 was unable to move her arm and screamed in pain every time it was moved. The resident was medicated with over the counter pain medications and an X-ray was ordered, as well as a transfer to the hospital for evaluation. The resident was admitted to the hospital with [REDACTED]. She returned to the facility on [DATE] with a sling and orders for a pillow for positioning when in bed. Review of an X-ray taken in the facility on 01/15/18 revealed an acute medially angulated left humeral neck fracture. Review of information sent from the hospital when the resident returned on 01/18/18 revealed an X-ray report dated 01/15/18 at 9:06 P.M. showing an acute displaced oblique [MEDICAL CONDITION] proximal humerus. Review of a note from the hospital dated 01/17/18 at 2:40 P.M. revealed the resident was to not have any active or passive range of motion to her shoulder with no weight bearing on her left arm for at least 3-4 weeks. The note indicated with the significant disease in her left shoulder with the humeral head and rotator cuff dysfunction the physician doubted there will be any significant movement in the shoulder even once the fracture heals. Review of the investigation of this incident revealed a statement by State tested Nursing Assistant (STNA) #300. STNA #300 indicted Resident #43 rang her call light to go to the bathroom, but she was sliding out of the chair, so STNA #300 called for help. The statement indicated a nurse and another STNA came in and helped her reposition the resident. STNA #300's statement indicated she had her gait belt (a belt device placed around the waist of a person for the staff to assist them with transfers/mobility) but was unable to reach for it to keep the resident from falling to the floor. An interview on 01/29/18 at 3:28 P.M. with STNA #300 revealed she heard the resident's call light ring and when she went to see what the resident needed, she saw the resident had slid down in her chair. She denied the resident was actively sliding at the time but had somehow slid and was resting in the wheelchair, half off the seat. She stated she went out to the hall to look for someone to help her and saw STNA #301 so she called for help. She stated when STNA #301 came in, they realized they would need more staff to reposition the resident, so she went to the doorway and saw Registered Nurse (RN) #302 and asked him to come in. She verified she did not use the gait belt to transfer the resident either when she was positioned in the chair or after she sustained the injury, when staff moved her to the bed. She stated she was not sure why the belt was not used. Review of a statement from STNA #301 revealed she helped hold the resident's left leg, which had sustained a skin tear and was covered with a towel. An interview on 01/29/18 at 3:22 P.M. with STNA #301 revealed she was walking by the room and was summoned to help move the resident back in her chair. She stated the resident had slid out of the chair but was not actively sliding when she came in, and she and STNA #300 waited for the nurse to help reposition the resident. She stated after putting the resident in the chair, they decided to move her to the bed. STNA #301 verified a gait belt was not used for either of the transfers, even though one was available. She verified the gait belt allows staff to hold the belt instead of pulling against the resident's body to lift or reposition them. She verified the facility policy indicated a gait belt should be used when transferring a resident. Review of a statement by RN #302 revealed he was called by the STNA and informed help was needed to readjust the resident back to the seat as she was almost sliding down from the wheelchair. The nurse went in the room and observed the resident sliding down in the chair. The nurse, along with the two aides, attempted to readjust the resident and heard a sound on the residents left arm/shoulder. The resident complained of pain and had limited range of motion. An interview with RN #302 on 01/29/18 at 2:15 P.M. verified when he was called to the room, he saw Resident #43 had slid down in her chair. He denied that she was actively sliding when he went in the room. He stated one aide stood in front of the resident and lifted her feet, one aide hooked under the residents right shoulder and he hooked his arm under her left shoulder. He stated they lifted the resident back into the chair, also holding on to her pants to slide her back. He stated in the midst of the move, the resident began screaming and he heard a noise, described as a cracking or crunching sound. He stated he assessed the resident after she was repositioned, who was in pain and assisted the staff to then pivot transfer her to the bed, per her request. He indicated one aide had a gait belt, but stated they just moved her up in the chair without the gait belt so she would not fall further toward the floor. He verified that residents should be transferred with gait belts to prevent injury. Review of a the personnel file of RN #302 revealed he was disciplined on 01/19/18 for inappropriate repositioning of a resident, using her arms to move her, resulting in injury. Review of the facility restorative nursing transfer policy (undated) revealed a gait belt should be used when assisting a resident from bed to chair to prevent injury to the resident or employee. An interview was conducted with Resident #43 on 01/29/18 at 3:45 P.M. in her room. She did not remember specifics of the incident, but stated her left arm, which was noted with bruising, was getting better. She stated it only hurt when moved, but the pain had decreased. She stated she did not feel well on the day the surveyor interviewed her and declined to answer any further questions. Corrective Action included: · Review of the facility investigations revealed the facility interviewed all residents regarding possible abuse, conducted a thorough investigation of both the abuse as well as the incident resulting in the fracture, beginning on 01/15/18. · All nursing staff members were inserviced or would be inserviced prior to working their next shift on proper transfers, following individual resident orders, and using gait belts or mechanical lifts as appropriate. The inservice indicated residents were not to be transferred by lifting them under their arms. · The facility audited all residents to ensure their transfer orders were current and accurate. · The facility began random audits to ensure staff members were observed to transfer residents correctly according to their orders and using proper equipment to perform the task. · The facility instituted a quality assurance monitoring project to ensure STNA staff had gait belts available on their person to use to transfer residents. An interview with the Administrator on 01/29/18 at 3:50 P.M. verified staff performed an improper transfer technique by not using the gait belt which resulted in the fractured humerus of Resident #43. The Administrator verified all the above corrective actions were completed by 01/19/18. This deficiency substantiates Complaint Number OH 699.

Based on observations, medical record review and staff interviews, the facility failed to ensure wound assessments were completed and treatments were provided to promote healing of vascular ulcers. This resulted in actual harm for Resident #140 whose left heel vascular ulcer declined and became infected. This deficient practice affected two (#140 and #54) of four residents reviewed for wound care. The total facility census was 139. Findings include: 1. Resident #140 was admitted on [DATE] with [DIAGNOSES REDACTED]. On admission, the resident had a cast to his left ankle. A post-surgical consult note, dated 05/02/13, indicated the resident was seen by the surgeon post joint fusion of the left ankle and a debridement of a posterior heel wound to the left foot was completed. The cast was windowed (cut) at that time to allow for access of the wound area to the posterior heel. The surgical note indicated a dressing was applied to the ulcer to the left heel. The surgeon ordered daily dressing changes in the windowed cast area with either a dry sterile, non-adherent dressing and [MEDICATION NAME] topical [MEDICATION NAME] (for use in superficial wounds) or [MEDICATION NAME] (an antimicrobial dressing used for the treatment of [REDACTED]. On 07/11/13 at 12:20 P.M. interview with the resident's friend revealed the resident was again seen by the surgeon on 05/09/13 at which time the dressing, dated 05/02/13 was noted to still be in place to the left heel ulcer. The resident's friend indicated they were told by the physician the wound was infected and that wound care orders had not been followed by the facility. The friend indicated the resident was undergoing oxygen therapy for the wound and the surgeon indicated the resident might "lose his foot". Review of Resident #140's medical record revealed the dressing was never initiated by the facility after being seen by the surgeon on 05/02/13. There was no written documentation the facility had assessed or observed the left heel ulcer during the resident's stay in the facility. The resident was discharged from the facility on 05/09/13. On 07/11/13 at 12:07 P.M. and 2:27 P.M., interview with the director of nursing (DON) verified the dressing to the resident's left heel was never initiated and the facility had not completed any wound assessments or wound documentation of the left heel area while the resident resided in the facility. 2. Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was noted to have a vascular wound to her right heel on admission. The resident had current physician orders for wound care dated 06/17/13 to cleanse the right heel wound with normal saline, pat dry, apply Santyl ointment to wound bed, cover with four by four gauze pad and wrap with gauze wrap daily each morning and as needed (prn) and to cleanse the right heel wound with normal saline, apply a wet-to-dry dressing and wrap with gauze wrap daily each evening and prn. Santyl ointment and wet-to-dry dressings are treatments used in the debridement of necrotic wounds. A Skin Grid Pressure Ulcer Assessment completed 06/26/13 indicated the wound measured 7.0 centimeters (cm) long by 7.5 cm wide. The wound bed had eschar or slough (non-viable tissue). Record review revealed no deterioration in the wound. The facility was noted to complete timely assessments. During the complaint investigation, Resident #54 was noted to continue to have the wound to her right heel. On 07/11/13 at 8:55 A.M., Resident #54 was observed with a dressing in place to her right foot. There was no date on the dressing to indicate when the dressing had been completed or when the dressing had last been changed. LPN #17 verified the finding at the time of the observation. Review of the treatment administration record (TAR) for July 2013 revealed the wet-to-dry dressing order was never written onto the treatment record and therefore it had never been initiated. There was no written indication the ordered wet-to-dry dressings were completed for the resident. On 07/11/13 at 12:23 P.M. and 2:28 P.M., the director of nursing verified the lack of written evidence to support that staff were completing wet to dry dressings to the resident's right heel as ordered. This deficiency substantiates allegations contained in Complaint Number OH 776. This deficiency is continued non-compliance from the annual survey of 05/21/13.

Based on interview and record review, the facility failed to implement appropriate supervision and interventions to prevent a fall with injury resulting in Actual Harm of a fractured leg for one resident, Resident #133, out of three residents reviewed for falls. Findings include: Resident #133 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Her [DIAGNOSES REDACTED].#133 was assessed to be a high fall risk. Review of the minimum data set (MDS) assessment dated [DATE] documented that Resident #133 was assessed to be alert and oriented to self with short and long term memory problems and severely impaired cognition for daily decision making. She was assessed to have behavior symptoms that significantly interfered with resident care on a daily basis. The MDS assessment documented that Resident #133 was assessed to require extensive assistance of two plus staff members for transfers. Review of the undated care plan revealed Resident #133 was at risk for falls due to use of antipsychotic and antihypertensive medications, unsteady gait, incontinence, decreased strength and endurance, poor balance, arthritis, and poor safety awareness and impulsive behaviors. Interventions included the following: anticipate and meet needs as much as possible, assure well-fitting footwear with non-slip shoes or socks with grippers, assure well lit clutter free pathways, pressure sensitive alarm to bed, pressure sensitive alarm to chair and dycem (pad with non-skid surface) to wheelchair. The care plan did not address the assessed need for extensive assistance of two plus staff members for transfers. Review of the clinical note (nurse's notes) entry dated 05/03/13 reveal an unwitnessed fall while Resident #133 was in the dining room. The note did not indicate the type of chair the resident was sitting in at the time of the fall. A documented new intervention to prevent future falls was dycem on top and bottom of the wheelchair. A care plan report entry dated 05/03/13 indicated to replace the dycem on the wheelchair. The new intervention documented in the clinical notes was not included. Review of the facility's Nurses Aide's Information sheet dated 03/14/13 revealed Resident #133 was an extensive total one to two person assist for transfers and extensive two person assist for turning and positioning. Fall prevention interventions included wheelchair anti-tippers and special instructions of wedge cushion to wheelchair and the resident had behaviors including cursing, screaming disruptive sounds and spitting. The dycem intervention was not included on this form. This form was used by the state tested nurse aides (STNAs) to provide care and was not updated after Resident #133's 05/03/13 fall. Review of nurse ' s notes dated 05/23/13 at 11:33 A.M. revealed Resident #133 continued to have moods and behaviors. Review of nurses notes dated 05/26/13 at 5:46 P.M. revealed a late entry for 3:45 P.M. The STNA called the nurse into Resident #133 ' s room, stating that she had to lower the resident to the floor. The resident was laying on the mat on her left side with arm stretched and leg straight, being very vocal. Range of motion was performed and the resident was able to move her arms and legs. Staff used a gait belt to assist the resident into the wheelchair. The resident began to lean forward then was assisted into bed and safety precautions maintained. The resident complained of her leg hurting her and was medicated with Tylenol. The physician, nursing supervisor and Resident #133 ' s husband who was power of attorney (POA) were notified. X-rays of the left leg and knee were ordered. The note did not indicate what happened prior to the resident's fall. The radiology report dated 05/26/13 documented a fracture to Resident #133 ' s left leg. Nurse ' s notes dated 05/26/13 at 8:49 P.M. documented that x-ray results were received, and the physician was updated and gave a telephone order to send Resident #133 to the emergency room for evaluation. The resident's POA was updated. During an interview with the director of nursing (DON) on 06/20/13 at 1:40 P.M. along with review of the care plan for Resident #133, the DON stated the facility investigation report of the 05/03/13 fall revealed that the dycem on the wheelchair was old and ineffective and that it should have been checked by the facility staff and replaced. She stated the new intervention was to place dycem on top of the cushion and underneath the cushion of the wheelchair but it was not documented on the care plan. An interview conducted on 06/20/13 at 4:00 P.M. with the DON and MDS nurse along with a review of the MDS assessment dated [DATE] verified that Resident #133 was assessed as requiring extensive assistance of two plus staff members for transferring. Both agreed the MDS assessment was used to direct resident care. They verified during Resident #133's 05/26/13 fall, there was only one STNA assisting her during the attempted transfer. Although the need for two staff was documented consistently in the MDS assessment, the DON and MDS nurse stated Resident #133 only required two staff members for transfers if she had behaviors. This deficiency substantiates Complaint Number OH 552 and is continued noncompliance from the annual survey dated 05/16/13.

Based on observation, interview and record review, the facility failed to re-evaluate a resident after falls and implement new interventions to prevent future falls. Resident #216 fell and sustained a head laceration, then fell again and sustained a fractured leg. The facility also failed to ensure chair alarms functioned properly when in use. This affected Resident #182, who sustained a hip fracture from a fall and Residents #256 and #135 who had malfunctioning chair alarms. This affected four of six residents reviewed for falls. The facility identified nine residents who had fallen in the past 30 days, of 40 sampled residents. Findings include: 1. Resident #216 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #216 had a low risk for falls. She was able to ambulate independently in her room and on the unit with supervision. A falls risk plan of care was initiated on 09/15/11 and remained in effect during Resident #216's stay at the facility. Interventions to prevent falls included the following: Assure well fitting footwear with non-slip shoes or socks with grippers. Assure well-lit, clutter free pathways. Interventions also included keep the call light within the resident's reach, anticipate her needs, provide timely incontinence care, notify the physician of abnormal laboratory results, and provide occupational and physical therapy per physician order. The Interdisciplinary Plan of Care conference dated 09/16/11 revealed Resident #216 ambulated with the assistance of one other person. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #216 had three or more falls in the past three months. She was able to ambulate independently in her room and on the unit with supervision. A nursing progress note dated 11/24/11 at 2:10 A.M. revealed that a state tested nurse aide (STNA) found Resident #216 lying on the floor at the nursing station. One to one monitoring would be provided while the resident was awake and out of bed. Interview with Registered Nurse (RN) #4 on 02/02/12 at 6:40 P.M. confirmed there was no documentation regarding how staff would be assigned to provide one to one monitoring for the resident. She confirmed that interventions for supervising Resident #216 while she was ambulating in the facility were not included in the resident's falls risk plan of care. The facility's fall investigation report dated 11/24/11 was reviewed with RN #4. She confirmed that the witness statements provided by the nurse and two STNAs on duty revealed that they did not witness Resident #216's fall because they were performing other duties when the fall occurred. A nursing progress note dated 12/26/11 at 5:52 A.M. revealed that Resident #216 was found on the floor in another resident's room. She had a laceration to her left forehead near her eye. A nursing progress note dated 12/26/11 at 1:26 P.M. revealed that Resident #216 was sent to the emergency room for a computerized tomography scan (CT scan) and possible sutures to her head laceration. A nurse practitioner's progress note dated 12/26/11 revealed that Resident #216 received three sutures to her left forehead. The facility's fall investigation report dated 12/26/11 was reviewed with RN #4 on 02/02/12 at 6:40 P.M. She confirmed that the witness statements provided by the nurse and three STNAs on duty revealed that they did not witness Resident #216's fall because they were performing other duties when it occurred. There was no evidence that Resident #216 was supervised by staff when she ambulated on the unit before she fell on [DATE]. The facility's fall investigation report dated 12/26/11 revealed the following: condition that could have contributed to the fall: "There was a mattress on the floor of the room resident walked into that might have contributed to her falling." Environmental factors: "Inadequate lighting." The resident's activity immediately prior to her fall was described as wandering about the unit. A nursing progress note dated 12/30/11 at 11:09 P.M. revealed that at 10:50 P.M., Resident #216 was found on the floor in the TV lounge, lying on her left side. Resident #216 showed signs of discomfort upon movement of her left leg. The physician was notified and an x-ray of her left hip, femur and knee were ordered. X-ray results dated 12/30/11 revealed Resident #216's left femur was fractured. CT scans of her left hip were advised. Resident #216 was sent to the hospital on [DATE]. The facility's fall investigation report was reviewed with RN #4 on 02/02/12 at 6:40 P.M. Witness statements from two nurses and one STNA on duty revealed they were performing other tasks and did not witness Resident #216's fall on 12/30/11. A witness statement from a second STNA revealed that she was "doing rounds" and observed Resident #216 falling off of the couch as the STNA passed the lounge. RN #4 confirmed that no further investigation was completed to determine whether or not Resident #216 had been properly supervised by staff on 12/30/11 when she fell and fractured her femur. 2. Review of the medical record for Resident #256 revealed the resident was admitted to the facility on [DATE] at 4:30 P.M. with [DIAGNOSES REDACTED]. Her fall risk assessment revealed that she was at high risk for falls, and an order was written on 01/19/12 for alarms to her bed and wheelchair to alert staff of unassisted transfers or ambulation. Review of the nursing notes revealed that on 01/25/12 at 10:00 P.M., Resident #256 was found on the floor in her room between the bed and wheelchair. The note indicated that the resident's chair alarm did not sound to alert staff because the "string was too long." The resident did not have apparent injuries. Review of the incident with the director of nursing on 02/03/12 at 12:30 P.M. verified that although Resident #256 had an ordered for chair alarm, the investigation indicated that the alarm did not sound prior to the resident being found on the floor in front of the chair, because the string attaching the alarm to the resident was "too long." 3. Review of the medical record revealed that Resident #182 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan for falls (undated) revealed the resident was at risk due to unsteady gait, decreased strength and endurance and poor safety awareness. Nursing notes revealed Resident #182 sustained falls on 09/16/11, 10/26/11, 11/11/11, 12/16/11, and 01/14/12. Interventions to prevent falls after 01/14/12 included bed in a low position, mats to the floor and pressure sensitive alarms to bed and wheelchair. Review of nursing notes dated 01/26/12 at 7:45 P.M. revealed the nurse was notified by Resident #182's family member that Resident #182 had fallen to the floor. The nurse found the resident in the lounge area on his left side. He complained of pain to his left hip and had an abrasion to his left elbow. The resident was sent to the hospital and diagnosed with [REDACTED]. Interview with the director of nursing on 02/02/12 at 2:00 P.M. revealed that the investigation of the fall revealed that Resident #182's wheelchair alarm had not sounded. The director of nursing stated that the alarm had been placed under a wheel chair cushion or pad. She stated that the facility felt that the weight of the pad itself was enough to not set the alarm off when the resident stood. She verified that the resident's hip fracture resulted from a fall that was not witnessed by the staff and that the alarm did not function to signal staff that the resident had stood or moved from the wheelchair. 4. Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the fall risk assessment dated [DATE] indicate Resident #135 was at high risk for falls. Review of the nurse aide information sheet indicated Resident #135 was at risk for falls, and had bed and chair alarms. These interventions remain on the nurse aide information sheet dated 01/26/12. Observation on 02/02/12 at 10:49 A.M. revealed a chirping sound was heard in the Magnolia skilled dining room. At 11:27 A.M. the chirping sound was still heard in the dining room. Another surveyor and Licensed Practical Nurse (LPN) #2 were at the nursing station and verified hearing the chirping sound. At 11:27 A.M. LPN #2 walked into the dining room and identified the chirping sound to be Resident #135's chair alarm. Resident #135 was seated in a wheelchair. LPN #2 turned the alarm off and on, then returned to the nursing station and sat down. The chirping continued. At 11:35 A.M. the surveyor asked why the alarm was chirping. LPN #2 stated she did not know. LPN #2 indicated the chair alarm took nine volt batteries and she did not have any. She then paged the maintenance staff. Observation on 02/02/12 at 3:11 P.M., revealed Resident #135 was in the dining room in her wheelchair. The alarm was chirping. Interview with LPN #2 at that time verified the chirping sound continued. She stated she informed maintenance of the need for the nine volt battery and was told they did not have any. On 02/02/12 at 3:15 P.M. the administrator, RN #4 and RN #5 were informed of the chair alarm battery malfunction. RN #4 had nine volt batteries and immediately replaced the battery in Resident #135's chair alarm. This deficiency substantiates Complaint Number OH 120.

Based on observation, interview and record review, the facility failed to provide interventions to prevent the deterioration of a pressure ulcer for Resident #61. The resident's left ear pressure ulcer increased in size and became swollen and red. The facility also failed to properly clean a pressure ulcer for Resident #90. This affected two of five residents reviewed for pressure ulcers, of 14 residents with pressure ulcers in the facility. Findings include: 1. Resident #61 was admitted to the facility in 2010 and had [DIAGNOSES REDACTED]. The resident also was dependant on supplemental oxygen which was delivered by a nasal cannula continuously. The resident was at risk for pressure ulcers and had a Stage 4 pressure ulcer on her coccyx and an unstageable pressure ulcer on her right ear. On 01/30/12 Resident #61 returned from a hospitalization and was noted on the Weekly Pressure Ulcer Record dated 01/31/12 to have developed a Stage 2 pressure ulcer measuring 0.5 centimeter (cm) by 0.5 cm by 0.1 cm deep, on her left ear. Review of Resident #61's pressure ulcer care plan revealed no new interventions were initiated on 01/31/12 to protect the ear wounds from decline. On 02/02/12 at 10:30 A.M., Resident #61 was observed for a dressing change to the coccyx wound by Licensed Practical Nurse (LPN) #2. The resident was in bed on her left side with the left side of her head on the pillow. The resident's right ear pressure ulcer was visible as a darkened area in the middle of the outer edge of the ear. The resident had an oxygen cannula on with the tubing behind her ear. LPN #2 indicated that the resident was generally kept on her left side because of the ear wound on her right ear. Following the dressing change, Resident #61 was turned to check the left ear. The left ear was swollen and red with an open area of 1.0 cm by 1.0 cm. The oxygen cannula tubing was behind the ear including behind the area of the wound. At 11:00 A.M. the corporate nurse, Registered Nurse (RN) #5, was called in by the surveyor to verify the condition of the left ear wound. She verified the size of the wound had increased and was now swollen and red. 2. Review of the record of Resident #90 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. This dressing change was to be completed every other day and as needed. An observation was conducted on 02/02/12 at 2:40 P.M. with LPN #10 as she completed Resident #90's dressing change. She removed the old dressing, and after changing her gloves, she liberally sprayed the wound with a wound cleanser. The resident was laying on her left side. The wound cleanser was dripping out of the open wound and onto the surrounding skin. LPN #10 used a four by four gauze pad to wipe the skin around the wound, discarded that pad and then used another to wipe the skin around the wound. She then measured the wound as 2.5 cm wide by 3 cm long by 2.5 cm deep and continued with the treatment, applying the anti-fungal medication and the calcium alginate, then covering the area. Interview with LPN #10 on 02/02/12 at 3:05 P.M. verified that she had sprayed the wound cleanser into the wound, and had wiped the area around the opening in the sacrum with four by four inch pads, but had not cleaned the inside of the wound, or ensured that the liquid wound cleanser had been removed from the wound's deep crater before continuing with the treatment. She verified that the interior of the wound contained "tan slough" and that she had not ensured that the actual wound was cleaned during the treatment. The director of nursing verified on 02/03/12 at 12:30 P.M. that proper wound cleaning would involve using a four by four pad to gently press into an open wound to ensure it had been cleaned and that excess wound cleansing liquid would not be pooled in the wound prior to continuing with an ordered treatment. This deficiency substantiates Complaint Number OH 110.

Based on record review, facility investigative reports, review of facility policies and procedures, review of in-services, audits and interviews, the facility failed to ensure that two state tested nursing assistants checked the mechanical lift and mechanical lift pad prior to transferring one Resident (#71) resulting in a fall with injury and the facility failed to ensure that one resident (#59) was provided with two staff members during incontinence care and bed mobility resulting in a fall. This involved two residents out of a sample of three residents reviewed for falls. The facility census was 122. Findings include: 1. Review of Resident #71's medical records, nursing notes, care plans and minimum data assessment, (MDS), revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her husband was power of attorney. Resident #71's range of motion assessment revealed that she had partial loss of movement to bilateral extremities. On 11/01/09, the physician ordered a scoop mattress, a special chair (Broda), grab bars to the bed and to turn the resident every two hours. The care plan revealed that she was totally dependent with two assistants with a mechanical lift, (Hoyer lift) for all transfers. Resident #71's fall risk assessments were reviewed from 07/30/10 to 06/23/11 and revealed she sustained a fall on 06/23/11. Review of the nursing notes and the facility investigative report dated 06/23/11 revealed that Resident #71 sustained a fall from the Hoyer lift. A neurological check was completed after the fall. She was unable to follow command for hand grasps. Her right pupil was brisk; however, her left pupil was 'pin point' in size (pupillary defect). The investigation revealed the facility completed one neurologic check and Resident #71 was sent out to the hospital '911' per the physician's orders [REDACTED]. The investigation revealed that on 06/23/11 at 11:00 A.M., STNAs #9 and #15 were transferring Resident #71 via the Hoyer lift from her Broda chair to her bed. Resident #71 slid from the Hoyer pad to the floor landing on her buttocks, then falling into a supine position sustaining a laceration to the back of her head. The investigation revealed the left leg strap slid off the hook on the mechanical lift allowing the resident room to slide to the floor. A nurse was notified and a head-to-toe assessment was completed. A laceration was noted to the back of the resident's head. Range of motion was completed with the resident displaying facial grimacing. Neuro-checks were initiated and vital signs were obtained. Resident #71's husband was present on the unit at the time of the incident. The physician and the daughter were notified. Resident #71 was transferred to the hospital. An interview conducted with STNA #9 on 07/13/11 at 8:30 A.M. revealed that on 06/23/11 she was assisting a resident in the shower room. She revealed that she was coming out of the shower room when STNA #15 approached her and stated that Resident #71 was ready to be transferred back to bed. Resident #71 was sitting in her specialized chair (Broda) with the Hoyer pad underneath her. STNA #15 had attached the the Hoyer lift to the Hoyer pad. Both STNAs entered the room, STNA #9 stated she visually checked the Hoyer pad's straps and everything seemed to be in order. STNA #15 was standing behind Resident #71 and STNA #9 was standing in front of Resident #71. STNA #9 moved Resident #71's leg to the left and began to lift her to clear the Broda chair. STNA #9 stated, as they lifted Resident #71, the left leg strap "came off" the hook. Resident #71 slid out of the Hoyer, her feet were extended out and she landed on her back. She stated the back of her head hit the linoleum floor. She stated STNA #15 moved the Broda chair out of the way, and she moved the Hoyer lift. Resident #71 was awake and had about a quarter-size area of blood on the floor. The STNA stated she immediately called Licensed Practical Nurse, (LPN), #17 and Registered Nurse (RN) #4. Resident #71 was assessed and the "911" squad came and transported her to the hospital. STNA #9 revealed that STNA #15 stated that Resident #71's husband had come into the room while she was going out to get her. STNA #9 revealed that she did not physically check to see if the Hoyer strap was secure to all areas, she only completed a visual check. This was verified on 07/13/11 at 11:46 A.M. with the director of nursing. The DON verified that the staff should have re-checked the Hoyer pad and straps physically to ensure the safety of Resident #71. The surveyor and the facility attempted to contact STNA #15 on 07/13/11 at 10:50 A.M. and 12:26 P.M., there was no answer. STNA #15 no longer worked in the facility, her last day was 07/11/11. She was terminated for attendance concerns. Interview with the director of nursing on 07/13/11 at 11:46 A.M. revealed that Resident #71 was admitted to the hospital with [REDACTED]. She confirmed that Resident #71 was immediately sent out to the hospital '"911" due to the abnormal neurological check and the pupillary defects. Interview with STNA #2 on 07/13/11 at 9:13 A.M., revealed that when using the Hoyer lift, the straps need to be checked (physically) by yanking the strap. She stated if she left the room, when she returned she would always recheck the straps physically. Interview with STNA #11 on 07/13/11 at 9:44 A.M. revealed that she always checks the straps to the Hoyer to ensure they are secure and she added she would always recheck them if she had to leave the room for any reason. 2. Review of Resident #59's medical record, nursing notes, care plans and MDS revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #59 was alert and oriented and her own responsible party. On 04/12/11, the physician's orders [REDACTED]. Resident #59's weight was 244 pounds on 05/03/11. The activities of daily living care plan dated 06/04/11 revealed that Resident #59 was a Hoyer lift for transfers, dependent on staff and utilized the grab bars on the bed. She was assessed as a fall risk. Her MDS dated [DATE] revealed that she was an extensive assist with two staff members for bed mobility and transfers. Review of the nursing notes dated 05/03/11 and the investigative report dated 05/03/11 revealed that around 10:00 P.M., Resident #59 was receiving incontinence care by State tested Nursing Assistant, (STNA), #16. During the incontinence care Resident #59 rolled to the left side and rolled out of bed. No injuries were found with the assessment. Resident #59 was returned to bed, the physician and family were notified. Interview with Resident #59 on 07/13/11 at 10:35 A.M. and at 1:35 P.M. revealed that STNA #16 was assisting her with incontinence care. She stated she held on to the grab bar and pulled herself over to each side. She stated there was only one STNA in the room at the time. She stated she slid out of bed and was sitting on the floor when the nurses came in to assist. She revealed she had no injuries from the fall. Interview with STNA #16 on 07/13/11 at 11:00 A.M., revealed that she entered Resident #59's room to provide incontinence care on 05/03/11. She revealed Resident #59 was not her regular resident and she was not familiar with her care. STNA #16 confirmed that she did not look at Resident #59's STNA care plan prior to the care. Resident #59 was a two-person assist for bed mobility and incontinence care. STNA #16 revealed that at the time of the incontinence care, Resident #59 was positioned in an air loss bed. The resident assisted with the care by turning to her right side, towards the door. She kicked her left leg over the right leg with the STNA's assistance. STNA #16 instructed her to slow down. Resident #59 then turned on her left side, towards the window by kicking her right leg over the left leg. Her specialized boots were on bilaterally and her feet/boots began to slide off the bed. Resident #59 was holding on to the grab bar located at the top of the bed while turning. STNA #16 revealed that she called the nurse at this time, two nurses entered the room and assisted Resident #59 to the floor. She was assessed and suffered no injuries. Interview with STNA #2 on 07/13/11 at 1:48 P.M. revealed that Resident #59 was a two-person for bed mobility, turning and repositioning and incontinence care. STNA #2 provided this information via the computerized STNA care plans. STNA #2 revealed that Resident #59 always needed two staff for bed mobility. Resident #59 was re-interviewed on 07/13/11 at 1:35 A.M. by the surveyor and RN #3. She verified that she slid out of bed on 05/03/11, while she was receiving incontinence care. She confirmed that there was only one STNA in the room at the time. She stated when she slid out of bed, the STNA attempted to assist her; however, she was on the floor before the nurses entered the room. She stated her boots went first, then she went down on her buttocks. She confirmed she did not get hurt. This deficiency substantiates Master Complaint Number OH 307 and Complaint Number OH 304.