Every finding on record at Greenbriar Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interviews, record review, review of the facility incident investigation, and policy review, the facility failed to maintain a hazard free environment free from unsecured smoking materials and smoking inside the facility in undesignated smoking areas. Actual harm occurred on 02/12/26 when Resident #4, who was cognitively intact, wheelchair dependent, and dependent on staff assistance for transfers due to impairment to his lower extremities, lit a cigarette while in his bed and the cigarette fell to contact a flammable agent (cologne) on his bed and on his body. Resident #4 was sent to the hospital on [DATE] for evaluation where he was diagnosed with second degree burns (partial thickness burn that damages the outer layer and underlying layer of skin characterized by severe pain, intense redness, blistering and swelling) to his right thigh. This affected one (Resident #4) of three residents reviewed for smoking. The facility identified 22 residents who smoke. The facility census was 97.Findings include: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including paraplegia, chronic obstructive pulmonary disease (lung disease), nicotine dependence, bipolar disorder, and chronic pain.Review of the smoking assessment for Resident #4 dated 11/20/25 completed by Licensed Practical Nurse (LPN) #203 revealed Resident #4 was independent with smoking.Review of facility documents titled Smoking Acknowledgement Form and Resident Smoking Guidelines, signed by Resident #4 and dated 11/20/25 acknowledged receipt of the smoking policy and the resident smoking guidelines. The smoking guidelines indicated smoking materials were to be kept by facility staff, smoking was to occur only in designated areas and smoking materials were to be returned to facility staff when done smoking. This was for all smokers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact, had impairment on both sides of the lower extremities, used a wheelchair for mobility, required set-up assistance for eating, was dependent on staff for transferring, and had adequate vision, sight, and hearing. Review of the care plan dated 01/14/26 documented Resident #4 was a smoker. The goal was to utilize nicotine products in a safe manner. Interventions included smoking evaluation, educating the resident on designated smoking areas, educating on the facility smoking policy, and providing safe smoking devices if required. Review of a facility incident investigation dated 02/12/26 revealed on 02/12/26 at approximately 02:50 A.M. Certified Nurse Aide (CNA) #612 authored a witness statement documenting Resident #4 activated his call light. When staff entered the room they noticed a haze, a chemical smell, and noticed burns on Resident #4's clothes. The nurse was immediately notified that help was needed. CNA #612 noted a cologne bottle was on the floor. Review of the staff witness statement dated 02/12/26 at approximately 02:50 A.M. authored by Licensed Practical Nurse (LPN) #562 revealed that when she arrived to the room, she noticed a [NAME] of smoke, a chemical odor, and Resident #4 had burn marks on his clothes. Emergency Medical Services (EMS) was immediately called. LPN #562 noted a cologne bottle was on the floor. A written interview dated 02/12/26 at 9:30 A.M. conducted by the Regional Director of Clinical Operations (RDCO) and Clinical Liaison LPN #555 revealed Resident #4 thought he was at home, lit a cigarette, dropped the lit cigarette onto himself and when he attempted to retrieve the cigarette, his arm pressed into his cologne bottle which caused it to spray and ignite. Resident #4 stated he was aware he was not to smoke in his room. Review of the hospital transfer form dated 02/12/26 at 3:15 A.M. revealed Resident #4 was transferred to the hospital. Review of the progress note dated 02/12/26 at 5:14 A.M. revealed Resident #4 was transferred to the hospital. Review of the progress note dated 02/12/26 at 7:10 A.M. revealed Resident #4 was admitted to the hospital with second degree burns. Review of the hospital document titled Internal Medicine History and Physical dated 02/12/26 at 8:42 P.M. revealed Resident #4 presented to the emergency room due to smoking in his room at the nursing home, caught cologne on fire and sustained partial thickness burns (second degree burn) to his right thigh. Resident #4 received bacitracin ointment and silver sulfadiazine cream to his burns. Resident #4 refused intravenous (IV) catheter placement and lab draws. Review of the progress note dated 02/12/26 at 10:33 P.M. revealed Resident #4 returned to the facility.Review of the progress note dated 02/13/26 at 1:39 A.M. by Nurse Practitioner (NP) #873 revealed Resident #4 returned from the hospital due to smoking in bed and sustained second degree burns on three to five percent of their body, primarily the thigh.Review of the smoking assessment dated [DATE] at 1:10 P.M. revealed Resident #4 was an independent smoker.Review of the physician orders for Resident #4 revealed orders to monitor burn areas for signs and symptoms of infection every shift and night shift dated 02/13/26, bacitracin (a topical antibiotic) ointment apply to thigh two times daily dated 02/13/26, and silver sulfadiazine cream (a topical antibiotic used for burns) apply to thigh topically at bedtime dated 02/13/26. Review of the Smoking Acknowledgement Form, signed by Resident #4 on 02/13/26 revealed he received a copy of the facility smoking policy and agree to abide by the policy. Review of the skin grid assessment dated [DATE] at 11:44 A.M. revealed Resident #4 refused the skin and wound assessment. Review of the progress note on 02/18/26 by NP #873 revealed she saw Resident #4 in the facility to follow up for second degree burns of the thigh. Review of the skin grid assessment dated [DATE] at 4:00 P.M. revealed Resident #4 had a burn to his front right thigh which measured 4 centimeters (cm)in length by 6.2 cm width with no depth. Review of the skin grid assessment dated [DATE] at 4:13 P.M. revealed Resident #4 had another burn site to their right thigh which measured 2.5 cm in length by 4 cm in width with no depth. During an interview on 02/19/26 at 12:57 P.M., Resident #4 stated on 02/12/26 he was in bed at the facility, thought he was at home, lit a cigarette, and dropped the lit cigarette onto his lap. When he attempted to retrieve the lit cigarette, it came into contact with spray of cologne that was in the bed causing it to burn on his thigh and abdomen. Resident #4 stated he normally kept his smoking items on his person instead of giving them to the staff to keep secure. Resident #4 confirmed he had received education on the smoking policy and smoking materials were to be kept with the staff. He stated he signed a copy of the smoking policy and no longer kept smoking materials since the incident. During an interview on 02/19/26 at 1:05 P.M., Registered Nurse (RN) #634 stated smoking items were supposed to be secured by staff after residents were done smoking. However, at the time this incident occurred on 02/12/26 with Resident #4, smoking items were not always returned to staff to secure, and residents had kept smoking items on their person. During an interview on 02/19/26 at 1:16 P.M., LPN #515 confirmed smoking items were supposed to be secured by staff after residents were done smoking. However, at the time this incident occurred on 02/12/26 with Resident #4, smoking items were not always returned to staff to secure, and some residents kept smoking items on their person. During an interview on 02/19/26 at 1:30 P.M., Resident #7 stated she kept her smoking items on her person and didn't return them to staff to secure, but now she did since being educated by the staff. During an interview on 02/19/26 at 1:40 P.M., CNA #692 confirmed smoking items were supposed to be returned to staff after smoking. At the time the incident with Resident #4 had occurred it was known that some residents had kept smoking items on their person or hidden in their rooms. During an interview on 02/19/26 at 2:07 P.M., LPN #562 confirmed smoking items were supposed to be secured by staff after residents were done smoking. However, at the time the incident with Resident #4 occurred, smoking items weren't always returned to staff to secure, and some residents maintained smoking items on their person or in their rooms. During an interview on 02/19/26 at 2:55 P.M., CNA #612 confirmed smoking items were supposed to be secured by staff after residents were done smoking. However, at the time the incident with Resident #4 occurred, smoking items weren't always returned to staff to secure and some residents kept smoking materials on them. Review of the policy titled Resident Smoking Guidelines, undated, revealed that smoking was only permitted in designated smoking areas, the facility would store smoking materials in a secure area when not in use, and smoking items were to be returned to facility staff when smoking was completed. The deficiency was corrected on 02/12/26 when the facility implemented the following corrective action: On 02/12/26 at 8:00 A.M. initial policy review with all 22 smokers was completed by the Administrator. On 02/12/26 Resident #4 was interviewed by Clinical Liaison LPN #555 and Regional Director of Clinical Operations for root cause analysis. The Regional Director of Clinical Operations, Administrator, and Director of Nursing conducted a root cause analysis. On 02/12/26 all residents capable were interviewed by the Director of Nursing if anyone smoked in their room and if they kept smoking items in their room. On 02/12/26 skin checks were performed on residents unable to be interviewed, and no new concerns were identified. On 02/12/26 the Administrator and Director of Nursing were provided education on the new smoking policy and procedure by the Regional Director of Clinical Operations which included staff supervised smoking, designated smoking times, turning smoking items into facility staff at the conclusion of smoking times, and the facility was smoking free for all new admissions. On 02/12/26 the Administrator provided education to all facility staff on the new smoking policy and procedures. Anyone scheduled off would receive education before working next shift. On 02/12/26 from 1:00 P.M. to 1:30 P.M. an ad hoc resident council meeting was conducted by the Administrator, Director of Nursing, and Activities Lead #405 to inform residents of the changes to the smoking policy and procedure. The facility identified smokers were spoken to individually about the changes to the smoking policy and procedures. On 02/12/26 the facility had all smoking residents sign a smoking acknowledgment form, smoking materials were taken by a staff member to secure, a progress note was made that residents received education on the new smoking policy and procedure, the signed policy was scanned into Point Click Care (the electronic medical record), and a new smoking assessment was completed. On 02/12/26 an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted which included a root cause analysis, the new smoking policy and procedure, and the purchase of individual lockable bags to secure resident smoking items. Staff present included the Administrator, Admissions Staff #807, Minimum Data Set (MDS) Registered Nurse (RN) #408, MDS RN #413, Social Services Designee (SSD) #409, Therapy Manager, Business Office Manager (BOM), Administrator in Training (AIT) #205 and the facility Medical Director. On 02/12/26 at 9:21 P.M. a report was made to the State Fire Marshal. On 02/12/26 new signage for designated smoking times were posted throughout the facility. On 02/13/2025 Resident #4's smoke detector in his room was tested by the contracted fire protection company to ensure correct function. Room audits were conducted by the Administrator, Director of Nursing, and Unit Managers on 02/13/26, 02/14/26, 02/15/26, 02/16/26, and 02/17/26. An interview on 02/23/35 at 9:43 A.M. with the Administrator revealed room audits will be conducted of five smoking resident's rooms each week for two months and then re-evaluated at QAPI. This deficiency represents noncompliance investigated under Complaint Number 2744541.

Based on resident interviews, staff interviews, observation and facility policy review, the facility failed to ensure sufficient staff to meet the needs of the residents. This affected four (Residents #83, #49, #42, and #95) interviewed regarding staffing concerns and had the potential to affect all 102 residents residing in the facility. Findings include:Interview on 06/23/25 at 9:33 A.M. with Resident #83 revealed there was only one nurse, and one aide scheduled daily.Interview on 06/23/25 at 9:56 A.M. with Resident #49 revealed the unit was understaffed, and the call light response was poor. Interview on 06/23/25 at 10:28 A.M. with Resident #42 revealed the Certified Nursing Assistants (CNAs) were lazy and would stand in the hallway talking while call lights were sounding which resulted in lengthy call light responses. Interview on 06/23/25 at 10:45 A.M. with Resident #90 revealed there was never enough staff and usually only one nurse and one aide working.Interview on 06/24/25 at 2:25 P.M. with Resident #95 revealed there was a day when there was one aide for 45 residents. Interview on 06/23/25 at 1:36 P.M. with CNA #253 she was scheduled on the Providence unit from 7:00 A.M. to 3:00 P.M. but was moved to the Lifestyle II unit due to there were no CNAs there that morning, which was likely due to call offs or staff running late. CNA #253 reported that inadequate staffing interfered with residents receiving proper care.Interview on 06/23/25 at 2:10 P.M. with CNA #311 revealed staffing levels were always short, CNA's felt overworked at times, and care, such as showers, were not always provided as a result. Interview on 06/23/25 at 10:59 A.M. with Staff Scheduler #211 revealed staffing levels were based on facility census and then staffed by each hallway. For Lifestyle II unit the census was 26. Staff Scheduler #211 reported that the facility was overstaffed.Interview on 06/23/25 at 10:25 A.M. with Licensed Practical Nurse (LPN) #214 revealed there was not enough staff. LPN #214 stated there was only one aide on her unit from 7:00 A.M. until 10:00 A.M. LPN #214 stated she called her supervisor and the scheduler and received no help until 10:00 A.M. LPN #214 was tearful during the interview and stated the residents deserved better. LPN #214 stated this is a frequent occurrence. Interview on 06/24/25 at 11:10 A.M. with LPN #208 revealed she was behind with her medication pass, which was related to not having enough staff. LPN #208 stated there were only two aides on the 100-unit that day and she had to assist with patient care. Interview on 06/25/25 at 10:15 A.M. with CNA #290 revealed staffing was an issue in the facility. CNA #290 reported the 200-unit operated best with four aides, but there were only three that day. CNA #290 reported she barely got her work completed as a result. While incontinence care was always completed, sometimes showers must wait until the next day. CNA #290 also reported Administration was not responsive to resident care needs based on census.Interview on 06/25/25 at 10:35 AM interview with LPN #208 revealed she worked the afternoon shift from 3:00 P.M. to 11:00 P.M. the previous evening with only two CNAs most of shift and made repeated attempts to contact the scheduler. On 06/25/25 at 10:40 A.M. an interview with CNA #212 revealed they often work short staffed due to report offs and tardiness. CNA #212 stated it took hours to get help in and reported most nurses do not help with get ups and call lights. Interview on 06/25/25 at 10:55 A.M. with CNA #211 who was also the scheduler verified there were two aides on the 200-unit on 06/24/25 for 1.5 hours at the beginning of the shift. CNA #211 stated there were three aides on 200-unit from 4:30 P.M. to 5:30 P.M. then two aides again until 7:00 P.M. CNA #211 stated there were three aides for the remainder of the shift. On 06/26/25 at 12:30 P.M. an interview with Physical Therapy Assistant (PTA) #243 revealed staffing was an issue and reported she assisted with answering call lights and had brought staffing issues to the Administrator and Director of Nursing (DON); however, the issues were not addressed. On 06/26/25 at 12:55 P.M. an interview with Occupational Therapist (OT) #321 revealed there was an issue with staff showing up on time; however, staffing issues were addressed in management meetings. Observation on 06/26/25 at 7:19 A.M. revealed only one nurse was present on the Lifestyle II unit. Interview at the time of the observation with LPN #293 confirmed she was the only one on the unit and that no CNAs arrived at 7:00 A.M. as scheduled. LPN #293 did not have a schedule and was unsure which staff were scheduled.Observation on 06/26/25 between 7:19 A.M. and 7:30 A.M. Activity Director #257 and Registered Nurse (RN) #233 were observed asking LPN #293 if there were any CNAs on the unit to which LPN #293 responded, no. Interview on 06/26/25 at 9:32 A.M. with LPN #293 revealed multiple complaints related to inadequate staffing on the Lifestyle II unit were made to Unit Manager #314 and the DON in writing but unattendance and tardiness continued. LPN #293 kept copies of the written staffing complaints and provided them. LPN #293 also confirmed the night shift left promptly at 7:00 A.M., and no one stayed over to assist. LPN #293 also reported multiple staffing complaints were made in writing.Review of the staffing complaints provided to Unit Manager #314 and the DON in writing included the following: Review of a staffing complaint dated 03/01/25 by LPN #293 revealed CNA #256 failed to complete any of documentation for the entire shift and instead, talked on the phone and did schoolwork which was a frequent occurrence which was addressed with CNA #256 multiple times. Review of a staffing complaint dated 04/24/25 by LPN #293 revealed a nurse from another unit called LPN #293 to say she only had one aide and needed another. LPN #293 went to assist as her medication pass, and documentation was completed. Review of a staffing complaint dated 06/08/25 by LPN #293 revealed on 06/08/25 at approximately 7:50 A.M. LPN #293 asked Social Service Designee (SSD) #211 if CNA #256 had called off or reported she was going to be late. LPN #293 and CNA #297 provided care and hoped that CNA #256 would show up by 10 A.M. At 10:45 A.M. LPN #293 reached out to SSD #211 for an update on CNA #256. SSD #211 reported attempts were made to contact CNA #256 but were unsuccessful. At approximately 11:00 A.M. LPN #293 went to another unit and asked CNA #288 if she would assist. At 12:00 P.M. it was still only LPN #293 and CNA #297.The punch detail for 06/15/25 3:00 P.M. to 11:00 P.M. shift for the Providence unit revealed CNA #203 worked 2:59 P.M. to 10:59 P.M.; CNA #292 worked 2:57 P.M. to 10:58 P.M.; CNA #230 worked 3:00 P.M. to 8:00 P.M.; and CNA #281 worked 10:00 P.M. to 11:00 P.M. The punch times reflected there were only two aides from 8:00 P.M. to 10:00 P.M.Interview on 06/26/25 at 9:44 A.M. with Staff Scheduler #211 confirmed there were no CNAs on Lifestyle II unit as scheduled, and she was notified at 7:07 A.M. by RN #233 that no CNAs showed up. Staff Scheduler #211 reported she had not received any call-offs or notifications staff would be [NAME]. Review of the schedules for the nurses and CNAs for 06/15/25 and 06/22/25 to 06/28/25 did not reveal any concerns with staffing levels for the facility. However, review of the punch detail for 06/15/25 (Lifestyle II unit afternoon shift) and 06/26/25 (Lifestyle II unit day shift) revealed inadequate staffing levels on both shifts. The punch detail for 06/26/25 Lifestyle II unit day shift showed CNA #297's start time of 7:09 A.M.; however, she reported to the Regency unit upon arrival instead of Lifestyle II. CNA #297 did not report to the Lifestyle II unit until instructed to do so by Unit Manager #314 at approximately 7:30 A.M. The punch detail for CNA #311 revealed a start time of 8:19 A.M. and reported to Lifestyle II unit upon her arrival. Review of the Facility Assessment revealed Lifestyle II unit day shift was to have one nurse and two to three CNAs. Review of the Providence unit afternoon shift revealed it was to be staffed with two nurses and three to four CNAs. Staffing levels per the Facility Assessment were inadequate for 06/15/25 and 06/26/25. Review of the undated Nurse Staffing Information Policy revealed the facility would provide the sufficient number of staff to care for the resident population. Daily nurse staffing requirements would vary based upon resident census, acuity, and safety needs. This deficiency represents non-compliance investigated under Complaint Numbers OH00166996 (1272220), OH00163755 (1272216), OH00165292 (1272223), OH00164858 (1272218), and OH00164711 (1272222).

Based on record review, observation, interview and facility policy review, the facility failed to store insulin (a medication used to stabilize blood sugars) in a proper manner to ensure efficacy. This affected six (Residents #27, #61, #76, #90, #99, and #109) of 23 (Residents #3, #12, #27, #30, #31, #35, #40, #41, #49, #50, #52, #55, #61, #73, #75, #76, #78, #87, #90, #94, #95, #99, and #109) who were identified as utilizing insulin. The facility census was 102.Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 02/10/23 with diagnosis including type two diabetes mellitus with diabetic chronic kidney disease, and long-term use of insulin. Significant orders included Fiasp FlexTouch (a fast-acting insulin)100 units per milliliter solution pen-injector: Inject five units subcutaneously before meals for diabetes mellitus. hold for blood sugar less than 130, dated 3/5/25. Review of the quarterly Minimum Data Set Assessment (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating Resident #27 was cognitively intact. Review of the care plan dated 06/02/25 revealed Resident #27 had diabetes. Interventions included administering insulin injections per order. On 06/23/25 at 10:25 A.M. an observation of the medication cart for the 400 unit revealed an aspart insulin pen (generic brand of Fiasp) for Resident #27 that was opened and undated. Licensed Practical Nurse (LPN) # 214 verified the aspart insulin pen for Resident #27 was opened and not dated at the time of the observation. 2. Review of the medical record for Resident #90 revealed an admission date of 02/11/23 with diagnosis including type two diabetes mellitus with hyperglycemia, and long-term use of insulin. Significant orders included Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 Unit/Milliliter (Insulin Lispro) Inject as per sliding scale: if blood sugar is 0 - 150 = 0 units Give 6 units with meals plus mod dose 2 units for every 50 above 150; 151 - 200 = 2 units; 201 - 250 = 4units; 251 - 300 = 6units. If blood sugar is greater than 300 give 8 units, subcutaneously with meals, dated 04/15/25. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS of 15 oout of 15, indicating Resident #90 was cognitively intact.Review of the care plan dated 04/25/25 revealed Resident #90 had diabetes. Interventions included administering insulin injections per order. On 06/23/25 at 10:25 A.M. an observation of the medication cart for the 400 unit revealed a Humalog insulin pen (name brand for lispro) for Resident #90 that was opened and undated. LPN # 214 verified the Humalog insulin pen for Resident #90 was opened and not dated at the time of the observation. 3. Review of the medical record for Resident #99 revealed an admission date of 10/07/20 with diagnosis including type two diabetes mellitus with diabetic polyneuropathy. Significant orders included Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 Unit/Milliliter, Inject eight units subcutaneously before meals for diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS of 15 out of 15, indicating Resident #99 was cognitively intact. Review of the care plan dated 04/16/25 revealed Resident #99 had diabetes. Interventions included administering medications per medical provider ordersOn 06/23/25 at 10:25 A.M. an observation of the medication cart for the 400 unit revealed a Fiasp insulin pen for Resident #99 that was opened and undated. LPN # 214 verified the Fiasp insulin pen for Resident #99 was opened and not dated at the time of the observation. 4. Review of the medical records for Resident #61 revealed an admission date of 02/13/25 with diagnoses including type two diabetes mellitus with hyperglycemia. Significant orders included Insulin Lispro Injection Solution 100 Unit/Milliliter, inject as per sliding scale: if blood sugar is 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 399 = 8 units; 400 - 600 = 8 units and call medical doctor for further orders, dated 06/20/25.Review of the quarterly MDS assessment dated [DATE] revealed a BIMS of 15 out of 15, indicating Resident #61 was cognitively intact. Review of the care plan dated 05/15/25 revealed Resident #61 had diabetes. Interventions included administering medication per medical providers orders.On 06/23/25 at 11:00 A.M. an observation of the medication cart on the 200-hall revealed lispro insulin pen for Resident #61 opened and not dated. Registered Nurse (RN) #314 verified the lispro insulin pen for Resident #61 was opened and not dated at the time of the observation. 5. Review of the medical record for Resident #76 revealed an admission date of 01/10/25 with diagnoses including type two diabetes mellitus with diabetic polyneuropathy. Significant orders included glargine insulin subcutaneous solution pen injector 100 Units/Milliliter, inject 25 units subcutaneously two times a day for diabetes, dated 01/10/25.Review of the significant change MDS assessment dated [DATE] revealed a BIMS of 15 out of 15, indicating Resident #76 was cognitively intact. Review of the care plan dated 06/13/25 revealed Resident #76 had diabetes with neuropathy. Interventions included administering medications per medical provider's orders. On 06/23/25 at 11:00 A.M. an observation of the medication cart on the 200-hall revealed a Lantus (brand name for glargine insulin) insulin pen for Resident #76 opened and not dated. RN #314 verified the Lantus insulin pen for Resident #67 was opened and not dated at the time of the observation. 6. Review of the medical record for Resident #109 revealed an admission date of 05/15/25. Resident #109 was discharged on 06/20/25. Significant diagnosis included type two diabetes mellitus without complications. Significant orders included Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 Unit/Milliliter, inject as per sliding scale: if blood sugar 200 - 249 = 2 units; 250 - 300 = 4 units; 301 - 350 = 6 units if above 350 or below 60 call doctor, subcutaneously at bedtime for diabetes mellitus. Review of the five-day MDS assessment dated [DATE] revealed a BIMS of 15 out of 15, indicating Resident #109 was cognitively intact.Review of the care plan dated 5/15/25 revealed Resident #109 had diabetes. Interventions included administering insulin injections per order.On 06/23/25 at 11:00 A.M. an observation of the medication cart on the 200-hall revealed a Humalog (brand name for lispro insulin) insulin pen for Resident #109 opened and not dated. RN #314 verified the Humalog insulin pen for Resident #109 was opened and not dated at the time of the observation. Review of the facility policy titled; Storage of Medications, dated 08/2020, revealed medications and biologicals are to be stored safely securely and properly. Under Section 3 titled; Expiration Dating sub point #3 revealed certain medications or package types such as IV solutions multiple dose injectable vials, ophthalmic, nitroglycerin tablets and blood sugar testing solutions and strips require an expiration date shorter than the manufacturers' expiration date once opened to ensure medication purity and potency. Sub point #5 revealed when the original seal of a manufacturer's container or vial is initially broken the container or vial will be dated. The nurse shall place a date open sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require a different date.This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, interview and facility policy review, the facility failed to ensure Resident #106 was safely discharged to another skilled nursing facility. This affected one (Resident #106) of the five residents reviewed for discharge. The facility census was 102. Findings include:Review of the closed medical record revealed Resident #106 was admitted to the facility 05/03/24 with diagnoses of sequelae of cerebral infarction, epilepsy, systemic lupus erythema and autoimmune hepatitis. Resident #106 was cognitively intact and required maximal assistance with toileting hygiene, showers, and dressing along with moderate assistance with personal hygiene and transfers. Review of the progress note dated 03/20/25 at 2:34 P.M. revealed Resident #106 requested to have a referral sent to facilities closer to Akron, Ohio. [NAME] Care in [NAME], Ohio reached out and accepted the referral. All pertinent information requested was sent over for review and the facility accepted. All resident items were packed up by staff. Review of the progress note dated 03/21/25 at 10:08 P.M. revealed Resident #106 had not been transported to the new facility as of yet and all her belongings were gone, and Resident #106 was upset. A call was made to [NAME] Care to check if they had arranged transportation and was informed it was arranged by Greenbriar. Multiple calls were made to local transport companies and transportation was arranged with Emergency Medical Services (EMS) Transport for 03/22/25 with pick-up time between 1:30 P.M. and 3:30 P.M. A call was placed to [NAME] Care to notify them of the date and time of transport. Review of progress note dated 03/22/25 at 10:47 A.M. revealed Social Services confirmed with Admissions Director #239 that transportation had been set up and notified Resident #106. Interview on 06/23/25 at 11:38 A.M. with Social Service Designee (SSD) #211 revealed Resident #106 requested to discharge to a facility closer to where she originally lived which was in Akron, Ohio. On 03/20/25 SSD #211 received a call from [NAME] Care in [NAME], Ohio reporting they set up transportation and would pick up Resident #106 at 2:15 P.M. At 2:07 P.M. SSD #211 was notified there was a pending authorization. At 2:25 P.M. SSD #211 asked if transportation was still coming. After no response was received, SSD #211 sent a follow-up email at 3:29 P.M. to [NAME] Care admission Director #320. At 3:42 P.M. SSD #211 received an email response that said pending. SSD #211 asked if transportation would be pushed back to the following day and on 03/21/25 at 1:19 P.M., [NAME] Care admission Director #320 replied that the authorization was still pending, and transportation was on standby. At 3:25 P.M. SSD #211 asked again if authorization had been received and at 3:27 P.M. [NAME] Care admission Director #320 replied, no. At 3:29 P.M. SSD #211 emailed [NAME] Care admission Director #320 and provided her personal phone number and requested she be contacted if an authorization was received over the weekend. On 03/22/25 Resident #106 complained about not having left yet and Greenbriar Admissions Director #239 contacted [NAME] Care to find out what the holdup was and one of [NAME] Care's nurses read Greenbriar Admissions Director #239 a progress note that stated they were waiting for Greenbriar to set up transportation. Afterwards, Greenbriar admission Director #239 called and set up transportation. On 03/22 at 9:04 A.M. [NAME] Care admission Director #320 emailed SSD #211 at 9:04 A.M. to notify her authorization was still pending. SSD #211reported she did not have remote access to her email so the email from [NAME] Care admission Director #320 was not received until 03/24/25. On 03/24/25 at 3:24 P.M. SSD #211 replied to [NAME] Care admission Director #320 that she was unaware there was no authorization and reported a nurse at [NAME] Care read [NAME] Briar admission Director a progress note that [NAME] was waiting for Greenbriar to arrange transportation. SSD #211 explained she found out a week later that Resident #106 was not admitted to [NAME] Care and was diverted to a hospital where she remained in the emergency department for approximately one week. SSD #211 reported she later found out that [NAME] Care was out of network for Resident #106 and because of that they needed five denials before they could accept her. The Administrator spoke with Resident #106 and offered to allow her to return to Greenbriar, which she declined. SSD #211 stated it was a bad discharge.Review of the email conversation between SSD #211 and [NAME] Care admission Director #320 on 03/20/25 revealed the following: At 2:07 P.M. [NAME] Care admission Director #320 notified SSD #211 that there was a pending authorization from her Managed Care Organization (MCO) which was United Healthcare. At 2:25 P.M. SSD #211 asked if transportation was still coming. At 3:29 P.M. SSD #211 sent a follow-up email asking for an update. At 3:42 P.M. [NAME] Care admission Director #320 responded pending. At 4:08 P.M. SSD #211 asked if transportation would be pushed back to 03/21/25. At 4:15 P.M. [NAME] Care admission Director #320 responded unfortunately. Review of the email conversation between SSD #211 and [NAME] Care admission Director #320 on 03/21/25 revealed the following: At 1:19 P.M. [NAME] Care admission Director #320 reported authorization was still pending and transportation was on standby once approved. At 3:25 P.M. SSD #211 asked if the authorization was received. At 3:27 P.M. [NAME] Care admission Director #320 responded not yet, sorry. At 3:29 P.M. SSD #211 Provided her personal cell phone number and asked [NAME] Care admission Director #320 to give her a call if the authorization came back and she would notify the facility. Review of the email conversation between SSD #211 and [NAME] Care admission Director #320 on 03/22/25 revealed the following: At 9:04 A.M. [NAME] Care admission Director #320 reported the authorization was still pending and she would follow up with SSD #211 on 03/24/25. At 4:20 P.M. [NAME] Care admission Director #320 stated Hello, I got a call from my building that Resident #106 is being transported. We do not have authorization at this time. Review of the email conversation between SSD #211 and [NAME] Care admission Director #320 on 03/24/25 revealed the following: At 9:12 A.M. SSD #211 stated Hello, I wasn't aware that our admissions had set up transportation for her. Our admissions had called your building and was read a note that stated there was transportation issues which is why she hadn't been picked up yet, so she set it up. So, I do apologize for this miscommunication. I truly wasn't aware there was transport set. At 1:41 P.M. [NAME] Care admission Director #320 responded we are trying to work it out with the hospital she was diverted to. Interview on 06/23/25 at 12:35 P.M. with Greenbriar Admissions Director #239 confirmed her involvement in Resident #106's discharge and that a call was made to [NAME] Care to talk to the facility about admissions coming. Resident #106 's room was emptied as her fiance took her items to Akron. Resident #106 was to have also left, became upset, and started crying while waiting for transport. Greenbriar Admissions Director #239 called the accepting facility and spoke to a staff member who stated they were waiting for Resident #106 so a transport company was contacted and transportation arranged for the next day. Five days passed and she found out accepting facility denied Resident #106 and she was at the emergency department. SSD #211 and the administrator took it from there. Interview on 06/30/25 at 9:12 A.M. with [NAME] Care admission Director #320 confirmed Resident #106 arrived at the facility around 10:00 P.M. and that the authorization was still pending at that time. She further explained she had previously asked SSD #211 not to send Resident #106 until the authorization was received. Upon arriving at [NAME] Care Resident #106 was diverted to the hospital because there was no authorization received, and admissions did not receive the Preadmission Screening and Resident Review (PASRR) results stating Resident #106 was appropriate for a skilled nursing facility. Review of the email conversation between SSD #211 and [NAME] Care admission Director #320 confirmed the email communications were identical to those provided by SSD #211. Review of the undated Transfer and Discharge Policy revealed orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility. This deficiency represents non-compliance investigated under Complaint Numbers OH00166058 (1272224) and OH00164151 (1272217).

Based on record review, interview and contract review, the facility failed to ensure medications were administered as ordered in a timely fashion after admission for Resident #111. This affected one (Resident #111) of eight residents who were reviewed for medication administration. The facility census was 102. Findings include:Review of the medical record for Resident #111 revealed an admission date of 06/29/25 at 6:50 P.M. with diagnoses including vesicointestinal fistula, peritoneal abscess, encounter for surgical aftercare following surgery on the digestive system, acute diastolic heart failure, hypothyroidism, arteriosclerotic heart disease, hypertension, and gastroesophageal reflux. Review of the admission assessment dated [DATE] revealed Resident #11 was alert and oriented.Review of the care plan dated 06/29/25 revealed Resident #111 had an infection. Interventions included administering antibiotics per medical providers orders. The care plan also revealed Resident #111 utilizes antidepressant medication. Interventions included administering medications as ordered.Review of the physician's orders included assessing Resident #111's pain level every shift. With each new medication order, the medication may be held until it arrives from the pharmacy, fluoxetine (an antidepressant) 40 milligrams, give two capsules by mouth in the morning for depression, amoxicillin (an antibiotic) 875 milligrams give one tablet by mouth every 12 hours four bacterial infection for five days dated 06/29/25, omeprazole (a medication that reduces stomach acid) 40 milligrams one capsule by mouth in the morning for reflux, metoprolol (a blood pressure medication) 25 milligrams one tablet by mouth daily for hypertension, loratadine (an antihistamine) 10 milligrams one tablet daily for allergies, isosorbide (a medication for coronary artery disease) extended release tablet 60 milligrams one tablet by mouth in the morning for coronary artery disease, levothyroxine (a medication for thyroid gland function) 100 micrograms give one and a half tablets daily for hypothyroidism, diazepam (an antianxiety medication) two milligrams give one tablet by mouth every eight hours as needed for anxiety dated 06/30/25, and oxycodone (a narcotic pain medication) five milligrams give one tablet by mouth every six hours as needed for seven days dated 06/30/25. Review of the medication administration record (MAR) dated 06/01/25-06/30/25 revealed fluoxetine 40 milligrams with a start date of 06/30/25 at 7:00 A.M. was not administered as ordered, isosorbide 60 milligrams with a start date of 06/30/25 at 5:00 A.M. was not administered as ordered, levothyroxine 100 micrograms with a start date 06/30/25 at 5:00 A.M. was not administered, metoprolol 25 milligrams with a start date of 06/30/25 at 7:00 A.M. was not administered, omeprazole 40 milligrams with a start date of 06/30/25 at 5:00 A.M. was not administered and amoxicillin 875 milligrams with a start date of 06/29/25 at 9:00 P.M. was not administered. Review of the facility stock medication list revealed the following medications were available in the facility starter kit (a house stock of medications to be utilized until medications can be delivered from the pharmacy): isosorbide, levothyroxine, metoprolol, omeprazole, and amoxicillin and could have been administered. On 07/02/25 at 8:48 A.M. an interview with Registered Nurses (RNs) #258 and #314 revealed there was an issue starting 06/27/25 with the facility computer system communicating with the pharmacy system regarding new medications. On 07/02/25 at 10:00 A.M. an interview with Resident #111 revealed she did not start getting medications until the evening of 07/01/25. On 07/02/25 at 1:00 P.M. an interview with Corporate Compliance RN #325 verified the house stock medication list, and the medications that could have been started for Resident #111.A review of a document titled; Pharmacy Services Agreement, signed on 05/01/25, revealed the pharmacy will deliver to the facility any prescriptions and supplies at least daily Monday through Sunday. Exhibit A of the document revealed the pharmacy will supply medications to the facility and its residents in a prompt and timely manner, provide house stock of medications to the facility, provide 24 hour seven days a week emergency pharmaceutical services via an on-call pharmacist and provide the facility with a medication administration system. This deficiency represents non-compliance investigated under Master Complaint Number OH00167150 (1272221) and Complaint Numbers OH00166373 (1272215), Complaint Numbers OH00163755 (1272216), and OH00164858 (1272218).

Based on record review, facility self-reported incident (SRI) review, interview and facility policy review, the facility failed to ensure Resident #61 was free from misappropriation. This affected one (Resident #61) of one resident reviewed for abuse, neglect and misappropriation and had the potential to affect all residents residing in the facility. The facility census was 102.Findings include:Review of the medical record for Resident #61 revealed an admission date of 02/13/25 with diagnoses including type two diabetes mellitus with hyperglycemia, acquired absence of right leg below the knee, encounter for orthopedic aftercare following surgical amputation, chronic obstructive pulmonary disease (COPD), need for assistance with personal care, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15. Indicating Resident #61 was cognitively intact. Review of the facility SRI tracking number 261140 dated 06/02/25 revealed Resident #61 reported to the facility that 400 dollars was missing from her purse. Review of the investigation into SRI tracking number 261140 revealed Resident #61 counted her money on 06/02/25 at 2:30 A.M. There was 736 dollars in her purse. Resident #61 stated she never left the room until around 9:50 A.M. to go to the shower room. Resident #61 stated she returned to her room around 10:20 A.M. Later that day, Resident #61 checked her purse and there was only 336 dollars in it. Resident #61 then reported it to her nurse who in turn notified the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA and DON reviewed the contents of the purse which contained 336 dollars. A review of video footage within the investigation revealed the only person that entered the room of Resident #61 while she was in the shower was Certified Nurse Aide (CNA) #323. The police were notified.Review of a witness statement by the LNHA dated 06/04/25 revealed a review of video footage. CNA #323 was seated at the nurse's station at 10:05 A.M. on 06/02/25. CNA #323 was then seen looking around, appearing to assess her surroundings, including observing what the nurse at the station was doing. CNA #323 proceeded to walk toward the room of Resident #61 peered inside, then turned and walked down the hallway seemingly to confirm that Resident #61 and staff were still in the shower room. At 10:07 A.M, CNA #323 quickly returned to the room of Resident #61 and entered. CNA #323 did not leave the room until 10:09 A.M. Also, within the witness statement and review of the video footage, it was noted that CNA #323 was the only person to enter the room of Resident #61 during the noted time frame.Review of a statement by the LNHA dated 06/06/25 within the investigation revealed he had contacted [NAME] Police Detective (BPD) #317. BPD #317 stated, based on review of video footage showing CNA #323 entering the room for an extended period, her body language, and her inquiries regarding the status of surveillance cameras, the prosecutor has determined there was sufficient circumstantial evidence to proceed with the case.Review of a court document ticket #25B009852 dated 06/10/25 revealed a warrant to arrest CNA #323 was issued for theft less than 1000 dollars. Review of a time punch for CNA #323 revealed the last day worked was 06/02/25. CNA #323 punched out at 3:00 P.M.Review of the document titled; Employee Investigation Packet that had the name of CNA #323 on it revealed CNA #323 was suspended on 06/02/25. The document further revealed CNA #323 was terminated on 06/17/25 for theft of resident property. Review of an undated document titled; Employee Corrective Action Form revealed CNA #323 was terminated. The reason was listed as Other: Theft.On 06/26/25 at 10:34 A.M. an interview with BPD #317 revealed based on video footage and witness statements reviewed there was enough evidence to prosecute CNA #323. BPD #317 stated a warrant was issued for a misdemeanor first degree theft against CNA #323.On 06/26/25 at 11:00 A.M. an interview with the LNHA verified the contents of the investigation regarding SRI tracking number 261140. The LNHA stated a warrant was issued for the arrest of CNA #323. The LNHA further stated CNA #323 was suspended pending investigation into the event effective 06/02/25 and terminated from employment 06/17/25. On 06/26/25 at 11:05 A.M. an interview with Resident #61 revealed she had been talked to by LNHA and [NAME] police regarding missing money. Resident #61 stated she always keeps her purse with her but on that day, it slipped her mind. Resident #61 stated she counted her money that morning before her shower and had over 700 dollars. Resident #61 stated when she counted her money later that day, she was missing 400 dollars. Resident #61 stated she then reported it. On 06/26/25 at 12:07 P.M. an interview with CNA #290 revealed she was the aide who showered Resident #61 on 06/02/25. CNA #290 stated Resident #61 was incontinent prior to going to shower room so she changed her and remade the bed. CNA #290 further stated she was accompanied by Physical Therapy Assistant (PTA) #243 as therapy was working on transfers with Resident #61. CNA #290 stated she was unaware of any money missing until later that night when CNA #323 contacted her via phone stating she was suspended. CNA #290 stated she asked CNA #323 what she was doing in the room, and CNA #323 stated she was making the bed. CNA #290 further stated she thought that was odd as she had already made the bed. CNA #290 stated CNA #323 also asked her about surveillance cameras.Review of the undated policy titled; Ohio Abuse, Neglect and Misappropriation defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of residence belongings or money without the resident's consent. The document further stated it is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concern of the residents. The policy further stated it is the intent of the facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property.This deficiency was an incidental finding identified during the complaint investigation.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure a call light was within reach for Resident #52. The facility also failed to ensure Resident #3 and #28 were reasonably accommodated by staff in response to call light activation for care needs. This affected three residents (Resident #3, #28 and #52) of 31 residents reviewed for call lights. The facility census was 95. Findings include: 1. A review of medical records for Resident #52 revealed a date of admission [DATE]. Significant diagnoses included unspecified head injury, unspecified dementia and cognitive communication deficit. Significant orders included up ad lib with wheeled walker, scheduled toileting to promote continence, and hospice care. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had moderate cognitive impairment. The MDS also revealed Resident #52 had hearing aids, had clear speech and could make self understood. Resident #52 was occasionally incontinent of bowel and bladder. Review of the care plan dated [DATE] revealed Resident #52 had an activity of daily living (ADL) self-care performance deficit. Partial to moderate assistance for toileting (helper does less than half the effort), place call light within reach and remind resident to call for assistance. On [DATE] at 11:00 A.M. an observation revealed Resident #52 was sleeping in bed. The call light activation button was observed on the floor and behind the nightstand. Corporate Registered Nurse (CRN) #932 verified the location of the call light activation button at the time of the observation. 2. A review of medical records for Resident #3 revealed a date of admission of [DATE]. Significant diagnoses included chronic obstructive pulmonary disease and diabetes mellitus type two. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). The MDS also revealed Resident #3 had no communication issues and was frequently incontinent of bowel and bladder. A care plan dated [DATE] revealed Resident #3 had an activity of daily living (ADL) self-care performance deficit. The care plan also revealed Resident #3 was non-ambulatory and assistance with ADLs may fluctuate. Interventions included to place call light within reach and remind resident to call for assistance. Review of the facility documents titled Resident Council Minutes, dated [DATE] and [DATE] revealed multiple facility staff were in attendance at the meetings. An order of old business was documented to reflect staff were educated on the call lights at night and the staff would continue to be educated on timely answering of the call lights. Also, residents voiced concerns the aides sat at the desk and did not assist them with their needs. A review of the concern logs dated [DATE] and February 2025 revealed concerns for call lights. The Ombudsman was listed as identifying concern with call lights. On [DATE] at 10:00 A.M. an interview with the Ombudsman revealed the Ombudsman had current concerns related to facility staff not answering resident call lights in a reasonable amount of time. On [DATE] at 11:53 A.M. an interview with Resident #3, who regularly attended the resident council meetings, revealed she had expressed concern at the meetings that call lights were not answered timely and the facility administration was aware of this issue. 3. A review of medical records for Resident #28 revealed a date of admission of [DATE]. Significant diagnoses included cerebral infarction, hemiplegia (weakness on one side of the body) to the nondominant left side. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (cognitively intact). The MDS also revealed no communication deficits and Resident #28 was frequently incontinent of bowel and bladder. Review of the care plan dated [DATE] revealed Resident #28 had an ADL self-care performance deficit. Interventions included total dependence for toileting (helper does all the effort), mechanical lift required with transfers with two staff assist and place call light within reach and remind resident to call for assistance. On [DATE] at 10:15 A.M an observation of call lights for Resident #28 revealed the call light was activated by Resident #28 at 10:15 A.M. and as of 10:30 A.M. there was no staff observed entering the resident's room to answer the resident's call light. On [DATE] at 10:40 A.M. an interview with Resident #28 revealed her call light had been on for approximately 15 minutes and no staff had entered the room to help her since she had activated her call light. Resident #28 stated the staff do not answer call lights timely with her longest wait time being up to 45 minutes. A review of the policy titled Resident Rights, undated, revealed residents will have a method to communicate needs to staff. A call light or bell access will be within reach of the resident as one method to communicate needs to staff. Staff will answer call needs promptly. Any staff within the vicinity will answer call light and notify the appropriate personnel for care needs that may not be immediately remedied including but not limited to toileting, medications, and medical care.

Based on record review and interview the facility failed to ensure Resident #101's Power of Attorney (POA) signed Resident #101's admission paperwork as the resident's representative. This affected one resident (Resident #101) out of three residents reviewed for admissions. The facility census was 95. Findings include: Review of Resident #101's closed medical record revealed an admitted [DATE] with diagnoses including aphasia, following cerebral infarction, Parkinson's disease, type two diabetes mellitus, chronic kidney disease, muscle wasting and atrophy. Review of POA documents dated 05/29/25 revealed Resident #101's wife was designated POA. Review of Resident #101's admission paperwork revealed all admission paperwork was signed by Resident #101's son-in-law on 02/07/25 who was not an authorized representative of Resident #101 or his POA. Review of Resident #101's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. required supervision or touching assistance for eating, substantial to maximal assistance with dressing and bed mobility. Resident #101 was dependent on staff for oral hygiene, toileting hygiene, showers, and personal hygiene. Interview on 03/10/25 at 2:57 P.M. with Resident #101's family member revealed the POA was not given an opportunity to review and sign Resident #101's admission documents and instead the admissions girl came to Resident #101's room with an ipad stating she needed a family signature to finish some paperwork and had Resident #101's son-in-law sign and the son-in-law was not the POA. Interview on 03/11/25 at 3:30 P.M. with the Admission Director (AD) #842 verified Resident #101's son-in-law who was not his POA signed all admission paperwork including the Admission Agreement, Guarantor Agreement, Assignment of Benefits, Electronic Medical Record (EMR) photo consent, Vendor Consultation Consent for Ancillary Services or Insurance Plan Enrollment, Admission Checklist, Responsible Party/Resident Representative Agreement, Medicare Secondary Payer Determination, Authorization to Share Medical Information, Receipt of Information, and the Pharmacist Consult Agreement for Drug Therapy Management with Physician Patient Authorization and Consent for Care paperwork. AD #842 verified the POA should have signed as the POA for Resident #101. This deficiency represents non-compliance identified during investigation of Complaint Number OH00162996.

Based on record review, interview and observation the facility failed to ensure medications were administered as ordered by the physician. This affected two residents (Resident #70 and #357) of eight residents reviewed for medication administration. The facility census was 95. Findings include: 1. Review of Resident #357's medical record revealed an admitted [DATE] with diagnoses that included, acute and subacute infective endocarditis, septic arterial embolism, chronic kidney disease, stage two, ST elevation myocardial infarction (STEMI), other psychoactive substance abuse, uncomplicated intravenous drug use with Suboxone, bacteremia, methicillin resistant staphylococcus aureus infection, nicotine dependence. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #357 had intact cognition. Review of Resident #357 care plan dated 03/08/25 revealed a focus of substance use disorder with interventions to administer medications per medical provider's orders and evaluate the resident for the following symptoms ( but not limited to) and report to medical provider/resident/ resident representative, if present: stumbling, nodding off even when standing or in mid conversation, incoherent speech/slurred speech, rambling, sleepy erratic behavior, hyperactive, threatening, hostile, blood shot eyes, pin point pupils, pale face, sweaty unruly appearance, fumbling, nervous, jerky movements. Further review of Resident #357's medical record revealed Buprenorphine HCL- Naloxone HCL (Suboxone) Sublingual Film 2-0.5MG, give 2 tablets sublingually every 24 hours was ordered with a start date of 03/08/25. Review of the medication administration record (MAR) revealed this medication was not administered as ordered by the physician on 03/08/25, 03/09/25, and on 03/10/25 it was administered at 10:00 P.M. On 03/13/25 it was not administered as ordered. Review of the pharmacy delivery sheets revealed the Suboxone for Resident #357 was delivered on 03/10/25 and 03/12/25. Interview with Resident # 357 on 03/10/25 at 3:33 P.M. revealed that he did not receive his Suboxone as ordered by the physician. Resident #357 reported the nurse informed him it was not available, and he was concerned. Interview with the Administrator and Corporate Registered Nurse (CRN) #934 on 03/17/25 at 9:21 A.M. verified these medications were not administered on 03/08/25, 03/09/25, and 03/13/25 as ordered by the physician and that the medication did not arrive to the facility until 03/10/25. 2. Review of the medical record for Resident #70 revealed an admitted [DATE]. Diagnosis included metabolic encephalopathy, acute respiratory failure,endometrial cancer, venous insufficiency, and chronic stage three kidney disease. Review of the MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, required partial to moderate assistance with eating and oral hygiene, substantial to maximal assistance for bed mobility and was dependent for toileting, showers, dressing, and personal hygiene. Review of Resident #70's physician orders dated 03/10/25 revealed they were prescribed Dronabinol capsule 5 milligrams (mg) by mouth one time a day for appetite stimulant. Review of Resident #70's MAR dated 03/10/25 through 03/17/25 revealed Resident #70 had not received the medication as it was not available for administration. Review of Resident #70's progress notes dated from 03/11/25 through 03/17/25 revealed there was no communication with the Physician, Nurse Practitioner, or the Resident's family informing them the Dronabinol 5 mg was not available for administration, nor was there any documentation with the pharmacy regarding the medication not being available. Interview on 03/17/25 at 10:57 A.M. with CRN #934 verified Resident #70's Dronabinol five milligram (mg) dose used for an appetite stimulant due weight loss was ordered on 03/10/25 and had been marked on the MAR as unavailable to be given from 03/11/25 to 03/17/25. CRN #934 also confirmed there was no communication with the physician as to why it was not available nor was there communication with resident's family the medication was not available. Review of the medication administration policy, dated 2013, stated: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety of residents, visitors, and employees is a top priority of care. The purpose of this policy is to provide guidance for general medication administration to be provided by personnel recognized as legally able to administer. Administer medications only as prescribed by the provider. This deficiency represents non-compliance identified during investigation of Complaint Number OH00162996 and OH00161861.

Based on record review and interview the facility failed to ensure a bed hold letter was mailed to Resident #101's Power of Attorney (POA). This affected one resident (Resident #101) of three residents reviewed for notification of bed hold. The facility census was 95. Findings include: Review of Resident #101's closed medical record revealed an admission date of 02/04/25 and a discharge date of 02/16/25. Resident #101's diagnoses included aphasia, following cerebral infarction, Parkinson's disease, type two diabetes mellitus, chronic kidney disease, muscle wasting and atrophy. Review of Resident #101's POA documents, dated 05/29/2013, revealed Resident #101's wife was designated as POA. Review of Resident #101's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, required supervision or touching assistance for eating, substantial to maximal assistance with dressing and bed mobility. Resident #101 was dependent on staff for oral hygiene, toileting hygiene, showers, and personal hygiene. Review of Resident #101's bed hold notice revealed it was never sent via certified mail to the reisdents' POA. Interview on 03/10/25 at 2:57 P.M. with the POA of Resident #101 verified they had not received a notification of bed hold for Resident #101. Interview on 03/11/25 at 3:51 P.M. with the Business Office Manager (BOM) #818 verified Resident #101's bed hold letter was never mailed to the resident's representative/POA. This deficiency represents non-compliance identified during investigation of Complaint Number OH00162996.

Based on record review and interview, the facility failed to ensure Residents #9, #13, and #56 received the necessary services for showers to maintain personal hygiene. This affected three Residents (#9, #13, and #56) out of seven residents reviewed for showers. The facility census was 95. Findings include: 1. Review of the Grievance/Concern log minutes dated 12/03/24, 01/10/25, 01/22/25, 02/27/25, revealed multiple residents voiced concerns about not receiving showers as scheduled. Review of Resident Council meetings dated 01/29/25 and 02/26/25 revealed residents requested shower aides on shifts to help with showers. Medical record review for Resident #56 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, dysphagia, anxiety, difficulty in walking, cognitive communication deficit. Review of Resident #56's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. She required setup or clean up assistance for eating and was dependent on two staff members for oral hygiene, toileting hygiene, dressing, personal hygiene, bed mobility and showers. Review of Resident #56's care plan dated 02/26/25 revealed the resident had an Activity of Daily Living (ADL) self-care performance deficit requiring assistance with ADL's due to disease process, gait/balance problems, impaired cognition, bowel and bladder incontinence, weakness, right hand contracture, diagnosis of stroke with right hemiplegia, sleep disorder and restless leg syndrome. Interventions included staff assistance with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and tub/shower assistance by two or more staff members. Review of the facility shower schedule for Resident #56 revealed they were scheduled to have showers completed on every Tuesday and Saturday. Review of Resident #56's shower documentation dated from 02/24/25 to 03/11/25 revealed Resident #56 received seven out of 11 bed baths. Shower documentation indicated on 02/04/25, 03/01/25, 03/08/25 and on 03/11/25 the resident did not receive a shower or bath due to environmental limitations. Interview on 03/17/25 at 11:30 A.M. with the Director of Nursing (DON) and the Corporate Registered Nurse (CRN) revealed they did not know what the Certified Nursing Assistants (CNA) meant when they documented due to environmental limitations and they indicated it should not even be an option. The DON and CRN verified Resident #56 did not receive showers as scheduled. 2. Medical record review for Resident #13 revealed an admitted [DATE]. Diagnoses included epilepsy, paraplegia, chronic obstructive pulmonary disease, obstructive sleep apnea, diabetes mellitus typed two, neuromuscular dysfunction of bladder, and hypertension. Review of Resident #13's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition, was independent with eating, required setup or clean up assistance with oral hygiene, substantial to maximal assistance with toileting hygiene and bed mobility and was dependent on staff for showers and personal hygiene. Review of Resident #13's care plan revealed the resident was totally dependent by two staff members for showers or tub transfers with the resident doing none of the effort. Review of Resident #13's shower documentation from 02/05/25 to 03/11/25 revealed the resident received seven bed baths and no showers. Interview on 03/10/25 at 3:30 P.M. with Resident #13 revealed he only received bed baths and was never taken to the shower room. Resident #13 stated the staff have a gurney to use for showers and they do not use it on him. Resident #13 stated he does not feel clean with only getting bed baths and would like to go to the shower room and had expressed this to administration. Interview on 03/17/25 at 11:30 A.M. with the DON and the CRN revealed they confirmed Resident #13 had only received bed baths and not per his schedule or desire to go to the shower room. 3. Medical record review for Resident #9 revealed an admitted [DATE]. Diagnoses included end stage renal disease, hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease or end stage renal disease, paraplegia, unspecified, neuromuscular dysfunction of bladder unspecified, type two diabetes mellitus without complications, chronic venous hypertension (idiopathic) with ulcer of left lower extremity, acquired absence of right leg above knee, major depressive disorder, morbid (severe) obesity due to excess calories. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had a lower extremity (hip, knee, ankle, foot) impairment on both sides, mobility device wheelchair dependent, he had a catheter for urination and was occasionally in continent of bowel. He was totally dependent on two staff for transferring and totally dependent on one staff for set up to bathe and he had intact cognition. He was also assessed to be independent in most of his ADLs. He was assessed to be totally dependent on assistance by staff for transferring, personal hygiene, and set up for showers. Resident #9 had intact cognition. Review of Resident #9's plan of care dated 03/06/25 revealed the resident had ADL self-care performance deficit, required assistance with ADLs related to catheter use, incontinence, pain, paraplegia, weakness, end stage renal disease, functional deficit, right above the knee amputation (AKA), diabetes, morbid obesity and non-ambulatory. Interventions include shower/bathe self required substantial maximal assistance, required mechanical lift for transfers, with two-person support. Review of the skin assessment/shower sheets dated 02/01/25 through 03/11/25 revealed Resident #9 only received 8 showers total and failed to receive a shower on 02/04/25, 02/08/25, and 02/18/25. Review of Resident # 9 's shower scheduled revealed Resident # 9 was to receive a shower every Tuesday and Saturday, but his preference was to have showers every other day and only needed assistance with transferring and shower set up and he preferred to shower himself. Interview with Resident #9 on 03/10/25 at 4:22 P.M. revealed that some weekends, they get showers and some weekends they aren't even dressed until the afternoon, depending on whose working. Interview with the DON on 03/12/25 at 2:43 P.M. revealed Resident #9 did not allow anyone into the shower with him so staff would get him set-up and he did the rest. The DON confirmed Resident #9 did require maximum assistance with a mechanical lift to transfer for showers, and he did not receive showers as scheduled. Review of the ADL policy, undated, revealed it is the policy of this facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle preferences while in the care of the facility. Providing routine care by a nursing assistant includes but not limited to the following: assisting or provides for personal care bathing, dressing, toileting, eating, and hydration, and assisting with ambulation, transfer, repositioning, or transport. This deficiency represents non-compliance identified during investigation of Complaint Number OH00162996.

Based on record review, interview and policy review the facility failed to complete pre and post dialysis assessments for Resident #94 on each dialysis treatment day. This affected one resident (Resident #94) of one resident reviewed for dialysis. The facility identified four residents (#9, #76, #86 and #94) as being on dialysis. The facility census was 95. Findings include: A review of medical records for Resident #94 revealed a recent admitted [DATE]. Significant diagnoses included end stage renal disease and dependence on renal dialysis. Significant orders included assess dialysis shunt for thrill (a palpable vibration felt over the dialysis access shunt) or bruit (a sound of blood flowing through the access shunt) every shift, assess dialysis resident upon return from dialysis, no blood pressures/blood draws or intravenous access in left arm due to dialysis shunt, dialysis days Monday, Wednesday and Friday. Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 was cognitively intact. Active diagnoses within the MDS included dependence on renal dialysis. Special treatments within the MDS revealed Resident #94 to be on dialysis. Review of the care plan dated 02/04/25 revealed Resident #94 was on dialysis therapy. Interventions included on dialysis days administer medications before during or after dialysis according to medical provider orders, communicate with dialysis center regarding medications vital signs, weights, any restrictions, diet orders nutritional and or fluid needs, lab results and who to notify with concerns. Interventions also included evaluate the resident following dialysis treatment and report any abnormal findings to medical provider, the nephrologist, the dialysis center, the resident and or resident representative. A review of resident assessments titled Pre-dialysis assessment dated [DATE] within the medical record revealed only one pre-dialysis assessment was completed since Resident #94's recent admitted [DATE]. A review of resident assessments titled Post-dialysis assessment dated [DATE] within the medical record revealed only one post-dialysis assessment completed since Resident #94's recent admitted [DATE]. On 03/12/25 at 3:45 P.M. an interview with the Assistant Director of Nursing #860 revealed pre and post dialysis assessments are to be done on each dialysis treatment day. On 03/13/25 at 11:00 A.M. an interview with Corporate Registered Nurse (CRN) #934 revealed the only pre and post dialysis assessments completed on Resident #94 were 03/12/25. CRN #934 also verified the facility policy stated to complete pre and post dialysis assessments. On 03/13/25 at 1:50 P.M. an interview with Medical Secretary #935 from the dialysis center revealed Resident #94 had been at the dialysis center for treatment on 02/03/25, 02/05/25, 02/07/25, 02/10/25, 02/12/25. 02/14/25, 02/17/25, 02/19/25, 02/26/25, 03/03/25, 03/05/25, 03/07/25, 03/10/25 and 03/12/25. A review of the policy titled Hemodialysis Care and Monitoring, undated, revealed in section eight and subtitled, Pre-dialysis: Evaluation is completed within 4 hours of transportation to dialysis include and but not limited to accurate weight, blood pressure, pulse, respirations, in temperature. The evaluation should include medications administered or withheld prior to dialysis. The subsection titled pre dialysis also revealed to send a copy of the nursing evaluation with the resident to the dialysis center including the medication administration record and emergency contacts. In section nine, subtitled, Post Dialysis the nurse is to complete a post dialysis evaluation upon return from dialysis center to include but not limited to checking the thrill of the fistula, checking the bruit of the fistula, checking the pulse in the access limb, checking blood pressure, pulse, respirations, and temperature upon return of the facility, visual inspection of the site for bleeding, swelling and or other abnormalities, and any abnormal or unusual occurrence that the resident reports while at the dialysis center.

Based on observations, interviews, and record reviews, the facility failed to ensure Residents #53, #55, and #89 were smoking in a safe smoking area and not an area designated as non-smoking. This affected all three Residents #53, #59, and #89 who were reviewed for smoking. The facility census was 95. Findings include: 1.Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure with hypoxia, hemiparesis following cerebral infarction, and atrial fibrillation. Review of the entry Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had severe cognitive impairment with a memory problem. Resident #53 required extensive assistance for all activities of daily living. Review of the smoking assessments completed 10/28/24, 01/28/25, and 02/22/25 revealed Resident #53 was an independent smoker. Review of the care plan dated 01/06/25 revealed Resident #53 utilizes nicotine products. Interventions included she will use the products in a safe manner and to educate her on designated smoking areas. 2.Review of the medical record for Resident #55 revealed an admitted [DATE]. Diagnoses included cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction, and atrial fibrillation. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #55 had mild cognitive impairment. Resident required moderate assistance with all activities of daily living. Review of the care plan dated 01/26/25 revealed Resident #55 utilizes nicotine products. Interventions included that he will use the products in a safe manner and to educate him on designated smoking areas. Review of the smoking assessments completed 08/23/24, 11/23/24, and 02/24/25 revealed Resident #55 was an independent smoker. Review of the nursing progress note dated 10/17/24 revealed Resident #55 was reeducated on the facility smoking policy and the consequences of violating the policy. Resident #55 verbalized understanding and signed the policy j-off. 3.Review of the medical record for Resident #89 revealed an initial admitted [DATE] and a readmitted [DATE]. Diagnoses included non-pressure chronic ulcer of the right foot, gangrene, hypertension, diabetes mellitus type two, and cannabis use. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #89 had intact cognition. Resident #89 required moderate assistance with all activities of daily living. Review of the care plan dated 01/29/25 revealed Resident #89 utilizes nicotine products. Interventions included that he will use the products in a safe manner and staff will educate him on designated smoking areas. Review of the smoking assessment completed 01/15/25 revealed Resident #89 was an independent smoker. Observation on 03/10/25 at 2:20 P.M. revealed Resident #53, #55 with her visitor, and Resident #89 sitting on the back facility patio smoking. The patio was clearly marked with no smoking. All three Residents confirmed that they were smoking in a non-smoking area because they felt the walk to the smoking area was too far. Interview on 03/11/25 at 8:55 A.M. with the Assistant Director of Nursing (ADON) 910 revealed that the facility does not have supervised smoking. All residents are assessed and if they are an independent smoker they can smoke in designated areas when they want to. Interview on 03/13/25 at 2:03 P.M. with Resident #3 reported she had witnessed several residents smoking on the back patio even though they have another patio designated as the smoking area. Resident #3 stated she hoped the facility enforced the smoking policy. Review of the facility policy titled Resident Smoking Guidelines, undated, revealed it is the policy of this facility to promote 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. To provide smoke free areas outside on facility grounds for residents who do not smoke and who desire a smoke free area when outside.

Based on medical record review, review of the facility's self-reported incident (SRI), interviews and review of the facility policy, the facility failed to ensure timely and appropriate reporting of suspected verbal abuse and rough handling of Resident #75 by staff. This affected one resident (#75) of 33 residents residing on the Regency unit of the facility. The facility census was 100. Findings include: Review of the medical record revealed Resident #75 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia, mild intellectual disabilities, asthma, atherosclerotic heart disease of the native coronary artery, essential hypertension, iron deficiency anemia, obstructive reflux uropathy, bipolar disorder, muscle weakness, glaucoma, and unspecified chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 11/04/24 revealed Resident #75 had severe cognitive impairment and was dependent for toileting hygiene, dressing lower body, application and removal of footwear, and personal hygiene. Further review of the MDS revealed Resident #75 was frequently incontinent of urine and stool and exhibited no behaviors or rejection of care. Review of the care plan dated 11/04/24 revealed Resident #75 was incontinent of urine and was at risk for urinary complications related to malignant neoplasm of the prostate, benign prostatic hyperplasia (BPH), impaired cognition, impaired mobility, and obstructive uropathy. Interventions included the application of barrier creams as needed, wash, rinse, and dry perineum, and change disposable briefs and/or clothing after incontinent episodes. Further review of the care plan revealed Resident #75 had behavior problems related to mild intellectual deficits, bipolar disorder, and impaired cognition, including taking items that did not belong to him, being loud, exhibiting periods of sadness, and agitation when needs not immediately met. Interventions included approaching and speaking with Resident #75 in a calm manner. Review of the progress note dated 11/27/24 at 3:20 P.M. revealed the Executive Director and the Director of Nursing (DON) notified Resident #75's emergency contact that there was an allegation of verbal abuse. Resident #75 could not recall the incident, and no concerns were noted with his skin assessment. Accused staff member was suspended pending further investigation, and the [NAME] police were in the facility to follow-up. There were no progress notes between 11/24/24 and 11/27/24 at 3:20 P.M. indicating report of alleged abuse of Resident #75. Interview on 11/27/24 at 10:51 A.M. with the DON revealed he had received no report of suspected abuse, neglect, or mistreatment of a resident in the past week (review of the complaint intake information revealed the alleged abuse took place between 10:00 A.M. and 11:00 A.M. on 11/24/24). The DON further confirmed immediate reporting was necessary in order for the facility to take necessary steps to ensure immediate resident safety. Interview on 11/27/24 at 10:53 A.M. with the Executive Director (ED) confirmed he had not received any report of allegations regarding abuse or neglect of a resident by staff. The ED further detailed the facility's reporting and investigative process when such allegations occurred and concurred abuse allegations should be reported immediately. Follow-up interview with the ED and the DON on 11/27/24 from 10:58 A.M. to 11:03 A.M. confirmed there was one certified nurse aide (CNA) who had the first name of the staff member identified as the perpetrator in the complaint (CNA #409). During the interview, the ED immediately called the Scheduling Coordinator #365 to verify CNA #409 was not on duty and verbalized CNA #409 would be suspended pending an investigation, and he would file a facility SRI to the state agency. Interview on 11/27/24 at 1:25 P.M. with CNA #409 confirmed she worked on the Regency unit on 11/24/24. During the interview, CNA #409 denied any verbal abuse, physical abuse, or mistreatment of any type to any resident. She further stated this was not the first time she was accused of something in this facility and was tired of false accusations. Interview on 11/27/24 at 2:35 P.M. with the DON confirmed he had just learned a CNA (#379) just admitted to witnessing an incident between CNA #409 and Resident #75 on 11/24/24. At the time of this interview, CNA #379 was being interviewed by the ED, writing her statement, in the process of being suspended, and then would be speaking with the [NAME] police officer waiting outside the EDs office. Interview on 11/27/24 at 3:00 P.M. with CNA #379 confirmed she was instructed by CNA #409 to assist in cleaning up Resident #75 between 10:00 A.M. and 11:00 A.M. during her shift on 11/24/24. CNA #379 stated she witnessed CNA #409 running a large handful of wipes under water, throwing the wipes with force at Resident #75, telling him to clean your [expletive] self, shoving his shoulder to turn him against the wall, and calling him a disgusting [expletive]. Further interview revealed CNA #379 witnessed CNA #409 pull and wipe Resident #75's scrotum and surrounding area so roughly that Resident #75 groaned, and CNA reported Resident #75 to be clenching with a reddened face and a look of confusion and helplessness. During the interview, CNA #379 admitted she was shocked and scared and did not know what to do to help Resident #75. CNA #379 further confirmed she had received training on abuse reporting expectations, but was too afraid, so she called a friend, who was an aide who worked elsewhere, for advice and that friend called and reported an anonymous complaint to the Ohio Department of Health (ODH). During the interview, CNA #379 confirmed she told nobody who worked in the facility she witnessed verbal abuse and rough care by a co-worker (CNA #409) and that co-worker continued to work with the residents of the facility after the witnessed incident. Interview on 12/02/24 at 12:44 P.M. with Resident #75's family confirmed the facility notified her on 11/27/24 that there was an alleged incident of abuse of Resident #75 on Sunday, 11/24/24. The family of Resident #75 confirmed Resident #75 had no recollection of the incident and was unable to provide any details of that day. Interview on 12/02/24 with Resident #75 at 12:50 P.M. confirmed he had no recollection of the incident reported on 11/24/24. Further interview confirmed he felt safe in the facility and could provide no details related to verbal or physical abuse. Review of the in-process investigation for SRI tracking number(#)254531 revealed a witness statement written by CNA #379 on 11/24/24 confirming she witnessed Resident #75 receiving incontinence care from CNA #409 and that CNA #409 was angry, called Resident #75 names, swore at him, shoved his shoulder to the wall to turn him around, and wiped him so hard she was nearly knocking him over. Further review of the witness statement revealed CNA #379 did not intervene and did not report the allegation to anyone in the facility. Further review of the SRI investigation revealed CNA was suspended on 11/27/24 for failure to report allegations of abuse. Review of the undated policy titled Ohio Abuse, Neglect & Misappropriation revealed a covered individual, defined as anyone who is an owner, operator, employee, manager, contractor, or agent of the facility, was obligated to report any reasonable suspicion of a crime against a resident or person receiving care in a long-term care facility. The policy further revealed employees received training on abuse prevention and reporting as part of their orientation, annually, and as needed or indicated. The policy also revealed any suspected abuse or neglect was to be reported directly to the supervisor and reported immediately to the Executive Director or facility designee and investigated timely. This deficiency is an incidental finding identified during the complaint investigation.

Based on observation, medical record review, and interview, the facility failed to develop and implement comprehensive, effective and individualized pain management programs for all residents. The facility failed to ensure Resident #104 received pain medication as ordered and the facility failed to ensure Resident #60 was re-assessed timely following complaints of severe pain to determine if changes were needed to his medication regimen. This affected two residents (#60 and #104) of six residents reviewed for pain. Actual harm occurred on 11/14/24 when Resident #104, who had a diagnosis of metastatic (cancer cells have spread to areas other than the original tumor) lung cancer did not receive routine/scheduled pain medication as ordered to achieve effective pain relief/pain management and prevent shortness of breath resulting in complaints of increased pain which included facial grimacing and shortness of breath with pursed lip breathing. Findings include: 1. Review of Resident #104's medical record revealed the resident had diagnoses including malignant neoplasm of the lungs and chronic obstructive pulmonary disease. On 11/13/24 (at 8:00 P.M.) a new order was written for the administration of Morphine Sulfate (an opiate (narcotic) analgesic) 15 milligrams (mg) every four hours for metastatic lung cancer. Review of the medication administration record (MAR) revealed the 8:00 P.M. dose on 11/13/24 was not administered because Resident #104 was sleeping. In addition, the 12:00 A.M. and 4:00 A.M. doses of Morphine were not administered on 11/14/24 with a code to see nursing notes. However, the notes were devoid of a reason the medication was not administered. On 11/14/24 at 8:50 A.M., Resident #104's call light was observed on. The length of time it had been on was unknown at that time. At 8:55 A.M., Resident #104 ambulated to his doorway and spoke to Licensed Practical Nurse (LPN) #240 about getting pain medication. LPN #240 stated she was told Resident #104 did not receive pain medication over night or his morning doses because he was sleeping which Resident #104 denied. LPN #240 stated she would be with Resident #104 when she was done (preparing medication for another resident). At 8:57 A.M., Resident #104 had returned to his room and was sitting on the side of his bed. An interview with Resident #104 at the time of the observation revealed concerns he was having trouble getting his Morphine, stating he was supposed to get it every four hours. Resident #104 stated he had received no Morphine since 9:00 P.M. on 11/13/24. Pursed lip breathing, shortness of breath and facial grimacing were noted. Resident #104 stated the night nurse told him the facility was out of the Morphine. LPN #240 administered Resident #104's medication at 9:05 A.M. including the Morphine 15 mg. An interview on 11/14/24 at 9:09 A.M. with LPN #240 verified Resident #104's Morphine was scheduled every four hours. The last dose was signed out on the narcotic count sheet on 11/13/24 at 6:08 P.M. and she stated the Morphine was ordered for shortness of breath for terminal cancer. Further interview with Resident #104 on 11/14/24 at 9:10 A.M. revealed he was ordered the Morphine for both pain and shortness of breath. Resident #104 rated his pain an eight on a scale of zero to 10 with 10 being the most severe pain. On 11/14/24 at 11:55 A.M., Resident #104 stated he had received little relief from the Morphine administered that morning. His breathing continued to be labored and he rated his pain a six on a scale of zero to ten at that time. On 11/14/24 at 9:45 A.M., an interview with Registered Nurse (RN) #350 revealed he investigated the concern related to Resident #104's Morphine Sulfate administration. RN #350 verified the Morphine Sulfate was not administered in accordance with the physician's order and stated the nurses did not seem to understand when pain medication was ordered on a routine basis that it was necessary to offer it to maintain effective pain control even if a resident was sleeping. On 11/14/24 at 3:40 P.M., Nurse Practitioner (NP) #300 verified the order for Morphine indicated it was to be administered every four hours routine, not while awake or as necessary. The NP revealed attempts had been made to administer the Morphine while awake in the past and it was not effective and the NP indicated it was better to administer the medication around the clock. NP #300 stated it would take a while now for Resident #104 to obtain relief since he had not received the Morphine as ordered and that was why she wanted him to have it on a routine basis. When observations of purse lip breathing were shared with NP #300 she stated that could have been due to his respiratory status alone. Observations of facial grimacing were shared with no additional information/explanation provided. On 11/18/24 at 9:10 A.M., an interview with Hospice Nurse #270 revealed Resident #104's pain medication had been increased because he wasn't getting it routine and he had to wait when he asked for pain medication ordered on an as necessary (prn) basis. Hospice Nurse #270 revealed Resident #104 would not ask consistently for the as needed (prn) pain medication because he did not want to bother staff. 2. Review of Resident #60's medical record revealed diagnoses including osteoarthritis of both hips and osteonecrosis of the left femur (death to the bone that occurs when there is a disruption of blood supply to the thigh bone and could result in destruction of the hip joint and severe arthritis). On 11/01/24 an order was written for the pain medication Ultram 50 mg every eight hours as needed (prn) for pain. Review of the November 2024 MAR revealed pain severity levels recorded with prior administration of Ultram ranged from zero to ten with only one dose on 11/03/24 at 9:28 A.M. being ineffective. Review of the controlled drug administration record revealed the last dose was removed on 11/13/24. The time was difficult to read but appeared to be between 8:00 P.M. and 10:00 P.M. On 11/14/24 at 8:00 A.M., LPN #200 was observed conversing with Resident #60 when she entered his room to administer his medication. Resident #60 was in the bathroom and complained he had been in pain all night. LPN #200 responded the night nurse had reported when she went to administer Resident #60's pain pill the previous night he was sleeping so she and another nurse had to waste it. There were no more Ultram (pain pills) in the cart as the last dose had been wasted LPN #200 stated the Nurse Practitioner (NP) was supposed to be later (on this date) and would address the pain. When Resident #60's medication was administered on 11/14/24 at 8:34 A.M. and included gabapentin 200 milligrams (anticonvulsant which could be used for neuropathic pain) and Naproxen 250 milligrams (anti-inflammatory medication). On 11/14/24 at 11:58 A.M., interview with Resident #60 revealed he rated his pain at an 11 (on a scale of zero to 10). Resident #60 stated he had received Norco at the hospital and it was effective. Resident #60 stated he had discussed this with staff (could not provide names) but it had not been ordered yet. An interview with LPN #200 on 11/14/24 at 12:10 P.M. verified she had not reassessed Resident #60 to determine if his routine medication had been effective in relieving pain. LPN #200 verified she had not seen the nurse practitioner visit yet that day but stated Resident #60's Ultram was supposed to be delivered with medications that night. The November MAR indicated Resident #60 was provided 650 mg of acetaminophen on 11/14/24 at 12:40 P.M. for pain rated at ten on a scale of 0-10. The MAR indicated the acetaminophen was ineffective. On 11/14/24 at 3:40 P.M., NP #300 stated Resident #60 did not generally complain of pain when she visited. Resident #60's Gabapentin had been increased recently and staff were monitoring effectiveness. NP #300 stated Norco (pain medication) probably would be more effective if it had been effective when used previously. On 11/14/24, an order was written for hydrocodone/acetaminophen (Norco a narcotic pain medication) 5/325 mg one tablet every eight hours as needed (prn) for pain. On 11/18/24 at 10:38 A.M., Resident #60's facial expressions were noted to be more relaxed. Resident #60 stated he had been receiving Norco over the weekend and stated he was feeling great. Resident #60 stated he was sleeping better and he was now able to bend and stretch his left leg which he demonstrated. Resident #60 stated he had not been able to move his left hip and leg like that previously due to pain. Review of the facility's Pain Management and Assessment policy (implementation date not recorded) indicated the use of a one to ten pain scale revealed a ten severity represented it being the worst pain a resident had ever experienced. This deficiency represents non-compliance investigated under Complaint Number OH00159033.

Based on medical record review, review of controlled drug administration records and interview, the facility failed to ensure accuracy of records regarding medication administration. This affected one (Resident #60) of six residents reviewed for pain. Findings include: Review of Resident #60's medical record revealed diagnoses including osteoarthritis of the hips and osteonecrosis of the left femur. On 11/01/24, an order was written for ultram (pain medication) 50 milligrams (mg) to be administered every eight hours as necessary for pain. Comparison of the November Medication Administration Record (MAR) and the controlled drug administration record revealed discrepancies described below. The MAR indicated ultram was administered on 11/05/24 at 9:34 A.M. There was no documentation of the withdraw of the ultram for that date and time. The MAR indicated ultram was administered on 11/06/24 at 8:37 P.M. The controlled drug administration record indicated ultram was removed at 10:00 (what appeared to be 10 A.M.). The MAR indicated Resident #60 received ultram on 11/07/24 twice (at 10:51 A.M. and 9:38 P.M.) The controlled drug administration record indicated the withdraw of three doses of ultram that day (the times of one of the doses were difficult to read with the first dose signed out appearing to say 2051 (military time for 8:51 P.M.) but was recorded before doses were signed out at 11:30 A.M. and 9:40 P.M. The MAR indicated ultram was administered on 11/08/24 at 8:01 A.M. and 9:00 P.M. The controlled drug administration record indicated the withdraw of ultram at 5:32 (no indication of A.M. or P.M.), 8:00 A.M. and 9:00 P.M. On 11/10/24 at 9:00 P.M., ultram was withdrawn from the card of medications. There was no documentation on the MAR as to its administration. On 11/13/24 at either 8:00 P.M. or 10:00 P.M. a dose of ultram was removed with no documentation as to it being wasted or administered. On 11/14/24 at 3:20 P.M., the Director of Nursing (DON) verified discrepancies between Resident #60's MAR and controlled drug administration record. On 11/14/24 at 3:50 P.M. Licensed Practical Nurse (LPN) #200 stated she knew the ultram withdrawn on 11/13/24 was wasted as the night shift nurse waited until she arrived and they disposed of it together but she forgot to sign the form.

Based on observation, interview, record review, and facility policy review the facility failed to administer medications to Resident #31 in accordance with professional standards of practice. This affected one resident (#31) of two residents observed for medication administration. The facility census was 92. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, type two diabetes mellitus, chronic obstructive pulmonary disease, and peripheral vascular disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. Resident #31 required extensive assistance for all activities of daily living and had an indwelling urinary catheter and was always incontinent of bowel. Review of the care plan dated 08/14/24 revealed Resident #31 required assistance with all activities of daily living. Interventions included to provide set up and clean up assistance for eating and to provide supervision and touching assistance for oral hygiene. Observation of medication administration on 09/25/24 at 8:20 A.M. with Licensed Practical Nurse (LPN) #503 revealed she filled a medication cup with: Norvasc 10 milligrams (mg) tablet (a medication to treat high blood pressure and chest pain) Aspirin 81 mg tablet (blood thinner) Bumex 2 mg tablet (a medication to treat fluid retention and high blood pressure) Clonidine 0.1 mg tablet (a medication to treat high blood pressure) Losartan 25 mg tablet (a medication to treat high blood pressure) Vitamin D 25 micrograms (mcg) tablet (supplement) Sodium bicarbonate 500 mg tablet (a medication used to treat heartburn, sour stomach, and acid indigestion) Isosorbide 30 mg tablet 9a medication to treat chest pain) Cilostazole 25mg tablet (vasodilator) Coreg 25 mg tablet (a medication to treat high blood pressure and heart failure) Colace 100 mg tablet (stool softener) Iron 65 mg tablet (supplement) Symbicort inhaler (medication to treat asthma and chronic obstructive pulmonary disease) LPN #503 entered the room for Resident #31. She administered two puffs of the inhaler to Resident #31 and then encouraged him to rinse his mouth. Resident #31 had hand contractures and did not grab his water. LPN #503 then immediately handed the medication cup with the 12 tablets and instructed Resident #31 to take his medications. Resident #31 threw all 12 tablets into his mouth. LPN #503 then immediately left the room and went into the hallway to her medication cart out of sight of Resident #31. Resident #31 struggled to grab his glass of water and began to attempt to swallow his medications. Resident #31 then began to take sips of water and struggled and coughed to get his medications down. Resident #31 stated after he swallowed his pills wow that was tough. Interview on 09/25/24 at 8:25 A.M. with LPN #503 confirmed she did not watch and ensure Resident #31 swallowed all his pills safely. She reported that she also did not ensure Resident #31 rinsed his mouth after administering his inhaler. Review of the undated facility policy titled Medication Administration revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care. It revealed all inhaled medications residents will rinse mouth after steroid inhaler. It also revealed that nurses must remain with the resident until the medication has been swallowed. This deficiency is an incidental finding identified during the complaint investigation.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #48, who had an order to self-medicate, kept his medications stored appropriately. This affected one resident (#48) who the facility identified as the only resident in the facility that self-medicated. The facility census was 92. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, hypertension, and schizophrenia. Review of the physician's order dated 06/12/24 revealed that Resident #48 may keep his medications at his bedside and administer his medications to himself. Review of the self-administration of medication assessment dated [DATE] revealed that Resident #48 demonstrated secure storage for medication in his room. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #38 had intact cognition. Resident #48 required minimal assistance with all activities of daily living. Review of the care plan dated 09/18/24 revealed Resident #48 prefers to administer his own medication. Interventions included assist Resident #48 in securing his medication after administration, and to educate him on proper storage of the medications to prevent unauthorized access. Interview on 09/25/24 at 9:50 A.M. with Resident #48 revealed he had no concerns with his medications because he administered them to himself. He reported he gets his medications prefilled from a local pharmacy and he keeps them in his room and gives them to himself. Resident #48 reported he does not have a lock box for his medications because he does not need one. Observation during the interview revealed a cardboard box sitting in a paper bag next to his bed with Resident #48's information on it full of prefilled packets for administration. The outside of the box listed the medications inside and they included: Coreg 3.125 milligrams (mg) (medication to treat high blood pressure) Metformin 500 mg (medication to treat diabetes) Lisinopril 10 mg (medication to treat high blood pressure and heart failure) Prilosec 20 mg (medication to treat heartburn, a damaged esophagus, stomach ulcers, and gastroesophageal reflux disease) Lasix 40 mg (diuretic) Multivitamin tablets (supplement) Vitamin D3 5000 units (supplement) Colesevelam 625 mg (medication to treat high cholesterol and type two diabetes) Atorvastatin 10 mg (medication to treat high cholesterol and triglyceride levels) Jardiance 10 mg (medication to help lower blood sugar levels and treat type two diabetes) Interview on 09/25/24 at 11:20 A.M. with the Director of Nursing (DON) confirmed Resident #48's medications were not locked in storage. He reported Resident #48 was instructed to keep his medications in his drawer which did not have a lock. Interview on 09/25/24 at 11:50 A.M. with the Regional Nurse #504 confirmed Resident #48 did have his medications unlocked in his room because he removed the lock from his drawer. Review of the undated facility policy titled Resident Self-Administration of Medication revealed assessments will include addressing the following and documenting in the care plan to include storage of the medication. Review of the facility policy titled Storage of Medications, revised August 2020, revealed the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access. This deficiency is an incidental finding identified during the complaint investigation.

Based on interview, medical record review, and review of facility policy, the facility failed to ensure bathing was completed for Resident #55 and Resident #87 as scheduled. This affected two residents (Residents #55 and #87) of three residents reviewed for bathing. The facility census was 114. Findings include: 1. Review of the medical record for Resident #55 revealed an admitted [DATE] with diagnoses including primary hypertension, atrial fibrillation, type two diabetes mellitus, dysphagia, osteoarthritis, cerebral infarction affecting the left non-dominant side, and hemiplegia. Review of the care plan dated 02/25/24 revealed Resident #55 required assistance with activities of daily living (ADLs) related to pain, impaired mobility, weakness, and hemiplegia. Interventions included two staff for all shower transfers and one, sometimes two, staff to complete all the effort for bathing. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 06/07/24 revealed Resident #55 had intact cognition and impaired range of motion of the upper and lower extremities on one side. Further review of the MDS assessment revealed Resident #55 was dependent on others for bathing/showering. Review of the shower documentation revealed Resident #55 was bathed on 08/07/24, 08/14/24, 08/20/24, 08/21/24, and 09/03/24. Interview on 09/04/24 at 5:43 P.M. with State tested Nurse Aide (STNA) #329 revealed resident baths got missed by the STNAs because the bathing schedule was not always printed at the nurses' station and the information in the electronic record that should populate to the STNAs documentation tab was not always updated properly, so the STNAs never knew if a bath was missed unless the resident complained. Interview on 09/05/24 at 1:20 P.M. with Resident #55 revealed she was supposed to be bathed three times a week. Resident #55 further verbalized the facility did not adhere to the three times a week schedule a few months ago (dates unspecified), and recently Resident #55 went two weeks without any bathing at all. During the interview, Resident #55 said bathing resumed this week, but had not occurred for the two preceding weeks. Interview on 09/05/24 at 2:42 P.M. with STNA #372 revealed if a bath/shower was offered to a resident, it would be documented in the electronic medical record, whether the resident received the bath, refused the bathing task, or was not in the facility at the time the bath was scheduled. Interviews conducted on 09/05/24 between 5:40 P.M. and 6:05 P.M. with Nursing Staff Scheduler #395 confirmed Resident #55's shower schedule was every Monday, Wednesday, and Friday and there was no documentation of bathing between 08/21/24 and 09/03/24. Review of the undated policy titled Routine Resident Care revealed routine resident care was necessary to promote quality of life and dignity and included assistance with activities of daily living, such as bathing and dressing. The policy further revealed the facility was to promote resident-centered care and honor resident lifestyle preferences while attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs of each resident. 2. Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses including unspecified fracture of the lumbar vertebrae, low back pain, essential (primary) hypertension, chronic obstructive pulmonary disease (COPD), heart failure, type two diabetes mellitus, liver disease, osteoarthritis, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment completed 07/22/24 revealed Resident #87 had intact cognition and was dependent for bathing. Review of the care plan dated 04/16/24 revealed Resident #87 required assistance with activities of daily living (ADLs) related to functional deficits and pain. Interventions included one helper to perform all the bathing effort for Resident #87. Review of the shower documentation revealed Resident #87 refused a bath or shower on 08/03/24, received a bed bath on 08/14/24, 08/17/24, 08/21/24, 08/28/24, 08/31/24, and documentation the bath or shower was Not Applicable on 09/04/24. There was no documentation a bath or shower was offered between 08/03/24 and 08/14/24 or between 08/21/24 and 08/28/24. Interview on 09/04/24 at 5:35 P.M. with Medication Aide #351 confirmed there is a shower schedule at the nurses' station and Resident #87 gets showered during the afternoon shift (3:00 P.M. to 11:00 P.M.), but the STNAs were preparing to transfer Resident #87 to a different unit during that shift and she was uncertain about his shower schedule for that evening. Interview on 09/04/24 at 5:43 P.M. with State tested Nurse Aide (STNA) #329 confirmed uncertainty as to whether Resident #87 was scheduled to be bathed on this date, and that if he was, it would not be done on that unit because they were getting ready to move him to another unit. STNA #329 further revealed resident baths get missed by the STNAs because the bathing schedule is not always printed at the nurses' station and the information in the electronic record that should populate to the STNAs documentation tab is not always updated properly, so the STNAs never know if a bath is missed unless the resident complains. Interview on 09/05/24 at 3:00 P.M. with Resident #87 confirmed he had not received a shower on 09/04/24 and he denied refusing a bath or shower on 09/04/24. During the interview, Resident #87 emphatically stated, as he pointed to a box of personal items on his nightstand, that if the facility could not take the time to unpack his personal items (packed in a box from the room change), then how did the surveyor suppose they found time to give him a shower last night. Interview on 09/05/24 at 6:05 P.M. with Nursing Staff Scheduler #395 confirmed Resident #87 was on the shower schedule every Wednesday and Saturday and the available documentation does not reflect Resident #87 received a bath/shower twice a week for the past 30 days, including 08/03/24, 08/10/24, 08/24/24, and 09/04/24. Review of the undated policy titled Routine Resident Care revealed routine resident care was necessary to promote quality of life and dignity and included assistance with activities of daily living, such as bathing and dressing. The policy further revealed the facility was to promote resident-centered care and honor resident lifestyle preferences while attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00156864.

Based on record review, observation, interview and facility policy review, the facility failed to ensure resident smoking materials were maintained by the facility staff. This affected four (Residents #15, #64, #77 and #346) of four residents reviewed for smoking. The facility census was 94. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including spinal cord disease, paraplegia (paralysis to his legs), chronic obstructive pulmonary disease and nicotine dependence. Review of the Smoking Acknowledgement form revised on 03/30/16, revealed smoking materials could present a safety hazard and the facility had adopted a safety policy and procedure to provide a safe smoking area. Resident #15 signed this form on 06/13/23. Review of the quarterly smoking assessment dated [DATE] revealed Resident #15 was an independent smoker. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition. Observation and interview on 02/13/24 at 4:26 P.M. revealed Resident #15 had smoking materials in his room which including dried tobacco and cigarette papers. Resident #15 verified he was able to keep the smoking materials in his room. He stated he also had a lighter in his room but did not smoke in the building. Interview on 02/14/24 at 9:55 A.M. with Director of Admissions #262 verified residents were provided with the Smoking Acknowledgement form and the facility smoking policy upon admission. She verified the smoking materials were to be maintained by the facility staff per the policy. Observation and interview on 02/14/24 at 10:24 A.M. revealed Resident #15 to have five large bags of dried tobacco and ten cartons of cigarettes in his room on the left side of his bed on his floor. There were two cigarette butts laying on the resident's floor. Director of Plant Maintenance #270 was by the doorway of his room and verified smoking materials in Resident #15's room. Review of the facility policy titled, Resident/Patient Smoking, dated 03/25/16, revealed smoking safety instructions for all smokers included that all smoking materials would be maintained by the facility staff and provided to the resident/patient on request. 2. Review of the medical record for Resident #64 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease and nicotine dependence. Review of the Smoking Acknowledgement form revised on 03/30/16, revealed smoking materials may present a safety hazard and the facility had adopted a safety policy and procedure to provide a safe smoking area. Resident #64 signed this form on 10/06/20. Review of the quarterly smoking assessment dated [DATE] revealed Resident #64 was an independent smoker. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #64 had impaired cognition. Observation and interview on 02/14/24 at 9:11 A.M. revealed Resident #64 had smoking materials including cigarettes on his wheelchair that he was pushing back to his room. He stated he had been outside smoking. Resident #64 stated he kept his cigarettes and lighter in his room. Interview on 02/14/24 at 9:55 A.M. with Director of Admissions #262 verified residents were provided with the Smoking Acknowledgement form and the facility smoking policy upon admission. She verified the smoking materials were to be maintained by the facility staff per the policy. Review of the facility policy titled, Resident/Patient Smoking, dated 03/25/16, revealed smoking safety instructions for all smokers included that all smoking materials would be maintained by the facility staff and provided to the resident/patient on request. 3. Review of the medical record for Resident #77 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease and nicotine dependence. Review of the Smoking Acknowledgement form revised on 10/17/19, revealed smoking materials may present a safety hazard and the facility had adopted a safety policy and procedure to provide a safe smoking area. Residents were not to keep or store their smoking materials themselves and they had to be given to staff to be placed in a locked secured area. Resident #77 signed this form on 01/19/24. Review of the admission smoking assessment dated [DATE] revealed Resident #77 was an independent smoker. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had impaired cognition. Interview on 02/14/24 at 9:55 A.M. with Director of Admissions #262 verified residents were provided with the Smoking Acknowledgement form and the facility smoking policy upon admission. She verified the smoking materials were to be maintained by the facility staff per the policy. Interview on 02/14/24 at 10:52 A.M. with Registered Nurse (RN) #318 revealed Resident #77 kept his own cigarettes and lighter in his room. He stated the only time the staff will manage the smoking materials is if a resident attempts to smoke in their room. Review of the facility policy titled, Resident/Patient Smoking, dated 03/25/16, revealed smoking safety instructions for all smokers included that all smoking materials would be maintained by the facility staff and provided to the resident/patient on request. 4. Review of the medical record for Resident #346 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease and nicotine dependence. Review of the Smoking Acknowledgement form revised on 10/17/19, revealed smoking materials may present a safety hazard and the facility had adopted a safety policy and procedure to provide a safe smoking area. Residents were not to keep or store their smoking materials themselves and they had to be given to staff to be placed in a locked secured area. Resident #346 signed this form on 01/18/24. Review of the admission smoking assessment dated [DATE] revealed Resident #346 was an independent smoker. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #346 had intact cognition. Interview on 02/14/24 at 9:55 A.M. with Director of Admissions #262 verified residents were provided with the Smoking Acknowledgement form and the facility smoking policy upon admission. She verified the smoking materials were to be maintained by the facility staff per the policy. Interview on 02/14/24 at 10:49 A.M. with Medication Technician #237 verified Resident #346 kept her own cigarettes and lighter in her room. Interview on 02/14/24 at 10:52 A.M. with Registered Nurse (RN) #318 revealed residents kept their own cigarettes and lighters in their rooms. He stated the only time the staff will manage the smoking materials is if a resident attempts to smoke in their room. Review of the facility policy titled, Resident/Patient Smoking, dated 03/25/16, revealed smoking safety instructions for all smokers included that all smoking materials would be maintained by the facility staff and provided to the resident/patient on request.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, facility policy and procedure review and interview, the facility failed to meet the total nutritional needs of Resident #71, who received all nutrition/hydration via a percutaneous enteral gastronomy (peg) tube, to prevent a severe weight loss and abnormal sodium levels. The facility also failed to timely identify the weight loss and implement effective interventions to prevent additional weight loss for the resident. Actual harm occurred beginning on 04/02/23 when Resident #71, who was severely cognitively impaired, received nothing by mouth and received enteral feeding as her only source of nutrition/hydration was noted to have a 14.8-pound weight loss (from 03/21/23 209.4 pounds to 04/02/23 194.6 pounds) with no evidence the facility identified the weight loss or implemented effective interventions to prevent additional weight loss at that time. On 04/17/23 Resident #71 was noted to weigh 180.2 pounds which reflected a severe weight loss of 29.2 pounds/13.9 percent from 03/21/23 to 04/17/23. On 04/19/23 the resident's sodium level was noted to be critically high at 163 milliequivalents per liter (normal 135-148). The facility determined the weight loss and elevated sodium level were a result of the resident being administered an incorrect rate of enteral feeding. This affected one resident (#71) of seven residents reviewed for alternate means of nutrition and hydration. The facility identified five residents (#34, #58, #66, #67, and #71) who received enteral nutrition and hydration through a peg tube. The facility census was 87. Findings include: Review of the medical record for Resident #71 revealed an admitted [DATE] with diagnoses including cerebral infarction (stroke), cognitive communication deficit, aphasia (difficulty speaking), and dysphasia (difficulty swallowing). Review of the nutritional care plan, initiated on 12/29/22, revealed Resident #71 had a potential for altered nutrition status and nutrition related problems due to a therapeutic diet order, percutaneous endoscopic gastrostomy (peg) tube, need for enteral nutrition to meet estimated needs, obesity, history of weight loss, and weight refusals. The goals were for Resident #71 to maintain weight without significant weight loss, maintain/improve skin integrity, remain free of signs or symptoms of dehydration, be without weight loss, and not exhibit any signs or symptoms of aspiration through the next review. Interventions included dental referral as needed, observe for sign and symptoms of aspiration, obtain labs per medical providers order, obtain weekly weights if unplanned weight loss was identified, position resident properly for swallowing, and speech therapy and occupational therapy as needed. Further review of Resident #71's medical record revealed the resident was discharged to the hospital on 02/20/23 related to a stroke and returned to the facility on [DATE]. The physician orders for enteral feeding, ordered from 01/21/23 to 02/20/23 (hospitalization ) consisted of Glucerna 1.5 at 65 milliliters per hour (ml/hr) from 6:00 P.M. to 6:00 A.M., 45 ml/hr of water from 6:00 P.M. to 6:00 A.M., 200 ml bolus of Glucerna 1.5 with a 180 ml water flush twice a day in the A.M. and P.M. Review of the Medication Administration Record (MAR) for February 2023 revealed Resident #71 had no gastric residuals and all enteral feeding was delivered to Resident #71 as ordered. Review of Resident #71's weights dated 01/04/23 208 pounds (lbs), 02/08/23 210 lbs, 03/01/23 210 lbs revealed weights were stable plus or minus two lbs. Review of the physician orders upon readmission from the hospital on 02/28/23 revealed an enteral tube feeding order of Glucerna (the order did not specify if the Glucerna should be 1.2 or 1.5 calorie per milliliter) to run continuously at 45 milliliters per hour (ml/hr) with 100 ml (water) flush every four hours. Review of the dietary progress notes dated 03/01/23 revealed the registered dietitian completed a readmission assessment of Resident #71 and recommended to resume the prior tube feeding and flushes which had been meeting 100% of Resident #71's needs prior to the hospitalization . Resident #71's power of attorney agreed with the recommendation. Resident #71's care plan was updated on 03/01/23 to include the resident required tube feeding since the resident did not eat by mouth (NPO) with a goal to maintain nutrition and hydration status. Interventions included provide tube feeding per medical provider orders, administer flushes per medical provider's order, administer medications via tube per orders, check for place and residuals, head of bed elevated 30 degrees or higher, notify medical provider and resident representative of unplanned weight changes, nutritional consult on admission, quarterly, and as needed, obtain labs per medical provider's order, provide insertion site care, per orders, provide oral care. Review of the physician order dated 03/06/23 revealed Resident #71 to receive Diabetisource 1.2 at 30 ml/hr with a water flush of 30 ml/hr from 7:00 P.M. to 9:00 A.M and bolus feedings of 250 ml of Diabetasource 1.2 with 120 ml water flush two times a day at 9:00 A.M. and 12:00 P.M. The order was initiated on 03/07/23. Review of the Medication Administration Record (MAR) for March 2023 revealed Resident #71 had no gastric residuals and all enteral feeding was delivered to Resident #71 as ordered. Review of the weight records for March and April 2023 revealed on 03/07/23 Resident #71's weight was 210.8 lbs, on 03/14/23 and 03/21/22 the resident's weight was documented to be 209.4 lbs and on 04/02/23 the resident's weight was noted to be 194.6 lbs. This weight reflected a 14.8-lbs weight loss. There was no re-weight obtained after 04/02/23 in relation to the 14.8 lbs loss. Review of the dietary progress notes dated 04/06/23 and 04/10/23 revealed a recommendation by the dietitian to obtain a reweight to verify accuracy of the weights (referring to the 04/02/23 weight of 194.6 lbs, as there were no other weights documented in the medical record through the dietitian's note on 04/10/23). Review of the physician progress notes dated 02/12/23, 03/02/23, and 04/09/23 and authored by Physician #378 revealed Resident #71 did not have any edema, was not being treated with diuretic medication and there was no reference to her weight of 194.6 lbs on 04/02/23. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #71 had severe cognitive impairment and was receiving an enteral tube feeding with water flushes through a PEG tube. This assessment included the feeding method provided 51% or more of the resident's calories and 501 cubic centimeter (cc) or more of fluids through the PEG tube. On 04/14/23 a new order was received for Diabetisource 1.2 at 40 ml/hr with the same water flush of 30 ml/hr from 9:00 P.M. to 7:00 A.M. The bolus feedings also remained as ordered on 03/06/23. On 04/17/23 the resident was noted to weigh 180.2 lbs. This was noted to be an unplanned, severe weight loss of 29.2 lbs/13.9 percent from 03/21/23 to 04/17/23 for the resident. On 04/19/23 a re-weight was obtained of 182.6 lbs which continued to reflect a severe weight loss of 26.8 lbs. or 12.7%. A nutritional assessment dated [DATE] and authored by Registered Dietitian (RD) #327 revealed Resident #71 had estimated caloric needs of 1500-1800 per day, 50 to 80 grams protein per day and 1500 ml to 1800 ml fluid per day. With the resident receiving 40 ml of nocturnal enteral feeding of Diabetisource 1.2 over 14 hours, 30 ml water flush over 14 hours, and 250 ml bolus of Diabetisource 1.2 with a 120-cc water flush two times a day, Resident #71 was receiving 1272 kcal, 63 grams of protein, 1524 cc from flushes and tube feeding. Per RD #327, the tube feeding, and flush rate was meeting 85% of the resident's low end of estimated caloric needs of 1500. (It was important to note the tube feeding was meeting 70% of the high end of the estimated daily calorie needs of 1800 calories per day which over time would cause a caloric deficit to support weight loss). RD #327 noted 100% of the low end of estimated protein and fluid needs were being met. (It was also important to note the water flushes were meeting 70% of the high end of the estimated daily fluids which over time could cause a hydration deficit in the body leading to dehydration). The note indicated Resident #71 had lost 6.5 percent between 03/01/23 and 04/02/23 for a significant weight loss. RD #327 recommended to increase Diabetisource to 70 ml for 14 hours which would provide 1176 calories, continue bolus as ordered 250 ml twice a day to provide 600 kcal/500 ml for a total of 1776 kcal, 84 g protein, and 1142 ml free water. RD #327 charted this would meet Resident #71's estimated needs. Review of Resident #71's physician's orders revealed Diabetisource 1.2 was increased to 70 ml/hr on 04/17/23. No changes were made to the Diabetasource 1.2 bolus twice a day and no changes were made to the (water) flushes. Review of laboratory testing for Resident #71, dated 04/19/23, revealed a critically high serum sodium level of 163 milliequivalents per liter (mEq/l) with the normal serum sodium level reference of 135 to 148 mEq/l. An elevated serum sodium level can be an indicator of underhydration. Hypertonic dehydration happens when you lose water from your body but don't lose an equal quantity of electrolytes, specifically sodium. You will have high sodium concentration in your blood and other body fluids. Review of a progress note, dated 04/19/23, revealed the facility had received a call from the lab that Resident #71's sodium level was 163. Nurse Practitioner (NP) #328 was notified with a new order to hold bolus feeds and flushes at this time and start tube feeding of Diabetisource 1.2 continuous at 75cc/hr with water flush at 150cc/hr for two days. Review of Resident #71's physician's orders revealed on 04/19/23 an order was written at 1:00 P.M. to hold Diabetisource 1.2 at 70ml/hr with 30 ml water flush from 7:00 P.M. to 9:00 A.M. and the Diabetisource 250 ml bolus with 120 cc water flush and start Diabetisource 1.2 continuous at 74 cc/hr (this order for the rate of 74cc/hr did not match the 75cc/hr order given by the NP as documented in the 04/19/23 progress note) with 150 ml water flushes every hour for two days. On 04/19/23 at 5:00 P.M. an order was written to decrease the water flush to 100 ml/hr for 24 hours. Review of Resident #71's labs revealed on 04/24/23 the sodium level had improved to 152 mEq but remained elevated. Review of physician's orders for Resident #71 revealed on 04/24/23 water flushes were changed to 100 ml/hr overnight from 7:00 P.M. to 9:00 A.M. Review of a 04/24/23 Significant Change Nutritional Assessment revealed RD #327 charted 04/24 Na H (sodium high) under the lab results section of the assessment, a weight of 182.9 pounds on 04/24, and that weight trends were difficult to assess at the time due to possible scale error. The assessment indicated the resident appeared well hydrated but did not give any specific physical characteristics of the resident to explain how this was assessed. RD #327 indicated the resident was tolerating her tube feeding and 100% of her nutrition and hydration needs were being met. Review of Resident #71's progress note dated 05/01/23 revealed a sodium level of 139 mEq had improved to within normal range. NP #326 gave a new order to decrease the water flush to 50 cc/hr from 7:00 P.M. to 9:00 A.M. Review of Resident #71's physician's orders revealed on 05/01/23, water flushes were decreased to 50 ml/hr from 7:00 P.M. to 9:00 A.M. On 07/11/23 at 11:42 A.M. an interview was conducted with RD #327 who verified Resident #71 had a severe, unplanned weight loss related to a data entry error for the tube feeding orders initiated on 03/07/23. RD #327 explained Resident #71's enteral tube feeding administration rate was incorrectly entered at 30 cc/hr on 03/07/23 when it should have been entered at a higher rate of 70cc/hr on 03/07/23. RD #327 verified on 04/14/23, the rate was increased to 40cc/hr. RD #327 explained Diabetisource 1.2 at 30cc/hr continuous and at 40cc/hr did not meet the full range of Resident #71's nutrition or hydrational needs. RD #327 was unaware the enteral order had been entered incorrectly until it was pointed out to her when Resident #71 was found to have lost a significant amount of weight on 04/17/23. RD #327 explained the tube feeding rate was then increased to Diabetisource at 70 cc/hr. RD #327 stated residents on tube feeding should be weighed weekly, however, Resident #71 had not been weighed weekly between 04/02/23 and 04/17/23. RD #327 stated she gave nursing a list of the residents who needed to be weighed weekly, but she never received the completed list back. RD #327 said if Resident #71 had been weighed weekly as she should have been, the error may have been caught sooner. RD #327 verified Resident #71 was not on a physician ordered weight loss plan and the severe weight loss was not a planned weight loss. Observation on 07/12/23 at 11:15 A.M. of Resident #71 revealed an elderly woman who was alert but disoriented to person, place and time. She was unable to answer simple yes/no questions and was dependent on staff to provide her nutrition and hydration needs via PEG tube. Interview on 07/12/23 at 12:04 P.M. with Nurse Practitioner (NP) #328 revealed NP #328 was informed by the facility that Resident #71 had a significant weight loss identified on 04/17/23 and a critically high sodium level of 163 on 04/19/23. NP #328 verified Resident #71's weight loss and hydration issues required changes to her fluid and enteral feedings. The NP revealed Resident #71 was less alert when the Diabetasource 1.2 was running at 30ml/hr and then 40ml/hr with a flush of 30cc/hr from 7:00 P.M. to 9:00 A.M. between 03/07/23 to 04/17/23. Review of the facility policy titled Resident Weight, revised 05/19/16, revealed resident's weight would be accurately obtained within 24 hours of admission, with a significant change or as ordered by the physician. Weekly weights for four weeks would be obtained on new admissions and residents with unstable weights would be reviewed by the IDT (interdisciplinary team) to determine weekly or other frequency of weights. Residents on tube feedings would be weighted weekly unless otherwise ordered. A plus or minus five-pound weight change in one week would indicated the need for a reweight in 24 hours and notification to the physician, family and IDT is there was a plus or minus five pound confirmed change in weight. Weight loss concerns would be discussed at weekly clinical meetings. Review of the facility policy titled General Enteral Feeding Guideline, revised 08/12/16, revealed residents would be weighed weekly, water flushes would include the rate and interval, nutritional feeding would include the type, strength, amount and rate of the formula and feeding bolus or intermittent feeding would include the type, strength, amount and rate of the formula. The deficient practice was corrected on 04/19/23 when the facility implemented the following corrective actions: On 04/17/23 chart audits were completed on all resident with nutritional feeding. All residents had the correct orders, were receiving the correct amounts of formula, flushes and gastric residual and tube placement checks were signed off as completed. Also, charts were audited for timely assessments at a minimum of once per month by the dietitian and all of the resident audits were found to be completed appropriately. On 04/18/23 the DON provided education to RD #327 on enteral feeding orders and the policy and procedures for general enteral feeding and resident weights. On 04/19/23 the DON provided education to 32 nurses on the list of weekly weights and consistent technique of obtaining resident weights, timely completion of weights, scale types in the facility and accuracy of confirming tube feeding orders to include type and strength of the formula, rate of the formula and water flushes, caloric needs, mechanism of administration, and orders for residual checks and tube placement. On 04/19/23 the DON reviewed the policies and procedures for general enteral feeding guidelines and resident weights with the 32 nurses. Beginning on 04/24/23 the facility implemented a plan for weekly chart audits which continued through 05/22/23. All residents were found to have correct orders, correct amounts of enteral feeding formula, flushes and gastric residual checks. In addition, tube placement checks were signed off as completed. Also, charts were audited for timely assessments at a minimum of once per month by the dietitian and found to be complete. There were no further residents experiencing unplanned, significant weight loss related to incorrect data entry of the tube feeding orders from 04/17/23 through the date of this survey on 07/11/23. This deficiency represents non-compliance investigated under Complaint Number OH00144121.

Based on observation, record review, facility Self-Reported Incident (SRI) review, personnel file review, facility policy and procedure review and interview the facility failed to ensure incontinence care was provided in a manner to prevent an injury to Resident #5 and to ensure the care provided met the resident's total care needs. This affected one resident (#5) of three residents reviewed for incontinence care. Actual harm occurred on 09/26/22 when State tested Nursing Assistant (STNA) #9 provided rough care and forcefully pushed Resident #5 in bed while providing incontinence care resulting in the resident's buttocks splitting into an open wound. Prior to the injury occurring, Resident #5 had asked the STNA to stop, which she did not immediately. The resident reported increased pain to the area as a result of the incident. STNA #9 was subsequently terminated as a result of the incident. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a psychosocial well-being adjustment to new admission care plan, dated 05/12/22 revealed Resident #5 had anxiety, lack of acceptance to current condition and lack of motivation. Interventions included to explain all procedures and treatments and provide opportunities for resident and family to participate in care. Review of a nurse's note, dated 09/27/22 timed 3:30 P.M. and authored by Licensed Practical Nurse (LPN) #11, revealed Resident #5 notified this nurse of an incident that happened last night. The resident stated STNA #9 was really rough while performing care and rolled her hard that she almost rolled onto her stomach. The resident reported [STNA #9] pushed me so hard, she ripped my butt crack/tore skin. I told her to stop but she didn't. The note revealed this nurse and [STNA #20] checked the area where the resident stated hurt and an area was seen on her coccyx where her skin had split. The nurse informed LPN #14, LPN #13 and Assistant Director of Nursing (ADON) #16. The note indicated the resident would write statement. Review of the nurse's note, dated 09/27/22 timed 6:36 P.M. and authored by LPN #11, revealed this nurse wrote a statement related to the incident, gave it to ADON #16 and slid a copy in the Director of Nursing's (DON's) office. The note revealed the DON was notified of the incident and instructed staff to send STNA #9 home during the investigation. Review of Self-Reported Incident (SRI), tracking number 4 (dated 09/27/22) revealed an allegation of physical abuse involving Resident #5. The incident was noted to have occurred on 09/26/22 at 10:00 P.M. Resident #5 reported to LPN #11 and STNA #20 that STNA #9 had been rough with her while giving care. Resident #5 stated STNA #9 rolled her too far and too forcefully causing strain to her gluteal cleft. She also stated STNA #9 was rude and did not explain herself before or during care. The SRI revealed when Resident #5 complained, STNA #9 left the room and had another STNA come in to complete the resident's care. The facility concluded the allegation (of abuse) was unsubstantiated and evidence was inconclusive. However, abuse was not suspected. As a result of the incident, STNA #9 was terminated from employment at the facility due to disregard of resident rights and poor customer service. Review of a non-pressure skin grid assessment dated [DATE] and authored by LPN #14, the facility wound nurse, revealed Resident #5 had a new area on her inner buttocks which measured 1.8 centimeters (cm) in length by 0.1 cm width. The charge nurse notified this nurse to check resident and of incident. The area was not described as being open at that time and indicated the wound nurse practitioner (NP) would be asked to assess the area. Review of a skin/wound note, dated 09/29/22 and authored by NP #15, revealed Resident #5's chief complaint was wound evaluation for reddened area on coccyx. [CONDITION(S)] and scar tissue was noted to natal crease, with no openings or draining noted. The patient voiced concern of area on buttock during activities of daily living's (ADL), was evaluated by nursing staff and concerned of open area. Wound care nurse notified Healing Partners and the resident was evaluated today. Previously in April 2022 the resident had a Stage III wound (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) which had healed on 05/03/22 while residing at another skilled nursing facility. On evaluation today, scar tissue was present from previous wound with no openings and no drainage noted. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/30/22 revealed Resident #5 was cognitively intact, frequently incontinent of bowel and bladder, required extensive assistance from one person for bed mobility and rejected evaluation or care one to three days during the assessment period. Review of a skin/wound note, dated 10/04/22 and authored by NP #15 revealed Resident #5 had no [CONDITION(S)] and scar tissue noted to natal crease, no opening or drainage noted. The area was considered to be healed at this time. On 10/03/22 at 10:40 A.M. Resident #5 was observed in her room in bed. On 10/04/22 at 9:45 A.M. interview with the DON revealed the facility had submitted an SRI to the State Agency involving an incident with Resident #5 and STNA #9. During the interview, the DON reported this was the second SRI that STNA #9 had been involved in which was a red flag. On 10/04/022 at 10:00 A.M. and during a follow up interview at 4:15 P.M. interviews with Resident #5 were completed. During the interviews, the resident shared information related to the situation with STNA #9 and the provision of incontinence care. The resident revealed STNA #9 entered her room and said, hi, what do you need. Resident #5 replied, I need changed. The resident stated STNA #9 then unhooked her brief and she rolled herself onto her left side. The resident stated it was then that STNA #9 proceeded to push her buttocks one hand on each [expletive] cheek without explaining what she was going to do. Resident #5 revealed she was on her stomach/side with her [expletive] up. Resident #5 told STNA #9, ouch, don't touch me without speaking to me first. Resident #5 stated STNA #9 replied, well you're a little larger so I have to push a little harder to get you to roll. The resident revealed she continued to ask the STNA to stop and she finally did. The resident indicated STNA #9 didn't finish changing her and just walked out of the room. During the interview, Resident #5 revealed she was able to roll herself in bed. The resident indicated the STNA was very rough with her care, had hurt her and caused her to have a split on her buttocks (gluteal cleft) which was painful. On 10/04/22 at 10:25 A.M. during an interview with the DON, the DON played a voicemail from STNA #9 to Human Resources Director #7 from 09/27/22 at approximately 7:26 P.M. The voicemail included, Hi [HRD #7], this is [STNA #9] and I was at work this evening and the nurse from Providence [unit] told me that I was suspended and I told her I did report what went on with the resident in [Resident #5's room number] to the nurse and she [Resident #5] was delusional and saying things that I hadn't done .I didn't do anything. Interview with the DON at that time revealed Resident #5 was alert and oriented and not delusional. On 10/04/22 at 11:15 A.M. interview with LPN #11 revealed on 09/27/22 Resident #5 reported to her STNA #9 was really rough with her and that STNA #9 rolled her hard (in bed) to where she almost rolled on to her stomach. The resident had reported she told STNA #9 to stop because the STNA was pushing really hard. Resident #5 complained to LPN #11 her skin hurt and felt her skin/gluteal cleft was ripped. LPN #11 and STNA #20 viewed Resident #5's buttocks and there was a split in Resident #5's skin, approximately two inches in length appearing like a paper cut, above Resident #5's gluteal cleft. LPN #11 verified Resident #5 could assist in rolling herself. On 10/04/22 at 2:05 P.M. interview with LPN #14 revealed when LPN #11 notified her of Resident #5's concern involving STNA #9, LPN #14 observed Resident #5's buttocks and didn't find an open area. However, there was a pink line within the gluteal cleft. LPN #11 also verified Resident #5 was capable of rolling herself in bed. On 10/04/22 at 3:15 P.M. interview with the Administrator and DON verified STNA #9 demonstrated poor customer service when the STNA did not communicate with Resident #5 prior to providing care. On 10/05/22 at 6:15 A.M. Resident #5 was observed receiving incontinence care. The resident assisted the staff to turn in bed and was noted to be dependent on the staff (LPN #17 and LPN #19) for the actual incontinence care itself. Review of the personnel record for STNA #9 revealed a hire date of 07/22/22. An employee corrective action form dated 10/04/22 revealed STNA #9 was terminated due to performance/policy violation and failure to meet performance during 90-day probationary period. Review of the facility undated Perineal Care - Male & Female policy revealed perineal care would be care planned for each individual resident to meet his or her specific needs, choice and frequency. Preparation: Review the resident's care plan to assess for any special needs of the resident. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. For female residents: ask the resident to turn to her side with top leg slightly bent, if able. This deficiency substantiates Complaint Number OH 706.

Based on medical record review, review of hospital records, review of laboratory test results, review of the facility policy titled [MEDICATION(S)] Monitoring, review of the Prescriber's Digital Reference ( www.pdr.net) website and interviews with the facility staff, the facility failed to contact the physician or nurse practitioner regarding critical laboratory results and continued to administer an oral anticoagulant [MEDICATION(S)] (a blood thinning medication ) to Resident #30 who had Prothrombin Time (PT) and International Normalization Ratio ( INR) levels ( levels to monitor blood clotting time to prevent serious risk of bleeding ) at critical levels. This resulted in Immediate Jeopardy for Resident #30 when lab results for critical PT/INR levels were not monitored and Resident #30 continued to receive the same dose of [MEDICATION(S)] leading up to her hospitalization on [DATE]. The likelihood for serious harm or death occurred on [DATE] when Resident #30 continued to receive [MEDICATION(S)] despite lab results dated [DATE] indicating the PT and INR laboratory test for the resident returned with critical values (PT 48.2 seconds and INR 4.8 with an expected therapeutic range of PT 9.3 seconds to 12.2 seconds and [MEDICATION(S)] therapeutic INR range of 2.0 to 3.5) which were not reviewed with a physician or nurse practitioner. On [DATE] Resident #30 experienced a nosebleed and coughing up bloody sputum and was ordered STAT (immediate) lab work for PT/INR levels which were reported as PT greater than 90.0 and INR greater than 8.0 in the critical lab value range. The resident was sent to the hospital for evaluation and was treated with Vitamin K to reverse the bleeding effects of the [MEDICATION(S)]. This affected one resident (Resident #30) of three residents reviewed who received [MEDICATION(S)]. The facility census was 103. On [DATE] at 2:49 P.M., the Administrator, the Director of Nursing (DON) and the Regional Clinical Nurse Manager (RCNM) #202 were informed Immediate Jeopardy began on [DATE] when the facility received abnormally high PT/ INR results for Resident #30 who was prescribed [MEDICATION(S)] and the facility failed to consult with a physician or nurse practitioner for directions related to the [MEDICATION(S)] medication for the resident. The resident was also receiving aspirin, [MEDICATION(S)] (antibiotic), Budesonide (inhaled steroid) aerosols and [MEDICATION(S)] (heart rate medication) that had potential drug interactions with [MEDICATION(S)] and required further monitoring for bleeding. Licensed Practical Nurse (LPN) #304 failed to consult with a physician or nurse practitioner when the facility received the elevated PT/ INR results on [DATE] and the resident continued to receive previously ordered doses of [MEDICATION(S)] 5 milligrams (mg) until [DATE] at 9:00 A.M. when the resident complained of a nosebleed and coughing up red sputum to LPN #305. LPN #305 notified Physician #200; an immediate PT/ INR was obtained, and the resident was sent to the hospital with a critically high PT result of greater than 90.0 seconds and INR result of greater than 8.0. Resident #30 was then sent to the hospital for evaluation and treatment where PT/ INR results were greater than 120.0 seconds for PT and greater than 10.0 for INR. The hospital administered Vitamin K ([MEDICATION(S)] antagonist) that reduced the residents PT/ INR. The resident was then admitted to the hospital critical care unit. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective measures. · On [DATE] at 6:12 P.M. Physician #200 reviewed Resident #30's medications and medical history to assess if it was appropriate to change to another method of anticoagulation. Due to the medical history Resident #30 remained on [MEDICATION(S)] with weekly PT/INR, complete blood count (CBC), and comprehensive metabolic panel (CMP). · On [DATE] and [DATE] the DON and RCN #201 reviewed medical records for the five residents (Resident #30, Resident #27, Resident #63, Resident #98, and Resident #99) who were ordered [MEDICATION(S)]. The review included ensuring the residents medical records included orders for PT/INR; notifications of abnormal PT/INR results to the physician or nurse practitioner and resident care plans were corrected. No deficient practices were noted from the review. · On [DATE] between 12:00 P.M. and 12:40 P.M. the DON, Staff Development Coordinator (SDC) #204 and Registered Nurse (RN) #300 reviewed resident records and prescriber orders to verify the most recent INR was included in the Medication Administration Records (MARs) for residents ordered [MEDICATION(S)]. · On [DATE] at 1:13 P.M. the DON provided disciplinary action to LPN #304 for failure to notify the physician of the high INR on [DATE]. Education on PT/INR policy, procedures, and MD/Nurse Practitioner notification of any abnormal labs were reviewed with LPN #304 over the phone as part of the disciplinary action. In person discipline with LPN #304 will take place prior to her next scheduled shift on [DATE]. · On [DATE] at 1:30 P.M. RN #300 and SDC #204 placed [MEDICATION(S)] Flow sheets on orange paper (to stand out from the other sheets of paper) in binders on the medication carts for each resident receiving [MEDICATION(S)] therapy. · On [DATE] between 1:50 P.M. and 2:45 P.M., the DON, SDC #204, and RN #300 educated 29 out of 29 licensed nurses on medication administration, [MEDICATION(S)] therapy, updated [MEDICATION(S)] flow sheets, and [MEDICATION(S)] administration now required most recent INR to be documented in the electronic MAR. Methods of education included in person and via telephone in conjunction with emails and text messages with education attached. · On [DATE] at 8:40 P.M. Registered Pharmacist (RPh) #205 completed an independent review of five of five [MEDICATION(S)] orders and the most recent PT/INR for Resident #30, Resident #27, Resident #63, Resident #98, and Resident #99 who were ordered [MEDICATION(S)]. There was no deficient practice found from the review. · Beginning on [DATE] the DON, SDC #204, and RN #300 will educate new hire and agency nurses on [MEDICATION(S)] therapy procedures prior to administering medications. · Beginning on [DATE] the DON, SDC #204, and RN #300 will complete weekly audits for four (4) weeks. [MEDICATION(S)] audits will be ongoing by an external consultant company ASCPRO with discrepancies reported to DON and RCN #201. · Beginning on [DATE] the Executive Director or the DON will monitor compliance in monthly Quality Assessment/ Performance Improvement (QAPI) meeting for three (3) months then as needed for one year. · On [DATE] between 9:00 A.M. to 10:30 A.M., LPN #306 completed head to toe skin check on Resident #30, Resident #27, Resident #63, Resident #98, and Resident #99 who were ordered [MEDICATION(S)]. There were no concerns for bleeding or bruising on the assessments. · Starting on [DATE] the licensed nurses scheduled as charge nurses will continue monitoring residents receiving anticoagulant therapy for abnormal bleeding, IE: bleeding gums, rectal bleed, hematuria, [CONDITION(S)], black stool, bruising, etc. every shift per physician's orders and weekly skin checks on all residents. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for minimal harm that is not Immediate Jeopardy) as the facility remained in the process of implementing their corrective action plan. Findings include: Review of the medical records for Resident #30 revealed, on [DATE], the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had intact cognition. The resident was receiving antibiotics, insulin, antidepressants, and an anticoagulant. Review of plan of care dated [DATE] revealed Resident #30 was at risk for abnormal bleeding related to the administration of [MEDICATION(S)] and Aspirin with interventions to include monitor for signs and symptoms of bleeding and notify the medical provider, resident and resident representative as needed. Obtain laboratory testing per orders and notify the physician or nurse practitioner of abnormal results. PT/ INR as ordered. Review of laboratory test results for Resident #30 included: on [DATE] at 4:55 A.M. PT was 12.0 seconds (normal range of 9.8 to 12.2 seconds) and INR 1.1 (standard anticoagulant therapeutic range of 2.0 to 3.0 and aggressive anticoagulant therapeutic range of 2.5 to 3.5); On [DATE] at 5:35 A.M. PT/ INR was 13.2 seconds and 1.2; on [DATE] at 5:19 A.M. PT/ INR was 51.3 seconds and 5.1; On [DATE], PT/ INR was 48.2 seconds and 4.8 and, on [DATE], PT was greater than 90.0 seconds and INR greater than 8.0 Physician orders for February 2022 and [DATE] included PT/ INR laboratory testing weekly every Monday, monitor for abnormal bleeding every shift and notify prescriber for new antibiotic or steroid therapy; Aspirin, [MEDICATION(S)] (antibiotic) 1.25 grams intravenously every 24 hours; [MEDICATION(S)] (heart rate medication) 200 mg every morning, Budesonide (steroid) aerosol treatments and on [DATE] [MEDICATION(S)] 4 mg every night. On [DATE], the [MEDICATION(S)] was increased to 5 mg every night for low PT/ INR result; on [DATE] [MEDICATION(S)] was increased to 6 mg every night for low PT/ INR result; on [DATE], an order to hold [MEDICATION(S)] for two days then resume [MEDICATION(S)] 5mg for a high PT/ INR result; On [DATE] there were no orders or consultations to address PT/ INR levels for Resident #30. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) for February 2022 and [DATE] revealed [MEDICATION(S)] was documented administered as ordered. On [DATE], [DATE], [DATE], [DATE], and [DATE], [MEDICATION(S)] 5mg by mouth every night was documented as administered to Resident #30. Review of the [MEDICATION(S)] flow sheet from [DATE] to [DATE] revealed on [DATE] Registered Nurse (RN) #300 documented Resident #30's INR was 4.8, the resident was taking [MEDICATION(S)] 5 mg, Telehealth CNP #206 was called and directed same dose to be continued and the resident was not on any antibiotics. Review of the CNP #206 progress notes dated [DATE] at 2:29 A.M. for Resident #30 indicated CNP #206 was contacted by the facility to address the resident's [MEDICATION(S)] trough level of 23.8 from the [DATE] lab report. CNP #206 wrote in the note Resident #30 had an elevated [MEDICATION(S)] trough, the [MEDICATION(S)] dose was low for the resident's weight so the plan was to administer [MEDICATION(S)] as scheduled. There was no mention of the elevated PT/INR levels by CNP #206. Review of progress notes dated [DATE] at 2:45 A.M. LPN #304 documented a skilled note stating Resident #30's vital signs were on the MAR, she was having no pain, there were no issues or concerns at the time of the note. There was no documentation regarding the PT/INR levels. Review of progress notes dated [DATE] at 1:41 A.M. LPN #304 documented a skilled note stating Resident #30's vital signs were on the MAR, she was having no pain, there were no issues or concerns at the time of the note. There was no documentation regarding the PT/INR levels. Review of the progress notes dated [DATE] at 4:16 A.M., LPN #304 documented a STAT [MEDICATION(S)] trough level. Review of the progress notes dated [DATE] at 12:02 P.M. LPN #305 documented Physician #200 was in to see Resident #30 due to Resident #30 reporting to LPN #305 nose bleeds and coughing frothy red sputum. Physician #200 gave a new order for PT/ INR, complete blood count, chest X-ray, a weekly metabolic panel and to hold the [MEDICATION(S)] until the laboratory results were received from the lab. Review of the progress notes dated [DATE] at 3:06 P.M. LPN #305 documented critical PT/ INR levels were reported to Physician #200 with a new order to send Resident #30 to the emergency department at the hospital. Review of the progress notes on [DATE] at 3:17 P.M. LPN #305 documented the ambulance services arrived and transported Resident #30 to the hospital and a nurse-to-nurse report was given to the hospital. Review of a progress note dated [DATE] at 7:20 P.M. revealed a late entry note stating Resident #30 was admitted to the hospital with septic shock, pneumonia of left lung, and an elevated INR. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed Resident #30 was seen by Physician #200 at the facility for a complaint of 12-to-24-hour history of coughing up some blood and some nosebleed. Physician #200 noted findings of lungs with scattered rhonchi (gurgling sound), bilaterally, hemoptysis (blood in sputum) with epistaxis (nosebleed), on [MEDICATION(S)]. STAT (immediate) INR; If elevated, the resident will be asked to go to urgent care. Review of the facility laboratory test results dated [DATE] for Resident #30 revealed the resident prothrombin time (PT) was greater than 90.0 seconds and the international Normalization Ratio (INR) was greater than 8.0. Review of hospital records dated [DATE] revealed, on [DATE], Resident #30 was admitted to the hospital emergency room (ER) from the facility for INR greater than 12.0 and positive for nosebleed and coughing up bloody mucous. Resident #30 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . In the ER, the resident's PT was greater than 120.0 seconds and INR was greater than 10.0; Vitamin K was administered in the ER and PT/ INR were reduced to PT 28.0 seconds and INR 2.6. On [DATE], Resident #30 was admitted to the hospital for septic shock and pneumonia. Interview on [DATE] at 3:00 P.M. with Resident #30 revealed she was sent to the hospital on [DATE] for elevated [MEDICATION(S)] levels, a bloody nose and coughing up bloody sputum. Resident #30 stated she started having the nosebleed and coughing up blood sometime during the night on [DATE]. Resident #30 stated she informed the nurse (Resident #30 could not remember the nurses name) on midnight shift about the bloody cough and nosebleed, but the nurse told her the air was dry in her room and the probable cause of the nosebleed. Resident #30 stated she then told the day shift nurse about the nosebleed and coughing up blood and Physician #200 assessed her sending her out to the hospital for the nosebleed and elevated [MEDICATION(S)] levels. Interview on [DATE] at 11:00 A.M. with LPN #305 revealed on [DATE] around 9:00 A.M. while passing medications, Resident #30 complained to her about a nosebleed and coughing up red frothy sputum since during the night. LPN #305 stated Resident #30 was not having any frank bleeding from her nose at the time, nor did the resident have bloody coughing for her, but the resident showed her a cup containing a scant amount of red fluid the resident claimed was bloody sputum. LPN #305 stated she obtained vital signs of Resident #30 which were within normal limits, and she contacted Physician #200, who was in the facility at the time. LPN #305 stated Physician #200 assessed the resident, ordered immediate PT/ INR and a chest X-ray. LPN #305 stated she later received a critical PT/ INR for Resident #30, so she contacted Physician #200 who ordered the resident to be sent to the hospital for evaluation. LPN #305 stated she contacted the ambulance service to transport the resident to the hospital and provided nurse-to-nurse report to the hospital. LPN #305 stated she was not aware of the results of the PT/ INR dated [DATE]. LPN #305 stated she was not aware of any issues or concerns with the laboratory test results for the PT/ INR prior to the resident's complaint of a nosebleed and coughing up blood. Interview on [DATE] at 12:21 P.M. with Physician #200 stated he did not believe he was consulted by any of the nurses at the facility between [DATE] and [DATE] concerning Resident #30's elevated PT/ INR results. Physician #200 stated there were other prescribers the nurses could have contacted about the resident's elevated PT/ INR results from [DATE] but he was not aware of the consults. Physician #200 stated Resident #30 had many co-morbidity factors that could have interfered with her [MEDICATION(S)] levels to include antibiotics and steroids as well as kidney disease, diabetes, and hypertension. Physician #200 stated on [DATE] he assessed Resident #30 at the facility and had the resident sent to the hospital related to her complaints of a nosebleed and coughing up blood in addition to a critical PT/ INR being received by Physician #200. Interview on [DATE] at 12:51 P.M. with CNP #201 revealed between [DATE] and [DATE], she was never consulted regarding elevated PT/ INR results received on [DATE]. CNP #201 stated she recalls being notified of an elevated PT/ INR on [DATE] for Resident #30 and she ordered the resident's [MEDICATION(S)] to be held for two days, then the dose resumed at the previous [MEDICATION(S)] 5 milligram (mg) dose daily. Interview on [DATE] at 7:20 A.M. with the DON stated on [DATE] around 12:00 P.M. a State tested Nurse Aide (STNA) reported to the DON and LPN #305 that Resident #30 was having a nosebleed. The DON stated they contacted Resident #30's physician who was in the facility and assessed the resident, ordered a STAT (immediate) PT/ INR to check the resident's clotting factors and ordered the resident to be sent to the hospital when a critical PT/ INR laboratory level was returned. The DON stated the resident was then admitted to the hospital and was readmitted to the facility on [DATE]. The DON stated on [DATE] Resident #30 had an ordered PT/ INR laboratory test with a [MEDICATION(S)] trough level that returned with a PT level of high at 48.2 seconds and an INR value high at 4.8 and the [MEDICATION(S)] trough level high at 23.8 micrograms/ deciliter (ug/ dl). The DON stated LPN #305 only consulted with the telehealth nurse practitioner concerning the [MEDICATION(S)] level because she had an ordered [MEDICATION(S)] dose to administer to Resident #30. The DON stated LPN #305 reported she had not looked at the included PT/ INR result because she did not have to administer [MEDICATION(S)] to Resident #30. The DON stated, between [DATE] and [DATE], no one consulted with a prescriber regarding the [DATE] elevated PT/ INR results for Resident #30 and they should have. Interview on [DATE] at 9:16 A.M. with RN #300 stated she never consulted with a physician or nurse practitioner concerning the [DATE] elevated PT/INR results and [MEDICATION(S)] results. RN #300 stated she remembered seeing the [DATE] elevated PT/ INR with the [MEDICATION(S)] trough level in Resident #30's medical records and a progress note from CNP #206, and she assumed LPN #304 had consulted with the telehealth about the PT/INR orders with the [MEDICATION(S)] consult. RN #300 stated she then documented the consultation in Resident #30's [MEDICATION(S)] flow sheet without verifying with LPN #305 or the telehealth CNP #206. RN #300 stated she did not contact LPN #304 to determine if she consulted with the telehealth nurse practitioner nor any physician concerning the elevated PT/ INR results from [DATE]. RN #300 stated she had not consulted with a physician or other nurses concerning Resident #30's elevated PT/ INR results from [DATE] blood draw. Interview on [DATE] at 2:33 P.M. with LPN #304 verified, on [DATE] at 1:00 P.M., she did not review the [DATE] PT/ INR laboratory results for Resident #30 with the telehealth nurse practitioner or any other prescribers. LPN #304 stated, at the time, she was focused on the [DATE] abnormal [MEDICATION(S)] blood levels because the [MEDICATION(S)] was scheduled to be administered during her shift and she did not have to administer the [MEDICATION(S)] to Resident #30. LPN #304 stated she should have added the abnormal PT/ INR to the telehealth consultation on [DATE], but she had completely overlooked the PT/ INR results on the page. LPN #304 stated she wrote a note on the laboratory results indicating Messaged telehealth, OK to give dose referred only to the [MEDICATION(S)] dose she was scheduled to administer to Resident #30. Review of the facility [MEDICATION(S)] Monitoring policy, review date [DATE], revealed the facility will have a process to review and communicate the PT/ INR laboratory test results to the provider for dose adjustments and monitoring. The prescriber will provide an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . All INR laboratory results are called to the prescriber in a timely manner when received to allow for dosage adjustments before the next scheduled dose is administered. Deviations outside of the therapeutic range will be immediately called to the prescriber before administering the drug and new orders will be obtained. Review of the Prescriber's digital Reference website (www.pdr.net) revealed patients prescribed [MEDICATION(S)] ([MEDICATION(S)]) who have renal impairment should be monitored more frequently to maintain therapeutic range. Patients with diabetes mellitus should be monitored for complications for tissue necrosis. Patients also taking [MEDICATION(S)] should be closely monitored of INR for the risk of increased prothrombin time (PT) and can cause serious or potentially fatal hemorrhagic (life threatening bleeding) complications. This deficiency substantiates the allegation in Complaint OH 385.

Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized restorative range of motion plan for Resident #94 to prevent a decline in range of motion and to prevent the development of hand contractures. Actual Harm occurred on 10/12/21 when Resident #94, who was admitted with no impairment in functional range of motion to his bilateral upper extremities developed contractures to both hands, increased pain with hand movement and the loss of function. Prior to the development of the contractures, the facility failed to develop a comprehensive and individualized plan of care for restorative nursing services, failed to consistently implement therapy recommended range of motion (ROM) services and failed to timely identify, report and implement new interventions for the resident to prevent the contractures and then adequately treat limitations in range of motion. This affected one resident (#94) of two residents reviewed for range of motion. Findings Include: Review of Resident #94's medical record revealed an admitted [DATE]. Resident #94 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A clinical admission evaluation, dated 02/05/21 indicated Resident #94 was able to move all extremities. There was no impairment in functional range of motion (ROM) of the upper or lower extremities. An Occupational Therapy (OT) evaluation, dated 02/06/21 indicated ROM of both upper extremities was within functional limits. An OT discharge summary, dated 03/04/21 indicated Resident #94 was referred to restorative nursing for a ROM program for both upper extremities. Record review revealed no restorative plan of care was developed or initiated following the resident's discharge from therapy. Active range of motion (AROM) was added to the electronic task bar to be to be provided by staff but did not indicate a frequency or what joints were to be included. An admission Minimum Data Set (MDS) 3.0 assessment, dated 02/11/21 indicated Resident #94 had no impairment in functional ROM in upper extremities but did have impairment of functional ROM in both lower extremities. Review of the monthly restorative AROM delivery records revealed the following: · March 2021 records revealed two days of refusals and one day with no documentation of AROM being offered/provided. · April 2021 records revealed four days of refusals and 13 days with no documentation of AROM being offered/provided. · May 2021 records revealed one day of refusal and 19 days with no documentation of ROM being offered/provided. · June 2021 records revealed 23 days with no documentation of AROM being offered/provided and one day of which staff documented ROM services were not applicable. · July 2021 records revealed two days of refusals, 11 days with no documentation of AROM being offered/provided and three days marked not applicable. · August 2021 records revealed nine days with no evidence of AROM being offered. · September 2021 records revealed 16 days with no evidence of AROM being offered. · October 2021 records revealed one refusal and 22 days with no evidence of AROM being offered. Review of a nurse practitioner progress note, dated 10/12/21 revealed Resident #94's hands had contractures. The degree of contracture was not indicated and no plan was documented to address the contractures at that time. In addition, there was no evidence the resident was referred to therapy for an evaluation of the contractures and no evidence the previous therapy recommended ROM program was evaluated for effectiveness. Continued review of the monthly restorative delivery revealed November 2021 records reflected 19 days with no evidence of AROM being offered. December 2021 records revealed 12 days with no evidence of ROM being offered. Resident #94 was in the hospital from 12/28/21 to 12/31/21 (not included in the 12 day count). A skin/wound note, dated 01/04/22 at 1:37 P.M. revealed Resident #94 had decreased ROM and contractures, including of the fingers of both hands. A therapy screen, dated 01/10/22 indicated Resident #94 had increased stiffness in his upper extremities and determined an OT evaluation was indicated. An OT evaluation, dated 01/10/22 indicated the evaluation was completed based on an OT screen for contractures of both hands. Resident #94 had limited functional use of his upper extremities. Resident #94 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Upper extremity muscle tone was hypertonic (stiff, difficult to move). Resident #94 had a decreased ability to grasp/release items and was at risk for skin breakdown of his palm. The evaluation indicated OT services were required to increase finger ROM, provide appropriate splints and to design, implement a restorative nursing program, and decrease painful condition of the upper extremities in order to enhance Resident #94's quality of life. An OT discharge summary dated 02/04/22 indicated recommendations for a right hand palm guard and passive ROM (PROM). On 02/07/22 at 9:25 A.M. Resident #94 was observed lying in bed with contractures of both hands. A palm protector was in place in the right hand. On 02/07/22 at 1:24 P.M. interview with Resident #94's guardian revealed Resident #94 did not have contractures prior to his admission to the facility. On 02/09/22 at 11:30 A.M. interview with Occupational Therapist (OTR) #1180 revealed therapy screened residents on a quarterly basis. It was during a screen on 01/10/22 Resident #94 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . OTR #1180 revealed Resident #94 had no functional use of his left hand now and use of his right hand varied. OTR #1180 revealed no one had previously reported a decline in ROM to Resident #94's hands or referred him to therapy for evaluation (prior to the screening done by therapy on 01/10/22). On 02/09/22 at 12:04 P.M. interview with Nursing Assistant (NA) #1090 revealed Resident #94 was totally dependent on staff for all care. NA #1090 revealed she had worked at the facility four months and Resident #94's hands had contractures the entire time. NA #1090 revealed she was unaware Resident #94 was supposed to receive ROM services. On 02/09/22 at 12:20 P.M. interview with State tested Nursing Assistant (STNA) #820 revealed when Resident #94 was admitted he had limitations in finger ROM of about 10 degrees. STNA #820 revealed she had provided ROM to Resident #94's hands but believed the contractures happened quickly within a few months time. STNA #820 stated she recognized the fingers were getting tighter and tighter until the resident had contractures. When asked if there had been a referral to therapy when the decline was noted STNA #820 offered no additional response. On 02/09/22 at 12:39 P.M. interview with Licensed Practical Nurse (LPN) #235 revealed Resident #94 had received restorative services off and on. During the interview, LPN #235 revealed ROM programs were supposed to be provided every day. On 02/09/22 at 1:33 P.M. interview with the Director of Nursing (DON) revealed she had been working at the facility for seven months and Resident #94 had contractures of his hands for at least that long. The DON verified restorative records did not reveal Resident #94 received ROM services consistently. On 02/09/22 at 1:57 P.M. interview with the DON revealed the facility had a lot of staff turnover and staff probably did not recognize the decline in ROM in order to refer Resident #94 to therapy for services sooner. The DON was unable to provide an explanation as to why the restorative program remained a program for active ROM instead of a change to passive ROM when staff started noting contractures. On 02/10/22 at 7:10 A.M. interview with Certified Nurse Practitioner (CNP) #1200 revealed she noticed Resident #94 exhibiting weakness in July 2021 and first identified the hand contractures in October 2021. CNP #1200 revealed Resident #94 was sickly when he was admitted and progressively worsened. When asked if she believed the contractures were unavoidable she stated not necessarily.

Based on interview and record review, the facility failed to prevent verbal abuse of one resident (Resident #72) by a State tested Nursing Assistant (STNA). Actual Harm occurred when an STNA threatened to turn off Resident #72's oxygen while she was asleep causing Resident #72 to become fearful. This affected one of 24 residents interviewed for abuse. The facility census was 94. Findings include: Resident #72 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/19/19, revealed Resident #72 was moderately cognitively impaired with no behaviors and required extensive assist of one for activities of daily living (ADL). Resident #72 experienced shortness of breath or trouble breathing when lying flat. Physician orders [REDACTED]. Interview on 03/27/19 at 9:58 A.M. with STNA #219 revealed she knocked on Resident #72's room to tell STNA #220 she was going on break on 02/28/19 at approximately 7:50 P.M., and STNA #219 reported STNA #220 gestured towards Resident #72 and said, I had to tell that one about herself. STNA #219 went on to explain STNA #220 was offended because Resident #72 told STNA #220 you people take too long to answer the call lights. STNA #220 assisted STNA #219 in pulling Resident #72 up in her bed. At that time, the resident told STNA #219 she needed to speak to the nurse. Interview on 03/27/19 at 11:00 A.M. with Resident #72 revealed STNA #220 answered the resident's call light and was ranting and raving. The resident stated the STNA was very rude, and the resident threatened to report her. STNA # 220 then told Resident #72 she would come into her room in the middle of the night and turn off her oxygen, so she would die and would not be able to report anyone. Shortly after, in the presence of STNA #219, STNA #220 threw Resident #72's call light out of her reach, under the roommate's bed. Resident #72 reported she could not sleep that night and still had difficulty sleeping. She was fearful STNA #220 would return to the facility and carry out her threat or get one of her friends working at the facility to take care of her. Resident #72 stated she still checks everyone coming into her room, fearful it may be STNA #220 or someone else coming to harm her. The resident stated she had not been offered psych services but would be willing to talk to the psychologist to try to get over her fear. Interview on 03/27/19 at 12:04 P.M. with the Director of Nursing (DON) revealed Resident #72 was comforted by staff after the incident but she and her roommate, Resident #5, were reluctant to discuss the matter with Licensed Social Worker (LSW) #203 on her first approach, but did so the second time the LSW approached them. The DON did not doubt the resident's story. Interview on 03/27/19 at 3:17 P.M. with Licensed Practical Nurse (LPN) #217, the nurse on duty at the time of the event, revealed Resident #72 was very tearful and shaking when she entered the room after the incident with STNA #220. The resident was fearful STNA #220 would sneak back into the building to hurt her. The LPN assured her she would be safe, and STNA #220 would not be allowed back in the building. LPN #217 reported she stayed with Resident #72 for about 20 minutes trying to comfort her. She and the STNAs checked on the resident about every 15 minutes throughout the nights to provide reassurance and comfort. Review of the 03/27/19 psychologist note for Resident #72 revealed the resident's anxiety was moderate/severe. The resident discussed the incident with STNA # 220, and the psychologist felt she was coping with it. Review of the facility's investigation of facility reported incident (FRI) # 5 of 03/01/19, regarding the verbal abuse by STNA #220, revealed the statements from Resident #72, her roommate, Resident #5, STNA #219, LPN #217 and LSW #203 verified the verbal abuse by STNA #220 towards Resident #72. The facility did not substantiate the FRI but indicated abuse was suspected, and STNA #220 was terminated.

Based on record review, observation and interview, the facility failed to implement physician ordered skin safety interventions for one resident (Resident #98). This resulted in Actual Harm when Resident #98 sustained a skin laceration to the left leg requiring an emergent hospital visit with 43 sutures following a transfer into bed. This affected one of two residents reviewed for accidents. The facility census was 94. Findings included: Record review revealed Resident #98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#98 was prescribed a blood thinning medication, Eliquis 2.5 milligrams (mg) twice a day. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/28/18, indicated Resident #98 had intact cognition and required extensive assistance of two staff for bed mobility, transfer, dressing, toileting, and hygiene. Review of the Plan of Care, with a date initiated of 09/07/18, identified the resident had poor skin integrity and the listed interventions included lamb's wool to wheelchair arms and legs, protective sleeves to the arms, compression bandages for her legs, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. On 09/16/18, the intervention was added to the plan of care to include lamb's wool to the left side of the bed frame. The lamb's wool interventions were written as physician orders [REDACTED]. Record review of a facility Occurrence Report, dated 02/27/19, revealed at approximately 7:05 P.M. State tested Nurse Aide (STNA) #207 and STNA #208 were transferring Resident #98 from her wheelchair to her bed. Resident #98 sustained a laceration to the left leg measuring 11.5 CM length by 5.0 CM width. She was sent to the hospital emergency department and required 43 sutures to the left leg and was prescribed antibiotic oral and topical treatment. STNAs #207 and #208 wrote statements detailing after transferring Resident #98 into her bed they noticed her left leg was bleeding through the bandage and notified the nurse on duty, Registered Nurse (RN) #205. Review of a progress note dated 02/27/19 at 10:01 P.M., authored by RN #205 revealed RN #205 went into Resident #98's room and identified the resident's left leg had an 11.5 CM length by 5.0 CM width area with exposed adipose tissue, bleeding with the skin flapped over. RN #205 wrote she attempted to clean it and the resident was complaining of pain so she pulled the skin into place and put a dressing on it. RN #205 wrote the injury occurred while she was being transferred into bed by two STNAs. Record review of the facility document titled Skin Grid Non Pressure V 5, dated 02/27/19, and authored by the Director of Nursing (DON), revealed that on 02/27/19 Resident #98 acquired a left lower front leg laceration measuring 11.0 CM length by 5.0 CM width by 0.0 depth. The wound was described as having no skin loss, red moist grainy color, a moderate amount of blood tinged exudate and no odor or pain. The form indicated that the entire left side of the bed frame was padded after the laceration as a new intervention. An interview was conducted on 03/25/19 at 4:55 P.M. with STNA #207 who indicated that during a stand pivot transfer with STNA #208 of Resident #98 on 02/27/19, Resident #98 was difficult to stand due to her weakness. STNA #208 said she was not sure exactly how the injury happened but she noticed her leg was bleeding when they put her into her bed after transferring her from her wheelchair. Interview was conducted on 03/25/19 at 5:55 P.M. with Resident #98's daughter who revealed that she requested a meeting be held with the staff approximately two weeks prior to the incident because she was losing faith that the facility staff would take proper care of her mother. The daughter explained that she felt her mother's leg injuries did not have to happen, and the staff was not moving her in a safe manner. Interview was conducted on 03/26/19 at 9:58 A.M. with the DON who stated she came into the facility minutes after the injury occurred on 02/27/19 and had the staff demonstrate to her how they transferred her. The DON explained that the STNA faced her feet towards the head of the bed so her left leg would have been next to the bed frame and the left side of the bed. The DON said that when she inspected Resident #98's bed frame there was lamb's wool on only the bottom half of the left side bed frame and she found blood on the metal bed frame and on the plastic hinge cover on same side of the bed. The DON said that she came to the reasonable conclusion that she injured her leg on the bed frame and/ or the plastic hinge cover. The DON had Maintenance Director (MD) #204 add more lamb's wool across the entire left side of the bed frame. Observation was conducted on 03/26/19 at 10:02 A.M. with the DON of Resident #98's bed. The entire left side of the metal bed frame was covered in lamb's wool yet the plastic hinge cover that the DON identified as an area with blood during the investigation remained without lamb's wool over it. The DON stated she did not think the plastic hinge cover needed to be covered in lamb's wool just the metal bed frame. Resident #98 was sitting in her room in her wheelchair with her foot rests and arm rests padded in lamb's wool, protective arm covers in place and compression bandages on both legs. Interview was conducted on 03/26/19 at 1:11 P.M. with Physical Therapist (PT) #210 who explained that Resident #98 at the time of her injuries was able to be transferred by two staff who would stand her up and pivot her from wheelchair to bed. PT#210 explained that she was discharged from therapy on 02/20/19 since Hospice was taking over her care, and on 03/04/19 her transfer status changed to a mechanical lift transfer due to weakness. Interview was conducted on 03/27/19 at 9:22 A.M. with MD #204 who stated that he inspected Resident #98's bed after her accident on 02/27/19 and found that only the bottom one foot portion of the left side of the bed frame had lamb's wool padding on it, so he added an additional three to four feet of lamb's wool to cover the entire left side of the metal bed frame. MD #204 verified he did not cover the plastic hinge cover on the left side of the bed frame. Observation was conducted on 03/27/19 at 10:41 A.M. of STNA #211 and STNA #212 performing a mechanical lift transfer of Resident #98 in her room. The STNAs lifted her out of her wheelchair using the lift and carefully placed her into her bed. Resident #98 appeared calm and said she felt safe during the transfer. She was wearing protective sleeves on both arms and compression bandages on both legs without signs of bleeding. Her wheelchair did not have lamb's wool on the right arm rest. STNA #211 verified the wheelchair did not have lamb's wool on the right arm rest. STNA #211 explained that she did not see it on the right arm rest the day before either but thought someone would have taken care of it by now. The left side of the metal bed frame was covered in lamb's wool up to the plastic hinge cover which was not covered in the protective wool.

Based on observation, record review and interview the facility failed to provide appropriate staff assistance for one resident (Resident #57) during a mechanical (Hoyer) lift transfer resulting in a fall. Actual harm occurred when Resident #57 fell to the floor during a Hoyer transfer by one state tested nursing assistant, (STNA). Resident #57 complained of increased pain rated a ten on a scale of one to ten, was transferred to the hospital and diagnosed with [REDACTED]. This affected one resident of three residents reviewed for falls. Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #57 had no memory or cognitive impairment and was completely dependent on staff for transfers. Review of Resident #57's current plan of care indicated the resident required extensive assistance of two staff to reposition in bed and to transfer using a mechanical lift. Review of the 02/09/18 pain assessment revealed Resident #57 had a pain severity of four out of 10 with 10 being the worst pain. Record review revealed Resident #57 fell to the floor during a Hoyer lift transfer on 05/02/18 and was sent to the hospital due to complaining of severe pain (level of pain 10 out of 10 on the pain scale) after the fall. The hospital records indicated that as a result of the fall Resident #57 sustained fractures to the eleventh and twelfth [MEDICATION NAME] vertebrae of his spine. A review of the facility fall investigation from the 05/02/18 incident revealed STNA #40 began a Hoyer lift transfer of Resident #57 without the assistance of a second STNA and the Hoyer lift tipped over causing Resident #57 to fall to the floor. Review of a witness statement dated 05/02/18 by STNA #40 revealed the STNA put Resident #57 into the mechanical lift herself and as she pulled the lift out it tipped, dropping Resident #57 to the floor. Observation on 05/24/18 at 10:00 A.M. revealed Resident #57 was lying in his bed. Resident #57 was unable to turn his head from side to side while engaging in conversation. He could only move his eyes from side to side to try to visually connect without grimacing in pain. Interview on 05/24/18 at 10:00 A.M. with Resident #57 revealed on 05/02/18 STNA #40 started a Hoyer lift transfer on him by herself. Resident #57 stated STNA #40 had him hanging up in the air over the shower chair to get his weight and as she turned him the Hoyer lift tipped over and he was dropped onto the floor. Resident #57 stated he was in severe pain, rating his pain a 10 out of 10 on the pain scale. Resident #57 said he was sent out to the hospital for an evaluation and told at the hospital that he had spinal fractures at [MEDICATION NAME] vertebrae #11 and #12. Resident #57 explained that he had been able to move himself around the facility in his motorized chair and take showers before the fall but was now unable to do either of those things. Resident #57 said that he will be re-evaluated by the orthopedic surgeon in six weeks and may need surgery if the fractures do not heal. Resident #57 stated he now required oxygen therapy and could not sit upright in a chair due to the injury. He has been bedridden since the accident. Resident #57 indicated his pain has become worse since the accident and it hurts him to even attempt to turn his head from side to side. Interview on 05/24/18 at 10:14 A.M. with the administrator verified Resident #57 had a fall from the Hoyer lift on 05/02/18 that resulted in spinal fractures. The administrator verified STNA #40 had attempted a Hoyer transfer without the assistance of a second staff member. Interview on 05/24/18 at 10:45 A.M. with the director of nursing (DON) revealed Resident #57 was not permitted to sit upright in a chair due to the type of spinal fractures he sustained so he chooses to stay in bed. The DON verified the resident's quality of life had declined and his pain had increased as a result of the fall. Review of the facility policy titled, Mechanical Lifts Transfer, dated 06/05/14 revealed two employees were to be perform the transfers for safety and support during a mechanical lift transfer. This deficiency substantiates Complaint Number OH 119 and Complaint Number OH 046.

Based on review of facility self-reported incidents (SRI), staff interview, resident interview and review of the facility's Abuse policy and procedure, the facility failed to prevent staff to resident physical abuse. Actual harm occurred for one resident (Resident #48) when State tested Nurse Aide (STNA) #10 held a pillow over the resident's face and hit her hand resulting in Immeduate Jeopardy. This deficient practice affected one (Residents #48) of three residents reviewed for abuse. The facility census was 94. On 04/08/16 at 4:20 P.M., the Director of Nursing (DON) and Regional Registered Nurse (RN) #21, were notified that Immediate Jeopardy began on 03/05/16 (unknown time) when STNA #10, STNA #11 and STNA#12 transferred Resident #48 into bed. After the resident was in bed, STNA #10 began to change the resident with STNA #11 and STNA #12 in the room. Resident #48 became resistive and combative with care and called STNA #10 a black (expletive.) STNA #10 then hit Resident #48 with a pillow, put the pillow over Resident #48 ' s face and held it there for a few seconds. Resident #48 grabbed STNA #10 ' s hand and STNA #10 hit Resident #48 on the hand. STNA #11 then told STNA #10 to stop. STNA #12 and STNA #10 left the room. Neither STNAs #11 or #12 reported the incident of physical abuse to a supervisor. The Immediate Jeopardy was removed on 04/02/16 when the facility implemented the following interventions: · On 04/02/16 at 11:10 A.M., STNA #12 completed a written statement and was suspended by the Administrator pending an investigation. · On 04/02/16 at 11:45 A.M., STNA #11 (who was already terminated on 03/09/16 related to use of a cell phone during work hours) was contacted by phone for a statement. · On 04/02/16 at 1:15 P.M., STNA #10 was contacted by the Administrator by phone, a statement was obtained and STNA #10 was suspended pending investigation. STNA #10 never returned to the facility. · On 04/02/16 (no time listed) skin checks were performed by the wound nurse, Licensed Practical Nurse (LPN) #22, for Resident #48 and Resident #60 (additional cognitively impaired resident). No suspicious injuries were found. · On 04/02/16 (no time listed) Human Resource Manager (HRM) #20 interviewed 31 alert and oriented residents (Resident #45, #64, #57, #15, #87, #58, #65, #76, #95, #83, #96, #17, #97, #34, #3, #56, #29, #13, #98, #77, #21, #50, #23, #11, #42, #46, #73, #88, #18, #43 and #1) and asked if they have ever been abused. No issues of abuse were identified. · On 04/02/16 from 11:30 A.M. to 04/03/16 at 12:00 A.M., all 133 employees, including department heads, nurses, STNAs, dietary, housekeeping and therapy received education related to reporting allegations of abuse and review of the facility abuse policy by the Administrator and DON. · On 04/06/16 (no time) questionnaires were filled out by 44 staff, including all disciplines and reviewed by the DON. The questions included; naming three types of abuse, what to do if abuse was witnessed, who to report to and what to do if a resident asked to make a purchase for them. No concerns were related to staff lack of understanding of the abuse policy. · On 04/12/16 at 11:00 A.M. interview with RN #21 revealed a plan for continued auditing related to abuse. Audits will be completed by each department head on three random residents per week for four weeks, then weekly for four weeks and then monthly on an ongoing basis. · On 04/12/16 from 6:45 A.M. to 6:52 A.M., interview with three staff including RN #40 and STNAs #18 and #19 revealed they worked the night shift. RN #40 was the night shift supervisor. All three employees indicated they received education related to the prevention of abuse at least annually and more recently had either attended a mandatory in-service or had been contacted and provided the education by phone. All three employees were knowledgeable of the policy and procedure for abuse and reporting of abuse. Although the Immediate Jeopardy was removed on 04/02/16, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility had not yet completed auditing processes. Findings include: Review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #48 received Hospice services. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment, was confused at times but had clear speech and was able to make simple needs known. Resident #48 was totally dependent upon the assistance of one to two persons for all activities of daily living. Review of an SRI and abuse investigative documentation dated 03/05/16 revealed on the day shift (no specific time) STNA #10 physically abused Resident #48. During care, the resident was uncooperative and STNA #10 was observed hitting Resident #48 with a pillow, putting the pillow over her face and holding it there for a few seconds and hitting the resident on the hand when the resident tried to push the pillow away. The abuse was witnessed by STNA #11 and STNA#12, who were both in the room at the time the abuse occurred. The abuse was never reported by STNA #10, STNA #11 or STNA #12. The SRI revealed on 04/06/16, STNA #14 told HRM #20 she overheard other employees (not identified) talking about the incident. The SRI indicated based on investigation the allegation of staff to resident physical abuse was substantiated by the Administrator. The SRI revealed on 04/05/16 (no time) STNA #10 was contacted by the Administrator and terminated and on 04/07/16 a letter of termination was sent to STNA #12. On 04/08/16 at 4:00 P.M., interview with HRM #20 and RN #21 revealed on the morning of 04/02/16, at approximately 11:00 A.M., STNA #14 reported an allegation of abuse. HRM #20 explained STNA #14 overheard STNA #10 had put a pillow over Resident #48 ' s face and hit her on the hand. HRM #20 notified the Administrator immediately and the Administrator came to the facility. STNA #10 was not working that day. HRM #20 interviewed STNA #12 who was in the facility. STNA #12 admitted to witnessing the abuse and not reporting it. STNA #12 wrote a statement, was suspended pending investigation and escorted from the building. At 11:15 A.M. HRM #20 called STNA #13 at home. STNA #13 indicated she did not see the abuse occur. On 04/02/16 at 11:45 A.M., HRM #20 interviewed STNA #11 by phone. STNA #11 had been terminated on 03/09/16 for using a cell phone while working on the floor. STNA #11 admitted she witnessed STNA #10 being rough with Resident #48 and hitting the resident with a pillow and on the hand. STNA #11 told STNA #10 to stop but did not report the abuse. HRM #20 indicated STNA #10 was interviewed by phone on 04/02/16 at approximately 1:15 P.M. and denied putting a pillow over Resident #48 ' s face, hitting the resident with the pillow or hitting the resident ' s hand. The Administrator informed STNA #10 she was suspended pending investigation. On 04/08/16 at 4:12 P.M., an interview by phone with STNA #11 verified she witnessed STNA #10 handle Resident #48 in a very rough manner, hit her with a pillow and then hit the resident on the hand. STNA #11 told STNA #10 to stop. STNA #11 did not report the abuse to the nurse, but told a coworker (STNA #13) what happened. STNA#11 did not remember for sure what day the abuse occurred but it was the last time she, STNA #10 and STNA#12 all worked together. Also, STNA #11 did not recall when she told STNA #13 about the abuse. STNA #11 said she received education on prevention of abuse but was too shocked, uncomfortable and scared at the time to report it. STNA #11 said she knew she should have reported it immediately. On 04/08/16 at 4:29 P.M., an interview by phone with STNA #12 verified she witnessed STNA #10 handling Resident #48 in a very rough manner, put a pillow over her head and then hit the resident on the hand. STNA #12 could not recall an exact date or time but said she had not worked with both STNA #10 and STNA #11 since. STNA #12 was uncomfortable reporting the abuse or talking to the Administrator. On 04/08/16 at 4:40 P.M., a phone interview with STNA #13 revealed STNA #11 told her STNA #10 put a pillow over Resident #48 ' s face. STNA #13 said she asked STNA #11 why she didn ' t report the abuse and STNA #11 indicated she did not observe the abuse, but just heard about it. On 04/08/16 at 5:00 P.M., Resident #48 was observed in her room, lying in bed. The resident appeared clean and well groomed. The resident ' s demeanor was calm and she smiled when spoken to but did not respond verbally when asked her name. On 04/11/16 from 4:00 P.M. to 4:40 P.M., interviews were conducted with five employees from the day and afternoon shifts. Interviews with STNAs #15, #16 and #17 and two nursing supervisors, LPNs # 31 and #32, revealed they were knowledgeable of prevention of abuse and the abuse policy. The staff revealed on 04/02/16 they either attended a mandatory in-service or had been contacted at home for a verbal in-service on the abuse policy and reporting abuse. On 04/11/16 at 5:00 P.M., interview with the DON revealed all staff received education regarding the abuse policy during orientation. There was an annual mandatory in-service, dedicated to prevention of abuse with review of the entire policy and actual presentation of possible abuse scenarios. Additionally, mandatory in-services, for all staff, were held the first Friday of each month during which customer relations issues were discussed and staff had the opportunity to ask questions. The DON indicated she had an open door policy for all staff, residents and family and made rounds multiple times on a daily basis. On 04/12/16 from 6:45 A.M. to 6:52 A.M., interview with three additional staff including RN #40 and STNAs #18 and #19 revealed they worked the night shift. RN #40 was the night shift supervisor. All three employees indicated they received education related to the prevention of abuse at least annually and more recently had either attended a mandatory in-service or had been contacted and provided the education by phone. On 04/12/16 at 8:00 A.M. interview with the DON and RN #21 verified the facility failed to prevent Resident #48 from physical abuse by STNA #10. Review of the facility Abuse, Neglect/ Misappropriation of Property Policy dated 05/13/09 revealed physical abuse included hitting, pinching, slapping and kicking. Alleged violations of abuse are to be reported immediately to the Administrator of the facility and other officials in accordance with state law.

Based on review of facility self-reported incidents (SRI), staff interview, resident interview and review of the facility's Abuse policy and procedure, the facility failed to immediately report and timely investigate observations of physical abuse as indicated in the facility's Abuse policy. Actual harm occurred when Resident #48 had a pillow held over her face and was hit in the hand by a staff member and the abuse was never reported. This resulted in Immediate Jeopardy for Resident #48 when State tested Nurse Aide (STNA) #11 and STNA #12 witnessed STNA #10 hold a pillow over the resident's face and hit her hand and did not report the abuse to a supervisor. The deficient practice affected one (Residents #48) of three residents reviewed for abuse. The facility census was 94. On 04/08/16 at 4:20 P.M., the Director of Nursing (DON) and Regional Registered Nurse (RN) #21, were notified that Immediate Jeopardy began on 03/05/16 (unknown time) when STNA #10, STNA #11 and STNA#12 transferred Resident #48 into bed. After the resident was in bed, STNA #10 began to change the resident with STNA #11 and STNA #12 in the room. Resident #48 became resistive and combative with care and called STNA #10 a black (expletive.) STNA #10 then hit Resident #48 with a pillow, put the pillow over Resident #48 ' s face and held it there for a few seconds. Resident #48 grabbed STNA #10 ' s hand and STNA #10 hit Resident #48 on the hand. STNA #11 then told STNA #10 to stop. STNA #12 and STNA #10 left the room. Neither STNAs #11 or #12 reported the incident of physical abuse to a supervisor. The Immediate Jeopardy was removed on 04/02/16 when the facility implemented the following interventions: · On 04/02/16 at 11:10 A.M., STNA #12 completed a written statement and was suspended by the Administrator pending an investigation. · On 04/02/16 at 11:45 A.M., STNA #11 (who was already terminated on 03/09/16 related to use of a cell phone during work hours) was contacted by phone for a statement. · On 04/02/16 at 1:15 P.M., STNA #10 was contacted by the Administrator by phone, a statement was obtained and STNA #10 was suspended pending investigation. STNA #10 never returned to the facility. · On 04/02/16 (no time listed) skin checks were performed by the wound nurse, Licensed Practical Nurse (LPN) #22, for Resident #48 and Resident #60 (additional cognitively impaired resident). No suspicious injuries were found. · On 04/02/16 (no time listed) Human Resource Manager (HRM) #20 interviewed 31 alert and oriented residents (Resident #45, #64, #57, #15, #87, #58, #65, #76, #95, #83, #96, #17, #97, #34, #3, #56, #29, #13, #98, #77, #21, #50, #23, #11, #42, #46, #73, #88, #18, #43 and #1) and asked if they have ever been abused. No issues of abuse were identified. · On 04/02/16 from 11:30 A.M. to 04/03/16 at 12:00 A.M., all 133 employees, including department heads, nurses, STNAs, dietary, housekeeping and therapy received education related to reporting allegations of abuse and review of the facility abuse policy by the Administrator and DON. · On 04/06/16 (no time) questionnaires were filled out by 44 staff, including all disciplines and reviewed by the DON. The questions included; naming three types of abuse, what to do if abuse was witnessed, who to report to and what to do if a resident asked to make a purchase for them. No concerns were related to staff lack of understanding of the abuse policy. · On 04/12/16 at 11:00 A.M. interview with RN #21 revealed a plan for continued auditing related to abuse. Audits will be completed by each department head on three random residents per week for four weeks, then weekly for four weeks and then monthly on an ongoing basis. · On 04/12/16 from 6:45 A.M. to 6:52 A.M., interview with three staff including RN #40 and STNAs #18 and #19 revealed they worked the night shift. RN #40 was the night shift supervisor. All three employees indicated they received education related to the prevention of abuse at least annually and more recently had either attended a mandatory in-service or had been contacted and provided the education by phone. All three employees were knowledgeable of the policy and procedure for abuse and reporting of abuse. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility had not yet completed auditing processes. Findings include: Review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #48 received Hospice services. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment, was confused at times but had clear speech and was able to make simple needs known. Resident #48 was totally dependent upon the assistance of one to two persons for all activities of daily living. Review of an SRI and abuse investigative documentation dated 03/05/16 revealed on the day shift (no specific time) STNA #10 physically abused Resident #48. During care, the resident was uncooperative and STNA #10 was observed hitting Resident #48 with a pillow, putting the pillow over her face and holding it there for a few seconds and hitting the resident on the hand when the resident tried to push the pillow away. The abuse was witnessed by STNA #11 and STNA#12, who were both in the room at the time the abuse occurred. The abuse was never reported by STNA #10, STNA #11 or STNA #12. The SRI revealed on 04/06/16, STNA #14 told HRM #20 she overheard other employees (not identified) talking about the incident. The SRI indicated based on investigation the allegation of staff to resident physical abuse was substantiated by the Administrator. The SRI revealed on 04/05/16 (no time) STNA #10 was contacted by the Administrator and terminated and on 04/07/16 a letter of termination was sent to STNA #12. On 04/08/16 at 4:00 P.M., interview with HRM #20 and RN #21 revealed on the morning of 04/02/16, at approximately 11:00 A.M., STNA #14 reported an allegation of abuse. HRM #20 explained STNA #14 overheard STNA #10 had put a pillow over Resident #48 ' s face and hit her on the hand. HRM #20 notified the Administrator immediately and the Administrator came to the facility. STNA #10 was not working that day. HRM #20 interviewed STNA #12 who was in the facility. STNA #12 admitted to witnessing the abuse and not reporting it. STNA #12 wrote a statement, was suspended pending investigation and escorted from the building. At 11:15 A.M. HRM #20 called STNA #13 at home. STNA #13 indicated she did not see the abuse occur. On 04/02/16 at 11:45 A.M., HRM #20 interviewed STNA #11 by phone. STNA #11 had been terminated on 03/09/16 for using a cell phone while working on the floor. STNA #11 admitted she witnessed STNA #10 being rough with Resident #48 and hitting the resident with a pillow and on the hand. STNA #11 told STNA #10 to stop but did not report the abuse. HRM #20 indicated STNA #10 was interviewed by phone on 04/02/16 at approximately 1:15 P.M. and denied putting a pillow over Resident #48 ' s face, hitting the resident with the pillow or hitting the resident ' s hand. The Administrator informed STNA #10 she was suspended pending investigation. On 04/08/16 at 4:12 P.M., an interview by phone with STNA #11 verified she witnessed STNA #10 handle Resident #48 in a very rough manner, hit her with a pillow and then hit the resident on the hand. STNA #11 told STNA #10 to stop. STNA #11 did not report the abuse to the nurse, but told a coworker (STNA #13) what happened. STNA#11 did not remember for sure what day the abuse occurred but it was the last time she, STNA #10 and STNA#12 all worked together. Also, STNA #11 did not recall when she told STNA #13 about the abuse. STNA #11 said she received education on prevention of abuse but was too shocked, uncomfortable and scared at the time to report it. STNA #11 said she knew she should have reported it immediately. On 04/08/16 at 4:29 P.M., an interview by phone with STNA #12 verified she witnessed STNA #10 handling Resident #48 in a very rough manner, put a pillow over her head and then hit the resident on the hand. STNA #12 could not recall an exact date or time but said she had not worked with both STNA #10 and STNA #11 since. STNA #12 was uncomfortable reporting the abuse or talking to the Administrator. On 04/08/16 at 4:40 P.M., a phone interview with STNA #13 revealed STNA #11 told her STNA #10 put a pillow over Resident #48 ' s face. STNA #13 said she asked STNA #11 why she didn ' t report the abuse and STNA #11 indicated she did not observe the abuse, but just heard about it. On 04/08/16 at 5:00 P.M., Resident #48 was observed in her room, lying in bed. The resident appeared clean and well groomed. The resident ' s demeanor was calm and she smiled when spoken to but did not respond verbally when asked her name. On 04/11/16 from 4:00 P.M. to 4:40 P.M., interviews were conducted with five employees from the day and afternoon shifts. Interviews with STNAs #15, #16 and #17 and two nursing supervisors, LPNs # 31 and #32, revealed they were knowledgeable of prevention of abuse and the abuse policy. The staff revealed on 04/02/16 they either attended a mandatory in-service or had been contacted at home for a verbal in-service on the abuse policy and reporting abuse. On 04/11/16 at 5:00 P.M., interview with the DON revealed all staff received education regarding the abuse policy during orientation. There was an annual mandatory in-service, dedicated to prevention of abuse with review of the entire policy and actual presentation of possible abuse scenarios. Additionally, mandatory in-services, for all staff, were held the first Friday of each month during which customer relations issues were discussed and staff had the opportunity to ask questions. The DON indicated she had an open door policy for all staff, residents and family and made rounds multiple times on a daily basis. On 04/12/16 from 6:45 A.M. to 6:52 A.M., interview with three additional staff including RN #40 and STNAs #18 and #19 revealed they worked the night shift. RN #40 was the night shift supervisor. All three employees indicated they received education related to the prevention of abuse at least annually and more recently had either attended a mandatory in-service or had been contacted and provided the education by phone. On 04/12/16 at 8:00 A.M. interview with the DON and RN #21 verified the facility failed to prevent Resident #48 from physical abuse by STNA #10. Review of the facility Abuse, Neglect/ Misappropriation of Property Policy dated 05/13/09 revealed physical abuse included hitting, pinching, slapping and kicking. Alleged violations of abuse are to be reported immediately to the Administrator of the facility and other officials in accordance with state law.

Based on review of facility self-reported incidents (SRI), staff interview, resident interview and review of the facility's Abuse policy and procedure, the facility failed to ensure allegations of physical abuse were reported and investigated immediately. Actual harm occurred when Resident #48 had a pillow held over her face and was hit in the hand by a staff member and the abuse was never reported. This resulted in Immediate Jeopardy for Resident #48 when State tested Nurse Aide (STNA) #11 and #12 witnessed STNA #10 hold a pillow over the resident's face and hit her hand. STNA #11 and STNA #12 did not report the abuse to a supervisor. This affected one (Residents #48) of three residents reviewed for abuse. The facility census was 94. On 04/08/16 at 4:20 P.M., the Director of Nursing (DON) and Regional Registered Nurse (RN) #21, were notified that Immediate Jeopardy began on 03/05/16 (unknown time) when STNA #10, STNA #11 and STNA#12 transferred Resident #48 into bed. After the resident was in bed, STNA #10 began to change the resident with STNA #11 and STNA #12 in the room. Resident #48 became resistive and combative with care and called STNA #10 a black (expletive.) STNA #10 then hit Resident #48 with a pillow, put the pillow over Resident #48 ' s face and held it there for a few seconds. Resident #48 grabbed STNA #10 ' s hand and STNA #10 hit Resident #48 on the hand. STNA #11 then told STNA #10 to stop. STNA #12 and STNA #10 left the room. Neither STNAs #11 or #12 reported the incident of physical abuse to a supervisor. The Immediate Jeopardy was removed on 04/02/16 when the facility implemented the following interventions: · On 04/02/16 at 11:10 A.M., STNA #12 completed a written statement and was suspended by the Administrator pending an investigation. · On 04/02/16 at 11:45 A.M., STNA #11 (who was already terminated on 03/09/16 related to use of a cell phone during work hours) was contacted by phone for a statement. · On 04/02/16 at 1:15 P.M., STNA #10 was contacted by the Administrator by phone, a statement was obtained and STNA #10 was suspended pending investigation. STNA #10 never returned to the facility. · On 04/02/16 (no time listed) skin checks were performed by the wound nurse, Licensed Practical Nurse (LPN) #22, for Resident #48 and Resident #60 (additional cognitively impaired resident). No suspicious injuries were found. · On 04/02/16 (no time listed) Human Resource Manager (HRM) #20 interviewed 31 alert and oriented residents (Resident #45, #64, #57, #15, #87, #58, #65, #76, #95, #83, #96, #17, #97, #34, #3, #56, #29, #13, #98, #77, #21, #50, #23, #11, #42, #46, #73, #88, #18, #43 and #1) and asked if they have ever been abused. No issues of abuse were identified. · On 04/02/16 from 11:30 A.M. to 04/03/16 at 12:00 A.M., all 133 employees, including department heads, nurses, STNAs, dietary, housekeeping and therapy received education related to reporting allegations of abuse and review of the facility abuse policy by the Administrator and DON. · On 04/06/16 (no time) questionnaires were filled out by 44 staff, including all disciplines and reviewed by the DON. The questions included; naming three types of abuse, what to do if abuse was witnessed, who to report to and what to do if a resident asked to make a purchase for them. No concerns were related to staff lack of understanding of the abuse policy. · On 04/12/16 at 11:00 A.M. interview with RN #21 revealed a plan for continued auditing related to abuse. Audits will be completed by each department head on three random residents per week for four weeks, then weekly for four weeks and then monthly on an ongoing basis. · On 04/12/16 from 6:45 A.M. to 6:52 A.M., interview with three staff including RN #40 and STNAs #18 and #19 revealed they worked the night shift. RN #40 was the night shift supervisor. All three employees indicated they received education related to the prevention of abuse at least annually and more recently had either attended a mandatory in-service or had been contacted and provided the education by phone. All three employees were knowledgeable of the policy and procedure for abuse and reporting of abuse. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility had not yet completed auditing processes. Findings include: Review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #48 received Hospice services. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment, was confused at times but had clear speech and was able to make simple needs known. Resident #48 was totally dependent upon the assistance of one to two persons for all activities of daily living. Review of an SRI and abuse investigative documentation dated 03/05/16 revealed on the day shift (no specific time) STNA #10 physically abused Resident #48. During care, the resident was uncooperative and STNA #10 was observed hitting Resident #48 with a pillow, putting the pillow over her face and holding it there for a few seconds and hitting the resident on the hand when the resident tried to push the pillow away. The abuse was witnessed by STNA #11 and STNA#12, who were both in the room at the time the abuse occurred. The abuse was never reported by STNA #10, STNA #11 or STNA #12. The SRI revealed on 04/06/16, STNA #14 told HRM #20 she overheard other employees (not identified) talking about the incident. The SRI indicated based on investigation the allegation of staff to resident physical abuse was substantiated by the Administrator. The SRI revealed on 04/05/16 (no time) STNA #10 was contacted by the Administrator and terminated and on 04/07/16 a letter of termination was sent to STNA #12. On 04/08/16 at 4:00 P.M., interview with HRM #20 and RN #21 revealed on the morning of 04/02/16, at approximately 11:00 A.M., STNA #14 reported an allegation of abuse. HRM #20 explained STNA #14 overheard STNA #10 had put a pillow over Resident #48 ' s face and hit her on the hand. HRM #20 notified the Administrator immediately and the Administrator came to the facility. STNA #10 was not working that day. HRM #20 interviewed STNA #12 who was in the facility. STNA #12 admitted to witnessing the abuse and not reporting it. STNA #12 wrote a statement, was suspended pending investigation and escorted from the building. At 11:15 A.M. HRM #20 called STNA #13 at home. STNA #13 indicated she did not see the abuse occur. On 04/02/16 at 11:45 A.M., HRM #20 interviewed STNA #11 by phone. STNA #11 had been terminated on 03/09/16 for using a cell phone while working on the floor. STNA #11 admitted she witnessed STNA #10 being rough with Resident #48 and hitting the resident with a pillow and on the hand. STNA #11 told STNA #10 to stop but did not report the abuse. HRM #20 indicated STNA #10 was interviewed by phone on 04/02/16 at approximately 1:15 P.M. and denied putting a pillow over Resident #48 ' s face, hitting the resident with the pillow or hitting the resident ' s hand. The Administrator informed STNA #10 she was suspended pending investigation. On 04/08/16 at 4:12 P.M., an interview by phone with STNA #11 verified she witnessed STNA #10 handle Resident #48 in a very rough manner, hit her with a pillow and then hit the resident on the hand. STNA #11 told STNA #10 to stop. STNA #11 did not report the abuse to the nurse, but told a coworker (STNA #13) what happened. STNA#11 did not remember for sure what day the abuse occurred but it was the last time she, STNA #10 and STNA#12 all worked together. Also, STNA #11 did not recall when she told STNA #13 about the abuse. STNA #11 said she received education on prevention of abuse but was too shocked, uncomfortable and scared at the time to report it. STNA #11 said she knew she should have reported it immediately. On 04/08/16 at 4:29 P.M., an interview by phone with STNA #12 verified she witnessed STNA #10 handling Resident #48 in a very rough manner, put a pillow over her head and then hit the resident on the hand. STNA #12 could not recall an exact date or time but said she had not worked with both STNA #10 and STNA #11 since. STNA #12 was uncomfortable reporting the abuse or talking to the Administrator. On 04/08/16 at 4:40 P.M., a phone interview with STNA #13 revealed STNA #11 told her STNA #10 put a pillow over Resident #48 ' s face. STNA #13 said she asked STNA #11 why she didn ' t report the abuse and STNA #11 indicated she did not observe the abuse, but just heard about it. On 04/08/16 at 5:00 P.M., Resident #48 was observed in her room, lying in bed. The resident appeared clean and well groomed. The resident ' s demeanor was calm and she smiled when spoken to but did not respond verbally when asked her name. On 04/11/16 from 4:00 P.M. to 4:40 P.M., interviews were conducted with five employees from the day and afternoon shifts. Interviews with STNAs #15, #16 and #17 and two nursing supervisors, LPNs # 31 and #32, revealed they were knowledgeable of prevention of abuse and the abuse policy. The staff revealed on 04/02/16 they either attended a mandatory in-service or had been contacted at home for a verbal in-service on the abuse policy and reporting abuse. On 04/11/16 at 5:00 P.M., interview with the DON revealed all staff received education regarding the abuse policy during orientation. There was an annual mandatory in-service, dedicated to prevention of abuse with review of the entire policy and actual presentation of possible abuse scenarios. Additionally, mandatory in-services, for all staff, were held the first Friday of each month during which customer relations issues were discussed and staff had the opportunity to ask questions. The DON indicated she had an open door policy for all staff, residents and family and made rounds multiple times on a daily basis. On 04/12/16 from 6:45 A.M. to 6:52 A.M., interview with three additional staff including RN #40 and STNAs #18 and #19 revealed they worked the night shift. RN #40 was the night shift supervisor. All three employees indicated they received education related to the prevention of abuse at least annually and more recently had either attended a mandatory in-service or had been contacted and provided the education by phone. On 04/12/16 at 8:00 A.M. interview with the DON and RN #21 verified the facility failed to prevent Resident #48 from physical abuse by STNA #10. Review of the facility Abuse, Neglect/ Misappropriation of Property Policy dated 05/13/09 revealed physical abuse included hitting, pinching, slapping and kicking. Alleged violations of abuse are to be reported immediately to the Administrator of the facility and other officials in accordance with state law.

Based on observation, record review and interview the facility failed to ensure interventions were in place to prevent the development of pressure ulcers for Resident #200 and Resident #151. Harm occurred when Resident #200 and Resident #151 were found to have developed unstageable pressure ulcers. This affected two residents (Resident #200 and #151) of three residents reviewed for pressure ulcers. Findings include: 1. Record review revealed Resident #200 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Braden skin risk assessment dated [DATE] indicated the resident was at risk for development of pressure ulcers The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was admitted with one Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer. The assessment revealed the resident required extensive assistance from staff for activities of daily living care. The MDS 3.0 assessment dated [DATE] revealed the resident had two Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcers. The assessment revealed the resident required extensive assistance from staff for activities of daily living care. Review of the skin grid dated 09/07/15 revealed there was a Stage II discovered on the left heel which presented as an open blister area with a small amount serosanguineous red that measured 5 centimeters (cm) in length, 6 cm in width and 0.1 cm deep. A corresponding progress note dated 09/07/15 revealed the State tested nurse aide (STNA) notified the nurse of a wound at the left heel when the STNA removed the resident's sock. The left heel presented as an open blister (Stage II) on the left heel. On 09/08/15 a care plan was initiated regarding pressure ulcers and potential for pressure ulcers development related to disease process, immobility and incontinence. The progress note dated 09/12/15 revealed the resident's heel dressing was changed this shift and noted to have a large amount of green drainage, no odor was noted at the time. The progress note dated 09/14/15 revealed the physician had been notified there was increased drainage, green in color, no odor. The resident complained of some pain. The skin grid dated 09/14/15 revealed left heel had a Stage II pressure ulcer. The progress note dated 09/17/15 revealed during morning rounds with the wound nurse practitioner, the resident's right heel was assessed and found to have a deep tissue injury (DTI) on the right bottom heel, and a large fluid filled blister on right lateral ankle. The skin grid dated 09/17/14 indicated the right heel had a black area on the bottom of the heel, the right lateral side of the ankle had a large fluid filled blister. Record review revealed a skin grid dated 09/21/15 revealed a Stage I pressure ulcer to the coccyx. The skin grid dated 09/28/15 revealed the coccyx had a Stage II pressure ulcer. The skin grid dated 10/01/15 indicated the left heel had a Stage II pressure ulcer that measured 3 cm long, 2 cm wide and 0.1 cm deep. The description indicated the skin was intact, from a blister, the fluid was absorbed, area was purple. (The description was one of an unstageable pressure ulcer.) Skin grid dated 10/01/15 revealed the right heel was a Stage II pressure that was healing. The skin grid dated 10/05/15 revealed the coccyx wound was unstageable. The pressure ulcer care plan was updated on 10/07/15 and 10/19/15. Resident #200 had a Stage II left heel pressure ulcer or potential for pressure ulcer development related to disease process. On 10/7/2015 the care plan indicated the left heel, right heel and coccyx had Stage III pressure ulcers. The left posterior ankle was a vascular ulcer. The update dated 10/19/2015 revealed the left heel healed. The update on 11/06/2015 indicated the resident had pressure ulcers and the potential for pressure ulcers development related to disease process,immobility and incontinence of bowel and bladder. The skin grid dated 10/07/15 revealed the coccyx was a Stage III with 10% yellow tissue. The skin grid dated 10/07/15 right heel Stage III, 4 cm long, 12 cm wide, without depth, dry dark red/black tissue, was previously a blister. The skin grid dated 10/07/15 left heel indicated a Stage III, was previously a blister and presented as dry brown tissue, no eschar with center red tissue. The skin grid dated 10/19/15 revealed the left heel ulcer was healed. The skin grid dated 11/13/15 indicated the right heel presented as a Stage III pressure ulcer with scant amount of serous drainage, wound bed black moist tissue. Skin grid dated 11/13/15 revealed the coccyx wound was a Stage III that measured 3 cm long, 0.5 cm wide and 0.2 cm deep with scant amount of serous drainage. An interview with the licensed practical nurse LPN #28 on 11/19/15 at 8:00 A.M. verified the documentation on the skin grids regarding the development of pressure ulcers. She verified the resident was admitted with no pressure ulcers and verified the MDS assessment completed on 10/21/15 was not accurate. She also verified the documentation indicated the right heel pressure ulcer was not discovered until it was black. LPN #28 indicated she began doing the wound care on 10/06/15. She stated she spoke with the wound clinic on 10/07/15 and asked them to stage the pressure ulcers. She stated the clinic informed her the right heel, the left heel and the coccyx were Stage III pressure ulcers. The orders from the wound care center dated 11/09/15 indicated the dressing change to the coccyx was changed from [MEDICATION NAME] AG (silver) to [MEDICATION NAME]. The orders on the physician orders [REDACTED]. An interview with LPN #28 on 11/19/15 at 11:15 A.M. verified [MEDICATION NAME] AG, the discontinued dressing, had continued to be used until 11/19/15. On 11/19/15 at 9:30 A.M. the dressing change was observed with LPN #28. She verified there was no padding on the left heel and Achilles areas as ordered to protect those areas. She verified these were compromised areas that had ulcers and had been healed. The LPN verified the right heel ulcer presented as completely covered with black tissue. The coccyx had two open areas that were only documented as one. The LPN verified there were two open areas on the coccyx. 2. Record review revealed Resident #151 had [DIAGNOSES REDACTED]. The current care plan regarding activities of daily living revealed the resident had a self-care performance deficit related to decreased mobility, endurance and strength and muscle weakness. The care plan indicated the resident had impaired cognitive function. Record review revealed a skin grid dated 05/25/15 related to a coccyx wound discovered as a open area that developed from a reddened area that measured 0.5 cm long and 0.25 cm wide-no further information was documented. The skin grid dated 05/26/15 for the coccyx area reflected an unstageable pressure that had 90% white tissue with pink tissue that measured 0.8 cm long, 0.6 cm and 0.1 cm with serous drainage. The documentation revealed the coccyx pressure ulcer was not discovered until it was unstageable. The skin grid dated 06/17/15 indicated the coccyx wound was a Stage II that measured 0.3 cm long, 0.2 cm wide and 0.2 cm deep with a pink center. The grid dated 07/02/15 indicated the coccyx pressure ulcer was Stage II pressure ulcer 0.2 cm long and 0.2 cm wide. The MDS 3.0 assessment dated [DATE] indicated the resident had a Stage II pressure ulcer and required extensive assistance with activities of daily living. The skin grid dated 08/04/15 revealed the coccyx ulcer was a Stage II pressure ulcer that measured 0.6 cm long, 0.4 cm wide and 0.2 cm deep. The wound was debrided by the nurse practitioner (NP), the wound bed was yellow. The resident needed a cushion while in the wheelchair and lay down for longer periods of time. There was a small amount of serous drainage. The skin grid dated 09/03/15 indicated the coccyx pressure ulcer was a Stage II that measured 0.4 cm long. 0.2 cm wide and 0.2 cm deep with a small amount serosanguineous drainage, yellow wound bed, debrided, staying off her bottom for so long during the day. The skin grid dated 10/01/15 revealed the coccyx pressure ulcer Stage II and indicated the wound bed was yellow, 0.5 cm long, 0.2 cm wide and 0.3 cm deep. The skin grid dated 10/08/15 indicated the coccyx pressure ulcer was unstageable and measured 1 cm long, 0.3 cm wide and 0.5 cm deep with serous drainage with wound bed white. The skin grid dated 10/26/15 indicated an unstageable pressure ulcer of the coccyx 0.8 cm long, 0.5 cm wide and 0.5 cm with serosanguineous drainage and 100% slough. The skin grid dated 11/06/15 indicated the coccyx pressure measured 0.8 cm long, 0.3 cm wide and 0.4 cm deep, 100% slough and undermining. The grid dated 11/13/15 the coccyx pressure ulcer measured 1 cm long, 0.5 cm wide and 0.4 cm deep. The ulcer was unstageable with undermining and 50-75% slough tissue. The resident was observed in bed with eyes closed at 5:45 P.M. on 11/19/15. Staff stated the dressing was not due to be changed at that time. The staff felt it would not be in the best interest of the resident to disturb her or the dressing at this time as the resident was resting and comfortable. An interview with director of nursing on 11/19/15 at 5:50 P.M. verified documentation of the staging of the coccyx wound did not match the description. She verified the documentation on 05/26/15 indicated the pressure ulcer on the coccyx was not discovered until it was unstageable. She verified the resident was an extensive assist for activities of daily living and a risk for developing pressure ulcer.

Based on observation, medical record review, review of missing resident policy, review of the agency nurse contract and interviews of facility staff, the facility failed to ensure adequate supervision was provided for Resident #10, who had cognitive impairment and required staff supervision, when the resident wandered through two alarmed doors, into an unoccupied, unheated closed unit undiscovered for approximately 13 hours as staff did not determine she was missing. This resulted in Immediate Jeopardy for one resident (Resident #10) of eight cognitively impaired and independently mobile residents in the facility. The resident census was 90. On 11/10/14 at 2:11 P.M., the Administrator and the director of nursing (DON) were notified that Immediate Jeopardy began on 11/01/14 at approximately 8:00 P.M. when agency licensed practical nurse (LPN) #50 could not locate Resident #10 and did not activate the missing resident protocol. Resident #10 was found at 8:05 A.M. on 11/02/14 by Maintenance Employee (MM) #60. Resident #10 was incontinent of urine, lying in a bed on the unoccupied closed unit, complaining of being cold and had an axillary temperature of 95 degrees (normal axillary temperature is 97.2 degrees) and a blood pressure of 145/100 (normal is 120/80). The unoccupied closed unit was separated from the occupied units by two separate alarmed doors and a breezeway. The closed unit was completely shut down, unheated and without staff. The call light system on the closed unit was functioning but did not communicate with the occupied unit. The average temperature outside on 11/01/14 was 38 degrees (according to the National Weather Service website). The Immediate Jeopardy was removed on 11/11/14 when the facility implemented the following corrective measures: *On 11/02/14 at 10:00 A.M., Resident #10 was ordered a Wanderguard (an alarming device that alarms near exit doors and locks the door) bracelet. *On 11/02/14 at 7:00 A.M., the DON began to educate all licensed nursing staff to complete walking nursing rounds at the change of shift and to visually count each resident to ensure correct census. Two licensed facility employees on vacation and leave who had not been educated were to receive this training upon their return to work. *On 11/02/14 at 7:00 A.M., the DON educated all eleven nursing supervisors to count each resident at 11:00 P.M. each day. * On 11/02/14 and 11/04/14, the DON began to educate all licensed and unlicensed facility staff to respond to all door and Wanderguard alarms. When an alarm sounds, staff must immediately check the door and surrounding area and a complete resident count must be completed. All alarms must prompt immediate staff response with a sense of urgency. Nine facility employees on vacation and leave would receive this training upon their return to work. *Review of an In-service and Summary Attendance record dated 11/02/14 at 7:00 A.M. revealed 26 licensed nurses were educated by the DON to complete walking rounds and count each resident at the change of shift. *Review of an In-service and Summary Attendance record dated 11/02/14 at 7:00 A.M. revealed 11 licensed nursing supervisors were educated by the DON on completing a total resident count at 11:00 P.M. every day. *Review of an In-service and Summary Attendance record dated 11/02/14 at 7:00 A.M. revealed 81 employees including nursing, housekeeping, maintenance, dietary and therapy staff were educated by the DON on door and Wanderguard alarms and the need for prompt response. *On 11/10/14, the Administrator created a Communication Plan that indicated all agency staff would be educated according to the facility ' s Agency Orientation Checklist/Staffing Agency Agreement/Position/Description/Evaluation which included the missing resident policy prior to their next scheduled day of work in the facility. *On 11/10/14, the Administrator began orienting the agency nurses and STNAs on the facility ' s Agency Orientation Checklist, including the facility policies. The Administrator provided Point Click Care medical record access for 22 of the current agency nurses and 17 agency STNAs and nurses were provided orientation and education to the facility ' s policies. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was implementing an on-going system for monitoring the corrective measures, all facility employees had not been trained and the system to provide computer record access to all agency employees had just been initiated. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plans for Resident #10 initiated on 06/02/14 revealed the resident had decreased mobility; had balance problems, was at risk for falls and episodes of incontinence, and required the extensive assistance of one staff for transfers and toileting. Resident #10 had impaired cognitive function and thought process related to her short and long term memory loss. Resident #10 had impaired vision and required extensive assistance of a staff member for toilet use, transfers, bed mobility. Interventions on the care plan included to monitor Resident #10 for an unsteady gait, frequent falls, depression, suicidal ideations, social isolation, blurred vision, fatigue and unusual behavioral symptoms. Review of an elopement assessment dated [DATE] revealed Resident #10 was not an elopement risk. Review of the November 2014 medication administration record (MAR) for Resident #10 revealed the following medications were ordered to be given on 11/01/14 at 9:00 P.M.: Tylenol 650 milligrams (mg), Aricept 10 mg (treatment of [REDACTED]. The resident was also to receive a snack at bedtime. LPN #50 had circled all of the 9:00 P.M. medications and the bedtime snack indicating they were not given but provided no further explanation. The MAR indicated Resident #10 received a nutritional supplement during the dinner meal (no exact time). Review of a nurse's note dated 11/02/14 (no time) and written by LPN #55 (employed by the facility) revealed when she received nurse to nurse (did not specify from whom) report the morning of 11/02/14, LPN #55 was told Resident #10 was in the hospital. At 8:15 A.M. maintenance (unidentified) came and said someone was sleeping in a bed in the new renovated unit. Resident #10 was found lying in the bed incontinent of urine. Review of a typed word document dated 11/02/14 (no time) and written by the DON revealed the agency nurse (LPN #50) was interviewed by telephone. LPN #50 received nurse to nurse report from LPN #55 at 7:00 PM on 11/01/14. This report indicated Resident #10 was alert and had no other issues. LPN #50 stated during the medication pass, she asked the State tested Nurse Aide (STNA) (unspecified) where Resident #10 was and the STNA told her Resident #10 was in the hospital. LPN #50 denied checking the resident's medical record to verify Resident #10 was sent to the hospital. The LPN verified she had no access to the medical record of the residents. LPN #50 denied hearing any door alarms sound during her shift. LPN #50 verified she did not provide care to Resident #10 at any time from 7:00 P.M. on 11/01/14 to 7:30 A.M. on 11/02/14. LPN #50 verified she did not administer physician ordered medications to Resident #10 during that time because she thought the resident was in the hospital. Review of the Resident Occurrence Follow-up Report dated 11/02/14 at 8:05 A.M. and written by Registered Nurse (RN) #35 (employed by the facility) revealed Resident #10 was found by maintenance man (MM) #60 in room 405 (located on the closed renovated unit), in the bed by the window. The call light was activated in the bathroom. Resident #10 was dressed in only a shirt, was covered with a sheet and blanket, lying face up in the bed and asking for help. Resident #10's tennis shoes were found in the bathroom. When asked if she was okay, Resident #10 replied she was cold. Resident #10's pants were wet and folded on the back on the wheelchair. When Resident #10 stood up, she complained of back pain and pointed to her lumbar sacral area. Resident #10 was assessed and had a few scratches at the bottom of her back toward her left hip. The resident's blood pressure was 145/100 and her temperature was 95 degrees Fahrenheit axillary. The physician was notified of the incident and no new orders were provided. The follow up report also indicated Resident #10 was very confused and appeared more confused than normal. Review of a pain assessment dated [DATE] at 8:15 A.M. and written by LPN #55 revealed Resident #10 was in no pain. Review of the Resident Occurrence Follow-up Report dated 11/02/14 at 11:00 A.M. written by MM #60 revealed Resident #10 was found lying on her back in bed on the closed unit. The call light was on in room 405; MM #60 went to the room to turn off the light, found Resident #10 in bed and went to get the nurse. Review of the Resident Occurrence Follow up Report dated 11/02/14 at 11:45 A.M. written by LPN #61 (employed by the facility) revealed maintenance (unspecified) told LPN #61 that someone was in the closed renovated unit. LPN #61 found Resident #10 asleep in a bed. Resident #10 was awakened, taken to the bathroom, cleaned up and brought back to the North hall. Review of the Resident Occurrence Follow-up Report dated 11/02/14 at 3:00 P.M. written by STNA #70 (employed by the facility) revealed she did not see Resident #10 when she arrived at work on 11/01/14 at 3:00 P.M. STNA #70 told LPN #50 around 8:00 P.M. to 9:00 P.M. that Resident #10 was in the hospital. Review of a nursing progress note dated 11/02/14 at 3:00 P.M. written by LPN #55 revealed Resident #10 was found on another wing in an empty bed and was incontinent of urine. A skin assessment was completed and identified no issues were noted. Resident #10 appeared to be more confused than normal. The resident was returned to her unit and given a shower. The resident denied any pain. The resident's family and physician were notified and a Wanderguard alarm bracelet was applied. Review of the National Weather Service's climate data report revealed the average outside temperature for the facility's location on 11/01/14 was 38 degrees Fahrenheit and on 11/02/14 was 37 degrees Fahrenheit. Review of a physician's progress note dated 11/03/14 revealed Resident #10 had [DIAGNOSES REDACTED]. The note documented "Incident 11/02/14. No known injury. Patient is very pleasant. Offered no complaints. No recollection of 11/02/14 incident." Review of an In-service and Summary Attendance record dated 11/04/14 at 7:00 A.M. revealed 64 additional employees, licensed and unlicensed, were educated by the DON on the importance of responding to door and Wanderguard alarms promptly. On 11/06/14 at 4:04 P.M., an interview and tour of the facility with RN #35 verified she worked the morning Resident #10 was found on the unoccupied unit. RN #35 stated she had no idea how long the resident was missing or when she was last seen. RN #35 walked to the exit door that Resident #10 used on 11/01/14. Observation of the exit door at the end of the hallway (near rooms 228/229) revealed the door was equipped with a Wanderguard (an alarming system) and a coded lock; the door was able to be pushed open without using a code. A small breezeway was located between this door and the next door to the unoccupied unit. The door to this closed renovated unit also had a coded lock but was able to be pushed open without a code. Both doors alarmed when opened. RN #35 revealed the coded locks were used to silence the door alarms only. Observation of the unoccupied unit revealed it was dark and very cold. RN #35 indicated Resident #10 was found in room 405 by MM #60 at 8:05 A.M. on 11/02/14 when he was working on the unit. RN #35 stated she arrived for work at 7:00 AM and was not informed in report that any resident was missing. Interview with the Administrator on 11/06/14 at 5:10 P.M. verified the last time Resident #10 was observed was around 6:00 PM on 11/01/14 when given a nutritional supplement and that Resident #10 was found at 8:05 AM the next day. The Administrator revealed this was documented on the MAR. The Administrator verified the agency nurses did not have access to the complete medical records of the residents. The Administrator verified agency nurse LPN #50 was assigned to the resident, thought Resident #10 was in the hospital and never checked on her for over 12 hours. The Administrator revealed all current licensed and unlicensed facility staff, except those on leave of absence or vacation, were educated after the incident and the staffing agency notified LPN #50 was not to return to the facility. Observation of Resident #10 on 11/10/14 at 7:20 A.M. revealed she wore a Wanderguard alarm bracelet to her right ankle. Resident #10 was confused to time and place and did not recall leaving the unit on 11/01/14. Interview with RN #35 on 11/10/14 at 8:20 A.M. revealed she started her shift at 7:00 A.M. on 11/02/14. During nurse to nurse report, RN #35 stated she overheard agency nurse LPN #50 state Resident #10 was in the hospital. At 8:05 A.M., MM #60 told RN #35 someone was in room 405 and he needed help. Resident #10 was found in a bed on the unoccupied unit. RN #35 verified the heat was off on the unit at that time and it was cold in the room. She did not know the temperature. RN #35 revealed Resident #10 was incontinent of urine, had removed her wet clothes, hung them on her wheelchair and was lying in the bed. RN #35 indicated the call light was sounding in the bathroom of room 405 and the call light system from this unoccupied unit could not be seen or heard in the occupied units. RN #35 verified the resident's shoes were located in the bathroom. RN #35 took Resident #10's temperature under her arm pit (axillary). The resident ' s temperature was 95 degrees. RN #35 called the resident's physician and informed him of the incident. RN #35 revealed she was the nurse in charge of the "center hall" and LPN #55 (employed by the facility) was the nurse in charge of Resident #10's hall (the North hall) the morning of 11/02/14. Interview on 11/10/14 at 8:50 A.M. with agency nurse RN #71 revealed she worked on 11/01/14 from 7:00 A.M. to 7:00 P.M. RN #71 was not assigned to care for Resident #10. RN #71 indicated she received report that day from an agency nurse. Agency nurse RN #71 stated she gave report to another agency nurse. RN #71 verified many agency nurses worked at the facility and it was difficult to remember the residents and their individualized care. RN #71 indicated the facility did not permit agency nurses to use the computerized medical record system called Point Click Care. On 11/10/14 at 8:53 A.M. an interview with STNA #72 (an agency STNA) revealed she worked at the facility on 11/01/14 from 11:00 P.M. to 7:00 A.M. STNA #72 revealed she was not assigned to care for Resident #10 and she thought Resident #10 was in the hospital that evening. STNA #72 indicated she had difficulty remembering residents because she was agency. On 11/10/14 at 9:12 A.M. an interview with LPN #50 revealed she was the agency nurse that worked 7:00 P.M. to 7:00 A.M. on 11/01/14 and she was assigned to care for Resident #10. LPN #50 revealed she received report from the day shift agency nurse (unidentified). LPN #50 verified she was not told Resident #10 was in the hospital. LPN #50 revealed when she started passing her 8:00 P.M. medications, she noticed Resident #10's bed was made and her light was off. LPN #50 walked into the hall and asked STNA #70 (the facility STNA assigned to Resident #10) where Resident #10 was. The STNA told LPN #50 that Resident #10 was in the hospital. LPN #50 indicated she was working on the North hall the entire thirteen hour shift, did not see Resident #10 and did not hear any doors alarm. LPN #50 stated Resident #10 must have gone into the unoccupied unit before 7:00 P.M., when she started her shift. LPN #50 revealed she was never provided an orientation on the facility's policy/procedure for missing residents and she was not given access to the resident's electronic medical records or their individualized care plans and was not aware of what specific care each resident required. LPN #50 verified she did not document on any resident during her shift because she had no access to the electronic medical record. Interview on 11/10/14 at 11:07 A.M. with LPN #61 (employed by the facility) revealed she worked 7:00 A.M. to 7:00 P.M. on 11/01/14. LPN #61 worked the South Hall and was not assigned to care for Resident #10. LPN #61 revealed she observed Resident #10 in her wheelchair near the nursing station around 6:00 P.M. LPN #61 revealed prior to 11/02/14, the nurses did not do a room to room report with a head count; they would just sit at the desk and get report from each other. LPN #61 indicated if a resident was missing, a "Code White" which was part of the facility's procedure, should be called and all staff should search for the missing resident. Interview on 11/10/14 at 11:35 A.M. with the DON revealed a new policy for room to room report and head count was initiated on 11/02/14 after the incident with Resident #10. Interview on 11/10/14 at 11:45 A.M. with the Administrator and the DON revealed they were "just informed" of a manual that the facility was supposed to use to train any agency nurse prior to their first shift in the facility. The Administrator indicated she and the DON were not aware of the manual because they had been hired at the facility only two months ago. The Administrator revealed the manual had most of the "important" policies in but was unsure if agency nurses were trained on the manual prior to their first shift. The Administrator verified the facility used many agency nurses. The Administrator also verified agency nurses did not have access to the facility's electronic medical record system called "Point Click Care" . The administrator verified all nursing notes, resident assessments, the Minimum Data Set (MDS) assessment and the resident's care plans were located in the Point Click system. The Administrator indicated it was the corporation's policy to not allow agency staff computer access. The Administrator stated a print off of each resident's Kardex (an abbreviated version of the care plan) was available for the agency nurses to use and if the agency nurses needed to document, they could document on paper. These paper notes were kept in the hard chart on each unit. These Kardex's were also available to all STNAs to provide care for their assigned residents. Review of a large black binder identified by the DON as the "agency orientation book" revealed the binder included job descriptions, orientation to the facility's lay out and structure and copies of the facility's policies and procedures including the Missing Resident policy. The binder was kept in the locked staff development office. Interview on 11/10/14 at 4:00 P.M. with MM#60 revealed he arrived at the facility at 8:00 A.M. on 11/02/14. MM #60 verified the unoccupied unit was empty, the lights and heat were off. MM #60 noticed the call light in room 405 was activated and thought it might have been a short in the wiring. MM #60 revealed he found someone in the bed in room 405 and went to get the nurses. MM #60 stated Resident #10 "was just lying there, she didn't talk to me." Interview with the Administrator on 11/10/14 at 5:00 P.M. verified LPN #50 and three additional agency staff (LPN #74, RN #71 and STNA #73) that worked on 11/01/14 and 11/02/14 were not oriented to policies and procedures prior to their shift on 11/01/14. The Administrator also verified many (unspecified number) of the agency nurses were not oriented to the facility until after the incident on 11/02/14. The Administrator revealed a new policy was initiated on 11/10/14 requiring all agency nurses to be oriented to the facility's policies and procedures prior to working. The Administrator also revealed all resident care plans and Kardex ' s would be available at the nursing units and the corporation was currently working on getting Point Click Care access for all agency staff (to enable them to have access to the resident's medical records) as soon as possible. Review of a document dated 11/10/14 (no time) and provided by the Administrator revealed a new policy that all agency staff will be educated according to the facility's Agency Orientation Checklist/Staffing Agency Agreement/Position/Description/Evaluation (the black orientation binder) prior to the first shift at the facility. Care plans and Kardex's would be available at the nursing units for Agency and staff use. On 11/12/14 at 7:20 AM, interview with LPN #75 (employed by the facility) revealed she was aware of the missing resident policy. LPN #75 called the policy "Code White." LPN #75 was knowledgeable of the procedure for a missing resident. On 11/12/14 at 7:30 AM, interview with LPN #76 (employed by the facility) revealed she was aware of the missing resident policy. LPN #76 referred to the policy as "Code White." LPN #76 was knowledgeable of the procedure for a missing resident. On 11/12/14 at 8:30 A.M. with the Administrator revealed on the evening of 11/10/14 and also on 11/11/14, she obtained Point Click Care medical record access for all 22 of the current agency nurses. The administrator also revealed all current agency nurses are now oriented and trained to the facility's policies and procedures. The administrator provided 22 New Employee User and Setup Information sheets (undated) listing a user access code for each agency nurse. The Administrator also provided an education log listing 11 of the agency nurses and STNAs indicating they were educated and oriented to the facility on [DATE]. On 11/12/14 at 11:25 AM interview with LPN #55 revealed she gave agency nurse LPN #50 report on 11/01/14. LPN #55 revealed she told LPN #50 that Resident #10 took her pills whole and had no problems. LPN #55 revealed she never indicated Resident #10 was in the hospital. LPN #55 also received report from LPN #50 the next morning on 11/02/14. LPN #50 told LPN #55 that Resident #10 was in the hospital. LPN #55 questioned LPN #50 as to when Resident #10 left and who sent her. LPN #50 said she didn't know. LPN #55 was knowledgeable of the missing resident policy. On 11/13/14 at 1:20 P.M. an interview with the DON and the Administrator verified all current agency nurses now had access to the entire electronic medical record. The Administrator is now keeping a record of all agency nurses and STNAs that were oriented and provided an electronic medical record access code. All new agency staff were to be oriented and provided access to the resident's electronic medical record upon the first day of work. The Administrator also revealed the MAR indicated Resident #10 was provided a health supplement during the dinner meal on 11/01/14. The Administrator stated dinner was around 6:00 P.M., so this was the last time she knew Resident #10 was observed by a staff member. The Administrator revealed the agency nurses had access to the hard (paper) medical record located on the units. These medical records contained a face sheet with the physician's and the family's phone numbers and it also contained any agency paper notes. The DON verified the STNAs were given report at the start of their shift by the nurse. The STNAs were not provided any documentation at the start of their shift. The DON revealed the Kardex for each resident was at the nursing station in case they needed it. On 11/13/14 at 2:55 P.M. Interview with STNA #70 revealed she was assigned to the north hall with STNA #78 from 3:00 P.M. to 11:00 P.M. on 11/01/14. The north hall was where Resident #10 resided. STNA #70 verified she told LPN #50 that Resident #10 was in the hospital on [DATE]. STNA #70 said she didn ' t know where the rumor started, but she just knew everyone was saying Resident #10 was sent to the hospital. STNA #70 verified she did not see Resident #10 at all during her shift and she did not think she was missing. STNA #70 verified she is not provided any paperwork at the start of her shift indicating the care needed for each resident. STNA #70 revealed the nurses tell her what care needs provided to each resident when getting report. STNA #70 was unaware of the Kardex located at the desk. Review of the facility's policy and standard procedure for Missing Resident dated 06/17/14 revealed "Personnel are responsible for resident's location. If a resident is missing, the nurse will organize the institution for a search of the center and the surrounding grounds. If the search fails to locate the resident in 15 minutes, nurse will notify the local police department and request search assistance." The facility utilized three separate staffing agencies to supplement the regular facility staffing. Review of all three agency staffing contracts issued on 08/07/14, 08/08/14 and 10/28/14 revealed the facility was responsible to train agency staff to the policies and procedures specific to that facility. This deficiency is an incidental finding from the complaint investigation.

Based on interview and record review, the facility failed to ensure Resident #99 who was identified at high risk for falls had fall prevention interventions in place as ordered by the physician. Harm occurred on 07/11/14 when Resident #99 fell and sustained a subdural hematoma requiring a hospital admission. In addition, the facility failed to ensure adequate supervision was provided to prevent a fall for Resident #122. This affected two of five residents reviewed for falls (Residents #99 and #122). The facility census was 93. Findings include: 1. Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On admission Resident #99 was assessed as a high risk for falls. Review of a progress note dated 07/10/14 timed 3:20 P.M., revealed Resident #99 toppled out of chair onto her left side. The resident denied pain and stated she did not fall. The progress note indicated Resident #99 was confused and did not understand her surroundings. As a result of the fall, the physician ordered a low bed and bilateral mats to the floor next to the bed for the resident's safety. Review of a progress note dated 07/11/14, revealed Resident #99 sustained an unwitnessed fall. The note indicated the nurse walked by Resident #99's room and observed her on the floor with staff members administering first-aid. The progress note indicated Resident #99 was actively bleeding from a laceration to the back of her head. Resident #99 was sent to the hospital for evaluation. Review of a progress note dated 07/12/14, revealed Resident #99 was admitted to the hospital with [REDACTED].#99 remained in the hospital until 07/16/14, when she was readmitted to the facility. Review of the facility's incident investigation for the 07/11/14 fall revealed Resident #99's bed was not in the low position, the call light was not in reach and the floor mats were not on the floor on either side of the bed as ordered by the physician for fall prevention interventions. The director of nursing (DON) was interviewed on 08/19/14 at 8:25 A.M. The DON verified Resident # 99 was supposed to have a low bed and floor mats in place as a safety precaution and verified they were not in place at the time of the fall. The DON verified the resident was sent to the hospital on [DATE], as a result of the fall. 2. Resident #122 was admitted on [DATE], with right hip hemiarthroplasty, hypertension, chronic obstructive pulmonary disease, anxiety, and [DIAGNOSES REDACTED]and no longer resided in the facility. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was alert and oriented, required extensive assistance of two persons for bed mobility, transfers, toileting, and hygiene. Resident #122 was frequently incontinent of bowel and bladder. Resident #122 had fallen in the month prior to admission and was assessed to be at high risk for falls. Review of a progress incident note dated 05/22/14 at 6:30 A.M., revealed the nurse was called into Resident #122's room by State tested Nurse Aide (STNA) #33. The resident was sitting on the bathroom floor in the corner across from the toilet and positioned on his left hip/thigh. Resident #122 was assisted off the floor by three staff and placed into a wheelchair. The resident was unable to move his right leg and complained of pain. The nurse assessed the resident, notified the physician, and administered pain medication. The resident was sent to the emergency room for an evaluation and returned with no additional orders. Record review of the 05/22/14 fall investigation revealed STNA #33 stated that after Resident #122 was finished using the commode, she helped him stand up. He was holding onto the guard rails as she provided perineal care. STNA #33 indicated Resident #122 turned and told her he could not stand any longer. STNA #33 tried to direct the turn and sit the resident on the toilet, but he turned around and began slowly sitting. STNA #33 helped Resident #122 to the floor and then proceeded to get the nurse. Interview with Physical Therapy Director, (PT) #34 on 08/14/14 at 3:15 P.M. revealed Resident #122 was evaluated as a maximum assist for transfers on 05/20/14. PT #34 stated that the transfer status of new residents was discussed during the morning meeting and that Resident #34 was assessed by therapy to require two persons to transfer. PT #34 stated Resident #122 was unable to take forward steps due to fear and pain and transferred from the bed to his wheelchair with moderate assistance of two persons. Review of therapy notes dated 05/21/14 revealed Resident #122 was a moderate assist of two persons for toilet transfers. An interview and review of the fall plan of care for Resident #122 was conducted with the DON on 08/14/14 at 4:00 P.M. The plan indicated the resident required one to two persons for transfers. The DON verified the resident should have been transferred by two staff members as assessed by the physical therapist. This deficiency substantiates Complaint Number OH 668 and Complaint Number OH 034.