Every finding on record at Harvard Gardens Rehabilitation & Care Center

Based on interview, record review, and policy review, the facility failed to ensure Resident #100 received all personal belongings upon discharge. This affected one resident (Resident #100) of three residents reviewed for discharge. Findings include:Review of the closed medical record for Resident #100 revealed an admission date of 09/08/23 and a discharge date of 02/24/26. Resident #100 diagnoses included diabetes, hypertension, bipolar disorder, anxiety and above the right knee amputation. Review of Resident #100 's admission Agreement dated 05/16/25 revealed the facility would take reasonable precautions to safeguard resident belongings, but was not liable for loss or theft unless due to facility negligence. Residents were encouraged to keep valuables secured or offsite. Review of the quarterly Minimum Data Set 3.0 dated 12/03/25 revealed Resident #100 was cognitively intact. Review of a late entry progress note dated 02/24/26 and timed at 8:15 P.M. and authored by Assistant Director of Nursing (DON) #600 revealed Resident #100 was being discharged to another long-term care facility with most of her personal belongings. The rest of her belongings would be delivered to resident. Interview on 06/15/26 at 11:17 A.M. revealed Resident #100 believed her mini-van was still at the facility parking lot and she never received the rest of her belongings. Resident #100 revealed in calling the facility, she was not able to get through to anyone to discuss retrieval of her belongings. Resident #100 revealed she still resided at the long-term care facility she was discharged to. Phone interview on 06/15/26 at 12:18 P.M. with former Licensed Social Worker (LSW) #200 revealed about half Resident 100's belongings were sent with her upon her discharge. He stated the other half were put in storage at the facility. He stated a driver from their sister facility said he would make a second trip to take the rest of her items to her. LSW #100 said he followed up with the sister facility however he never heard back from them. LSW #200 also stated Resident #100 had a mini-van parked at the facility but stated it was broken down. LSW #200 stated the former Administrator stated Resident #100 would have to make arrangements herself for it to be moved. LSW #200 stated he believed the facility dropped the ball on sending the remaining personal items. He stated he received an email approximately three weeks after discharge from Resident #200 stating she was trying to get a hold of someone from the facility about her belongings. He stated he forwarded the email to the former Administrator but was not aware of the results. LSW #200's last day was in March 2026.Interview on 06/15/26 at 12:52 P.M. with Director of Nursing (DON) and Administrator revealed Resident's 100's personal belongings were still at the facility and previously had a car at the facility. DON described the car as having no windows, only two tires and no alternator. DON revealed she remained in contact with Resident #100 but did not discuss her personal property at all.Interview on 06/15/26 at 1:29 P.M. with Administrator revealed they would offer to transport Resident #100's items to her since staff may have said they would transport belongings but normally they would not. Administrator revealed their policy was any items a resident left behind would be donated or disposed of after 30 days. Administrator revealed it was not reasonable to wait almost four months to send her belongings to her. Interview on 06/15/26 at 1:39 P.M. with Ombudsman revealed Resident #100 contacted her in May 2026 with concerns she did not receive her belongings or car.Interview on 06/15/26 at 2:23 P.M. with Administrator revealed he learned the sister facility's transport van had been broken down until about a month ago. Administrator confirmed there was no evidence arrangements were made for Resident #100 to receive her car.Phone interview on 06/15/26 at 3:31 P.M. with former Administrator #400 revealed he never had a personal conversation with Resident #100 about her belongings. He stated they were trying to look at options stating their bus was not great, the sister facility's bus was down recently and repaired about a month ago. He also stated they looked at renting a moving van but could not state why that option did not work out. Former Administrator #400 stated Resident #100 never reached out to him after discharge. Former Administrator #400 acknowledged receiving the email from LSW #200 but could not recall if he responded.Review of the facility policies titled Parking Lot and Facility Storage Policy, not dated, revealed two policies on the same form. Resident Personal Property Storage revealed upon discharge, transfer, death or abandonment of personal belongings, the facility would inventory and securely store resident property for a minimum of 30 days. Reasonable efforts would be made to notify the resident. After 30 days, if the property was unclaimed and all reasonable notification attempts have been documented, the facility may dispose of, donate, or otherwise manage the property in accordance with applicable laws and facility procedures. Parking Lot Liability Notice stated the facility provided parking for the convenience of residents, visitors and staff. They were not responsible for any loss, theft or damage to vehicles or personal property left in vehicles while parked on the premises. All vehicles were parked at the owner's sole risk. By using the parking facilities, you acknowledge and accept these terms. The policy did not require a signature.This deficiency represents non-compliance investigated under Complaint Number 3010602.

Based on observation and staff interviews, the facility failed to ensure resident use equipment and the physical environment were maintained in a safe, clean, sanitary, and well functioning condition. This deficient practice affected one resident (Resident #7) of three reviewed for physical environment and had the potential to affect all 105 residents residing in the facility.Findings include:During an observation and interview on 04/22/26 at 10:28 A.M., Resident #7 was noted to have a bed remote that was taped and non functional. The resident reported that there was a short in the remote and he was unable to adjust the bed. The blinds in Resident #7's room were also observed to be broken. The Director of Nursing (DON) confirmed these findings at the time of the observation.On 04/22/26 at 10:55 A.M., an observation with the DON in the dining room revealed a noticeable smell of tobacco. The windows were open due to outdoor temperatures at 76 degrees Fahrenheit; however, four of the five dining room windows were missing screens, permitting bugs to enter the facility. The DON verified these observations at the time.During an interview on 04/22/26 at 12:56 P.M., Maintenance Director #224 reported that measurements for the replacement blinds for Resident #7's room had been provided to the corporate office and blinds were ordered. He was unable to provide documentation showing the blinds had been ordered. He further stated that attempts were made to repair bariatric bed remotes, but the beds varied in style and remotes needed to be purchased. All ordering, he stated, must go through corporate.This deficiency represents non-compliance investigated under Complaint Number 2987038.

Based on observation and resident and staff interviews, the facility failed to ensure foods were served at a palatable temperature. This affected five (Residents #5, #7, #30, #50, and #100) of five residents interviewed for palatable food and had the potential to affect all 102 residents who received meals prepared by the kitchen. The facility identified three (Residents #31, #58, and #59) as receiving no food by mouth (NPO). The facility census was 105.Findings include:Observation of tray line on 04/21/26 from 11:45 A.M. through 12:44 P.M. revealed food was above 180 degrees Fahrenheit (F) on the tray line.Observation of the tray line service on 04/21/26 from 12:35 P.M. through 12:44 P.M. revealed the facility ran out of lids for the plates and used the bottoms in place of the lids, which did not fit tightly over the plate. Observation of test tray and interview on 04/21/26 at 12:59 P.M. with Dietary Manager (DM) #214 revealed the baked ham was 101.1 degrees F, and the collard greens were 111.0 degrees F. DM #214 verified that the ham and collard greens should have been hotter, and she was going to have corporate order more lids for the plates.Interview on 04/21/26 at 1:45 P.M. with Registered Dietitian (RD) #217 revealed that she does not do tray line audits. RD #217 stated that she didn't know that cold food was a problem.Interviews on 04/21/26 and 04/22/26 from 7:00 A.M. through 4:00 P.M. with Residents #5, #7, #30, #50, and #100 revealed they had concerns with taste and temperatures of food.Review of the facility policy dated 10/25 titled, Food Service Distribution, revealed that there was no standard for temperatures of food delivered to the residents.This deficiency represents non-compliance investigated under Complaint Number 2987038 and is a recite to the survey completed on 03/03/26.

Based on record review, observations, resident and staff interviews, review of dietary guidance from NephCure Kidney International and Kaiser Permanente, and facility policy review, the facility failed to ensure that therapeutic diet orders were accurately implemented for two residents (Residents #36 and #10) of three reviewed for therapeutic diets. The facility census was 105.Findings include:1. Record review showed Resident #36 was admitted on [DATE] with diagnoses including bacteremia, osteomyelitis, and diabetes mellitus. The comprehensive Minimum Data Set (MDS) 3.0 assessment was in progress. The plan of care dated 04/14/26, revised 04/19/26, identified an alteration in nutrition related to type I diabetes mellitus with an intervention to provide the diet as ordered. Physician orders for April 2026 indicated a consistent carbohydrate diet (regular texture, regular thin liquids).During lunch tray-line observation on 04/21/26 at 12:10 P.M., Resident #36's diet ticket incorrectly listed a renal diet. Dietary Aide (DA) #215 asked [NAME] #216 whether the resident should receive ham and collard greens. [NAME] #216 said Yes, and DA #215 placed the tray into the food cart. Upon further review, DA #215 and Dietary Manager (DM) #214 confirmed the spreadsheet listed the meal for renal diets as a pork cutlet; however, no pork cutlets were prepared. [NAME] #216 substituted chicken legs. On 04/22/26 at 8:52 A.M., DM #214 confirmed the diet ticket was incorrect and that Resident #36 should have been receiving a consistent carbohydrate diet, not a renal diet.2. Record review showed Resident #10 was admitted on [DATE] with chronic kidney disease, dysphagia, and polyosteoarthritis. The comprehensive MDS 3.0 assessment was in progress. The plan of care dated 04/02/26 identified an alteration in nutrition related to dependence on renal dialysis, with an intervention to provide the ordered diet. Physician orders for April 2026 included a renal (liberalized low protein) diet, low concentrated sweets, mechanical soft texture, and regular thin liquids.During lunch tray-line observation on 04/21/26 at 12:18 P.M., Resident #10's ticket listed a renal diet with mechanical soft texture. DA #215 asked [NAME] #216 if the resident should receive ham; [NAME] #216 said Yes. DA #215 confirmed the resident received ham, despite the spreadsheet indicating that renal diets should receive a ground pork cutlet. [NAME] #216 did not have ground pork cutlets or ground chicken prepared. At 1:45 P.M. the same day, Registered Dietitian (RD) #217 stated she did not perform tray line audits and was unaware that prescribed diets were not being followed.Spreadsheet review for 04/21/26 confirmed that the liberal renal diet should have included pork cutlet, buttered noodles, and green beans.Review of the facility policy titled Liberalized Low Protein Renal Diet (undated) prohibited cured and canned meats such as ham, bacon, sausage, corned beef, regular cheese, hot dogs, and cold cuts-items inconsistent with what residents were served.Authoritative dietary guidance reviewed during the investigation included:- NephCure Kidney International's renal diet overview, stating that renal diets limit sodium, phosphorus, certain proteins, and sometimes fluids to reduce waste buildup, maintain electrolyte balance, and slow kidney disease progression.- Kaiser Permanente's detailed guide describing a consistent carbohydrate diet (CCHO) as one that stabilizes carbohydrate intake across meals and snacks, typically 2-4 carbohydrate servings per meal, to maintain stable blood glucose levels. This deficiency represents non compliance investigated under Complaint Number 2987038.

Based on medical record review, review of facility policy, review of informational articles from American Cancer Society, and interview the facility failed to develop and implement a system for identifying, monitoring, and caring for Resident #3's implanted venous access device (a port placed under the skin for use to administer intravenous treatments to mitigate risk for infection. This affected one resident (#3) of three residents reviewed for vascular access devices. The facility census was 102.Actual Harm occurred on 03/04/26 when Resident #3 was identified by a non-facility oncology nurse at an outside appointment to have a dressing to an implanted venous access device that was heavily soiled. Resident #3 was assessed to be weak and dizzy and was transferred to the emergency room where the resident was admitted to the intensive care unit (ICU) for sepsis (a blood culture from the implanted venous access device revealed gram-positive cocci bacteria). On 02/20/26 Resident #3 had returned from the hospital with an implanted venous access device that remained accessed by a Huber (a non-coring needle used to access a subcutaneous implanted port used under sterile conditions.) needle and covered with a dressing. The facility's failure to identify the accessed device resulted in the device remaining accessed and without routine monitoring or site care until 03/04/26. Resident #3 remained in the hospital until 03/12/26.Findings include:Review of the medical record for Resident #3 revealed an admission date of 12/04/25 with diagnoses including personal history of malignant neoplasm of large intestine, malignant neoplasm of rectosigmoid junction, malignant neoplasm of colon, peritoneal abscess, anemia, sepsis, iron deficiency anemia, elevated white blood cell count, severe protein calorie malnutrition, artificial openings of urinary tract status, acquired absence of parts of the digestive tract, and candidal stomatitis.Review of the clinical census for Resident #3 revealed multiple hospitalizations which included from 12/22/25 to 12/28/25, 01/02/26 to 01/09/26, 01/17/26 to 01/20/26, 02/17/26 to 02/20/26, 03/04/26 to 03/12/26 and 03/16/26 to 03/22/26. On 03/31/26 the resident was transferred to the hospital and had not returned at the time of the onsite survey. Review of hospital record titled History and Physical Examination dated 12/22/25 revealed Resident #3 was admitted for tachycardia and sepsis related to urinary infection. Resident #3 was noted to be anemic and required blood transfusion of one-unit of packed red blood cells (RBCs) to increase hemoglobin levels. Resident #3 was noted to have a left-sided chest implanted venous access device. Resident #3's hemoglobin level was 7.3.Review of hospital record titled Lines, Drains, Airways, and Wounds dated 12/23/25 revealed Resident #3 had an implanted single port vascular access device to the left chest that was placed on 09/19/25.Review of admission Assessment and Baseline Care Plan dated 12/29/25 revealed Resident #3 re-admitted to the facility. There was no evidence the facility had identified Resident #3 had an implanted venous access device.Review of hospital record titled History and Physical Exam dated 01/02/26 revealed Resident #3 was admitted to the hospital for complaints of painless rectal bleeding. Resident #3 was found to have increase in size of lower abdominal mass which was compatible with progression of malignancy.Review of hospital record titled Infectious Diseases Progress Note dated 01/06/26 revealed Resident #3 had an implanted venous access device to left chest. There were no external signs of infection. Blood cultures were obtained showing Methicillin-resistant Staphylococcus epidermidis (MRSE) and unable to rule out contaminants versus a venous access device related blood stream infection. It was noted the device had been sterile to date.Review of hospital record titled Lines, Drains, Airways, and Wounds dated 01/09/26 revealed Resident #3 had an implanted single port vascular access device to the left chest that was accessed on 01/02/26.Review of progress note dated 01/09/26 revealed Resident #3 re-admitted to the facility. There was no evidence the facility had identified Resident #3 had an implanted venous access device.Review of hospital record titled History and Physical Exam dated 01/18/26 revealed Resident #3 was admitted for abdominal pain and diarrhea related to Clostridioides difficile (C. diff). Resident #3 was found to have low hemoglobin and hematocrit (H/H) levels of 4.5/13.7. Resident #3 received a transfusion of two units of packed RBCs to improve H/H levels. It was noted Resident #3 was unable to consistently receive chemotherapy due to recurrent infections.Review of hospital record titled Patient Handoff Communication dated 01/20/26 revealed Resident #3 had an implanted double port vascular access device to left chest that was accessed on 01/18/26.Review of progress note dated 01/20/26 revealed Resident #3 re-admitted to the facility. There was no evidence that the facility had identified Resident #3 had an implanted venous access device.Review of hospital record titled Emergency Department (ED) Provider Note dated 02/17/26 revealed Resident #3 was admitted to the hospital for evaluation of nephrostomy tubes and abdominal pain. Laboratory workup showed concern for anemia. Resident #3's H/H levels were noted to be low at 5.4/16.7. Resident #3 received a blood transfusion of two units of packed RBCs and was monitored without reaction.Review of hospital record titled History and Physical Exam dated 02/18/26 revealed Resident #3 was admitted for low H/H level of 5.4/16.7 and concern for dislodgement or obstructed nephrostomy tube. Resident #3 required a blood transfusion to address low H/H levels.Review of hospital record titled Initial Consult Gastroenterology dated 02/18/26 revealed gastroenterology was consulted for acute blood loss anemia. Resident #3 received a blood transfusion of two units of packed RBCs.Review of hospital record titled Internal Medicine Progress Notes dated 02/19/26 revealed Resident #3's H/H levels were 7.3/23.4. Resident #3 was given a blood transfusion during this admission. The note referenced Resident #3 had chronic anemia with an unclear etiology.Review of hospital record titled Palliative Medicine Initial Consult dated 02/19/26 revealed Resident #3 had not received chemotherapy since 10/28/25. It was noted chemotherapy had to be stopped due to recurrent hospital admissions with infections. A visit with infectious disease on 01/27/26 revealed no direct contraindication to resuming chemotherapy. It was noted Resident #3 had yet to have a follow-up visit with oncology and a message was sent to assist with scheduling the appointment. Review of progress note dated 02/20/26 revealed Resident #3 re-admitted to the facility. There was no evidence the facility had identified Resident #3 had an implanted venous access device.Review of the admission Assessment with Baseline Care Plan dated 02/20/26 revealed no evidence the facility had identified Resident #3 had an implanted venous access device, or that the device was accessed.Review of the Skin Observation dated 02/21/26 revealed no evidence the facility had identified Resident #3's had an accessed implanted venous access device.Review of the Skilled Assessment completed daily by facility nurses from 02/21/26 to 02/28/26 revealed no indication the facility identified Resident #3 had an accessed implanted venous device. The assessments made no mention of any site care or monitoring provided. Review of a Nurse Practitioner (NP) note dated 02/25/26 authored by NP #822 revealed the note was recorded as a late entry into the record on 03/23/26. The note did not include any indication that Resident #3 had an accessed implanted venous device.Review of the Skin Observation dated 02/28/26 revealed no evidence the facility had identified Resident #3's had an accessed implanted venous access device.Review of the Skilled Assessment completed by facility nurses on 03/02/26, 03/03/26, and 03/04/26 revealed no indication the facility identified Resident #3 had an accessed implanted venous device. The assessments made no mention of any site care or monitoring provided. Review of the physician orders from 02/20/26 to 03/04/26 revealed no evidence the facility had identified or obtained orders for monitoring or care of Resident #3's implanted venous access device.Review of the facility progress notes revealed there was no note to address Resident #3's condition prior to leaving for an outside oncology appointment on 03/04/26.Review of the infusion center record titled Progress Note dated 03/04/26 at 1:19 P.M. revealed Resident #3 arrived at the cancer center for an appointment. Resident #3 was found to have a Huber needle accessing his implanted venous access device. There was a heavily soiled dressing that was partially intact covering the device. The dressing appeared to be dated 02/11/26. The nurse at the infusion center removed the dressing and was able to get blood return. Resident #3 stated he was not feeling well. Resident #3 reported being uncomfortable, weak, and dizzy. The oncology physician was notified and recommended to send Resident #3 to the emergency room.Review of infusion center record titled Progress Note dated 03/04/26 at 1:49 P.M. revealed Resident #3 presented to the infusion center and was lethargic, uncomfortable, and unable to keep his head upright. The nurse noted urine in nephrostomy tubes appeared thick, contained mucous, and was purulent.Review of hospital record titled ED Provider Note dated 03/04/26 at 1:52 P.M. revealed Resident #3 presented to the ED with generalized weakness and abdominal pain which Resident #3 reported started overnight. Resident #3 was positive for tachycardia. Resident #3's nephrostomy tubes were inspected and appeared to be draining appropriately. Resident #3 was further evaluated for sepsis.Review of a facility progress note dated 03/04/26 at 4:00 P.M. revealed Resident #3 had not yet returned from an appointment. The facility nurse contacted the office and was notified Resident #3 had been sent to the emergency room. It was noted Resident #3 was admitted for abdominal wall abscess, sepsis, general abdomen pain, leukocytosis, bladder mass, and elevated serum creatinine.Review of hospital record titled ICU History and Physical dated 03/04/26 at 8:24 P.M. revealed Resident #3's lab work showed leukocytosis and elevated lactate levels. While being worked up for sepsis and being treated for chronic pain Resident #3 became hypotensive requiring ICU admission. It was noted Resident #3 was at cancer center appointment and felt dizzy and weak. Resident #3's port was noted to have been already accessed with a dressing labeled 02/11/26. It was noted the dressing was dirty.Review of hospital record titled Consult - General Surgery dated 03/04/26 revealed there was concern for abscess. Resident #3 had been followed with oncology for management of cancer and was last seen on 01/22/26. Last chemotherapy treatments were from 09/30/25 to 10/30/25. Resident #3's chemotherapy was on hold due to recurrent hospitalizations for infectious causes and acute-on-chronic anemia. Resident #3 was supposed to get chemotherapy today, however, was sent to ED for further evaluation. Evaluation of concern for abscess revealed there was no surgical intervention warranted.Review of hospital lab results dated 03/05/26 revealed blood culture results revealed MRSE and gram-positive cocci (GPC) in clusters. Urine culture results revealed greater than 100,000 of mixed microbiota. A Complete Blood Count (CBC) revealed low hemoglobin level of 5.2 grams per deciliter (g/dL). Resident #3 was given a blood transfusion of two units of packed RBCs on 03/05/26.Review of hospital record titled Infectious Disease Service dated 03/05/26 revealed Resident #3 was admitted to hospital for shock which could be combination of septic and hemorrhagic shock as his hemoglobin level was 5.2. Resident #3 had a left-sided chest wall implanted vascular access device. Blood cultures from the device revealed gram positive cocci (bacteria). Resident #3 was treated with Daptomycin (an intravenous antibiotic) and Zosyn (another intravenous antibiotic). The note also indicated the resident remained on oral Vancomycin (an antibiotic) for recurrent C. Diff.Review of progress note dated 03/12/26 revealed Resident #3 re-admitted to the facility. There was no evidence the facility had identified Resident #3 had an implanted venous access device.Interview on 04/09/26 at 10:53 A.M. with Registered Nurse (RN) #840 from the outside oncology office revealed on 03/04/26, Resident #3 came to office for a chemotherapy treatment. RN #840 stated Resident #3 had been on hold from treatments due to health issues. RN #840 stated when Resident #3 arrived for his appointment he appeared disheveled and unbathed. RN #840 stated their biggest concern was Resident #3's implanted vascular access device had been previously accessed. RN #840 described the device as still having a Huber needle accessing the port in Resident #3's chest. RN #840 stated there was a dressing over the device which was heavily stained and the edges were peeling up. RN #840 stated they were very concerned about infection risk. RN #840 reported Resident #3 was sent to the hospital from the oncology office. RN #840 stated the dressings were typically changed once per week. RN #840 stated Resident #3 had been discharged from the hospital on [DATE] to the facility with the Huber needle still in place. RN #840 stated she would have expected the facility to send Resident #3 back to the hospital to have the needle removed from the resident's implanted vascular access device. Interview on 04/09/26 at 11:08 A.M. with Certified Nursing Assistant (CNA) #808 revealed she regularly cared for Resident #3. CNA #808 was unable to recall if Resident #3 had a vascular access port when she provided bathing assistance.Interview on 04/09/26 at 11:18 A.M. with RN #802 revealed she regularly cared for Resident #3. RN #802 stated she was unaware of Resident #3 receiving chemotherapy treatments. RN #802 was unable to recall if Resident #3 had a vascular access port.Follow up email correspondence dated 04/09/26 at 1:06 P.M. from RN #840 revealed a review of Resident #3's hospital medical record was completed and revealed there were no appointments on 02/11/26. RN #840 reported Resident #3 was admitted to the hospital from [DATE] to 02/20/26. RN #840 stated she believed the dressing was actually labeled 02/17/26, however due to legibility and the condition of the dressing it was mistaken for 02/11/26.Interview on 04/09/26 at 1:51 P.M. with the Director of Nursing (DON) revealed the facility did not access implanted venous access devices. The DON confirmed there was no evidence in Resident #3's medical record for monitoring of his implanted venous access device. The DON was unable to provide any evidence the facility had identified the device or monitored the device in any way.Interview on 04/09/26 at 2:49 P.M. with RN #804 revealed she regularly cared for Resident #3. RN #804 stated she had observed Resident #3's implanted venous access device in the past. RN #804 stated she did not have any orders indicating to monitor or address the device. RN #804 stated she could not recall seeing the device accessed.Interview on 04/13/26 at 11:27 A.M. with NP #822 for Physician #820 revealed she was aware Resident #3 had an implanted venous access device. NP #822 stated she had not been notified there were any uses or issues with the device. NP #822 stated she had not visited Resident #3 at the facility and had only seen him in the hospital. NP #822 stated the hospital usually de-accessed the device prior to discharging a patient. NP #822 stated there would be risk for infection if the device was left accessed.Attempted interview on 04/13/26 at 4:24 P.M. with LPN #811 revealed she was a former employee, and the phone number provided was disconnected. LPN #811 had authored progress note on 03/04/26 when Resident #3 was admitted to the hospital.Interview on 04/14/26 at 9:05 A.M. with Physician #820 revealed Resident #3 did have implanted venous access device, however it would not be used by the facility. Physician #820 stated there was a large risk for infection and most nurses were not trained on proper use of the device. Physician #820 stated he was unaware Resident #3's device had remained accessed while at the facility. Physician #820 stated he was not the primary physician for Resident #3 while he was at the hospital. Physician #820 adamantly denied the facility should be handling the device; however, did state the facility could have identified and questioned the dressing date or access of the device. Physician #820 stated it was highly unusual that an implanted venous access device would remain accessed when a patient was discharged to a nursing home; however, he was unable to guarantee this.Review of facility policy Venous Access Site Care dated December 2024 revealed the facility would routinely assess, protect and maintain all venous access sites that were not currently being accessed. The site should be monitored at least once per shift for redness, swelling, pain, drainage, or dislodgement. Implanted ports that were not accessed do not require a dressing once healed.Review of web article titled About Your Implanted Port dated 09/29/25 authored by Memorial [NAME] Cancer Center revealed an implanted port is often called a Mediport or Port-a-Cath. An implanted port is a type of central venous catheter which protects veins from damage from repeated access. The implanted port can be used for blood samples, intravenous medications, intravenous fluids, intravenous blood products such as platelets and plasma, and intravenous contrast. Only trained healthcare providers should access ports. When accessed the port and needle would be covered with a dressing to keep the needle in place.Review of web article titled Blood Transfusions dated 10/30/24 authored by the American Cancer Society revealed blood transfusions may be necessary for some people with cancer related to type of cancer, side effects of cancer treatment, and some people who have had cancer for an extended time can develop anemia of chronic disease. Blood transfusions are given intravenously and can be given using central catheters.This deficiency represents non-compliance investigated under Complaint Number 2796317.

Based on interview, medical record review, and facility policy review, the facility failed to maintain safety during assisted ambulation, resulting in a fall. This affected one resident (#57) of three residents reviewed for falls. The facility census was 102.Findings include: Review of the medical record for Resident #57 revealed an admission date of 07/29/23 and diagnoses including Alzheimer's disease, dementia, generalized anxiety disorder, repeated falls, and abnormalities of gait and mobility.Review of the plan of care revised on 12/13/23 revealed Resident #57 has had an actual fall. Interventions include therapy evaluation and treatment as ordered, inquire for family input, bed against wall, call before fall signage in clear view, complete fall assessments, educate family and resident on fall risk, ensure appropriate footwear when out of bed, evaluate risk factors, and inform resident staff will assist her to the bathroom and with transfers.Review of Physical Therapy Discharge Summary from 08/21/25 revealed at time of discharge, Resident #57 was able to ambulate with a front-wheeled walker for 150 feet with supervision/touching assistance.Review of the Fall Risk Evaluation dated 01/20/26 revealed Resident #57 was not considered at high risk for falls.Review of the plan of care revised on 02/17/26 revealed Resident #57 required assistance with activities of daily, utilized wheelchair for locomotion, and may require assistance with locomotion. Interventions included assist resident to bathroom following meals, assist with activities of daily living, resident requires assistance with toileting hygiene and transfers, assist with one to two staff for bed mobility/transfers/toileting, may use sit-to-stand lift during episodes of fatigue, provide necessary equipment and adequate time for self-participation in daily care, and up in wheelchair for all meals.Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #57 had moderately impaired cognition. Resident #57 used a wheelchair for mobility within in the last seven days prior to the assessment. Resident #57 required partial moderate assistance for transfers and sit-to-stand. Resident #57 required supervision touching assistance for wheelchair use of 50 feet and 150 feet. Resident #57 was evaluated as not applicable for walking 10 feet.Review of nurse aide charting from 03/23/26 to 04/02/26 revealed for walking 10 feet, Resident #57 required partial/moderate assistance (helper provides less than half of the effort, lifts/holds/supports trunk or limbs) on 03/23/26, 03/24/26, and 03/25/26 and substantial/maximal assistance (helper does more than half of the effort, lifts/holds/supports trunk or limbs) on 03/28/26, 03/29/26, and 04/01/26. Nurse aide charting for walk in room revealed Resident #57 required limited assistance (staff provide guided maneuvering of limbs or other non-weight bearing assist) on 03/23/26, 03/24/26, and 03/25/26 and extensive assistance (staff provide weight-bearing support) on 03/28/26, 03/29/26, 03/30/26 and 04/01/26.Review of the Functional Abilities and Goals assessment dated [DATE] revealed Resident #57 required substantial/maximal assistance for moving from a sitting to a standing position. Walking 10 feet was not attempted due to medical condition or safety concerns.Review of the Fall Risk Evaluation dated 04/02/26 revealed Resident #57 was not considered at high risk for falls.Review of the Fall Investigation Report dated 04/02/26 revealed Resident #57 had fall in her room while using a walker. Resident #57 was noted to be alert and oriented to person and place. Resident #57 hit the back of her head and was sent to the hospital. There was no pain reported. The fall was witnessed by Certified Nursing Assistant (CNA) #812. Resident #57's physician and responsible party were notified.Review of a Pain Assessment/Evaluation dated 04/02/26 revealed Resident #57 had a fall. Resident #57's pain score was zero out of 10. Review of Post Fall Observations (72 Hour Documentation) dated 04/02/26 revealed Resident #57's blood pressure was 142/84, temperature was 97.8 degrees, pulse was 86, and oxygen saturation was 97 percent on room air. Resident #57 had not had a change in ADL ability from pre-fall activity. Resident #57 was alert and oriented.Review of a Fall Incident Report dated 04/02/26 revealed at 7:40 A.M., CNA #812 informed Licensed Practical Nurse (LPN) #809 that Resident #57 had fallen. Resident #57 was observed lying on her left side in front of her bed. Resident #57 stated she was attempting to go to the bathroom with a walker and lost balance and fell to floor. Resident #57 stated she had hit the back of her head. There were no apparent injuries noted and Resident #57 did not lose consciousness at time of fall.Review of a Witness Statement Form undated revealed CNA #812 stated she was assisting Resident #57 to the bathroom with a walker. CNA #812 noted there was a mechanical lift in the room which was in the way. CNA #812 stated while keeping a hand on Resident #57, she pushed the mechanical lift out of the way for an easier pathway. Resident #57 lost her balance and fell to the floor.Review of an Interdisciplinary Team (IDT) note dated 04/02/26 revealed Resident #57's fall was reviewed. Resident #57 was walking to the bathroom with a walker and lost her balance and fell. Resident #57 was sent to hospital for evaluation. A new fall intervention was added to post a 'call before fall' sign in room to remind the resident to ask for assistance.Interview on 04/13/26 at 12:19 P.M. with CNA #812 revealed she was assisting Resident #57 to get up and walk to bathroom with a walker. CNA #812 stated she was behind Resident #57 and noticed a mechanical lift leg was in the way, so CNA #812 pushed the mechanical lift out of the way. CNA #812 stated Resident #57 lost her balance and fell backwards. CNA #812 stated she had a hand near Resident #57's lower back. CNA #812 stated she did not use a gait belt (a belt worn around a patient's waist to provide caregivers a secure and comfortable grip for assistance with standing, walking, or transfers) during the ambulation or transfer. CNA #812 stated she notified the nurse who assessed Resident #57. CNA #812 stated she did not see any injuries or hear Resident #57 complain of pain. CNA #812 stated this was how she normally walked with Resident #57 and stated she had never used the sit-to-stand lift with Resident #57.Interview on 04/13/26 at 12:25 P.M. with Director of Rehabilitation #813 revealed Resident #57 had not been seen by therapy since August 2025. Director of Rehab #813 stated when Resident #57 discharged from therapy, she could safety ambulate with a walker and staff by contact guard assistance. Director of Rehab #813 stated when therapy staff ambulated with residents, they use a gait belt, and it would be recommended the nurse aides use gait belts as well.Interview on 04/13/26 at 2:33 P.M. with LPN #809 revealed she was not Resident #57's assigned nurse on 04/02/26, however CNA #812 had notified her when Resident #57 fell. LPN #809 stated she found Resident #57 lying on her left side on the floor with no visible injuries. LPN #809 stated Resident #57 reported hitting her head during the fall however was not in any pain. LPN #809 stated she called Resident #57's representative who requested Resident #57 be sent to the hospital for evaluation. LPN #809 stated she knew CNA #812 was in the room when Resident #57, but was unsure what type and amount of assistance the CNA was providing.Interview on 04/13/26 at 3:12 P.M. with the Director of Nursing (DON) revealed nurse aide staff do not use gait belts for Resident #57 and a hand to the back would be appropriate. The DON stated CNA #812 was educated to ensure all obstacles were out of the way before ambulating with a resident. The DON reported the documentation of nurse aides, care planning, MDS, and functional assessment was incorrect and insisted Resident #57 could ambulate by supervision with touching assistance. The DON reported Resident #57 remained out at the hospital.Follow up interview on 04/13/26 at 4:00 P.M. with Director of Rehab #813 revealed supervision with touching assist could be hands-on or hands-off. Director of Rehab #813 stated she felt it was appropriate for CNA #812 to push the mechanical lift out of the way and take hands off Resident #57 during ambulation. Director of Rehab #813 did not address questioning of how directly removing hands from Resident #57 during ambulation resulted in fall. Director of Rehab #813 did not address the current differences in functional ability charting compared to a therapy discharge from August 2025.Interview on 04/14/26 at 10:25 A.M. with the DON revealed there was no policy to address ambulation or transfers of residents.Review of facility policy Fall Prevention Policy dated November 2024 revealed staff would take proactive measures to ensure resident safety and minimize fall risk. Procedures for fall prevention included keeping walkways clear and free of clutter, encouraging residents to use assistive devices, and using proper transfer techniques and gait belts as needed.This deficiency represents non-compliance investigated under Master Complaint Number 2979859.

Based on observation and staff interview, the facility failed to ensure its dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all 107 residents residing in the facility. The facility census was 107.Findings include: Observation of the dumpster area on 02/23/26 at 8:00 A.M., upon entering the facility, revealed two dumpsters were overflowing with trash piled approximately two to three feet high. Further observation revealed three of the four dumpster lids were open.Interview and observation on 02/23/26 at 9:16 A.M. with Dietary Manager (DM) #525 verified the findings.

Based on observation, staff interview, and policy review, the facility failed to ensure residents' rights to privacy and confidentiality of their medical records were maintained. This had the potential to affect all 107 residents residing in the facility. The facility census was 107.Findings include:Observation and interview during medication administration on 02/25/26 at 8:48 A.M. revealed Licensed Practical Nurse (LPN) #556 was using her personal laptop computer to access and document resident medication administration. LPN #556 stated the use of personal laptops for documentation was normal within the facility and confirmed her device did not contain firewalls or protective security software to prevent unauthorized access to resident medical records.Observation and interview during a medication administration on 02/25/26 at 2:35 P.M. revealed LPN #541 was using her personal laptop computer to access and document resident medication administration. LPN #541 stated she used her personal laptop due to lack of availability of facility-issued laptops and confirmed her device did not contain firewalls or protective security software to prevent unauthorized access to resident medical records.Review of the facility policy titled, Medical Records, dated 07/01/23, revealed that every effort will be made to ensure records are confidential, secure, readily accessible to authorized staff, and retained in accordance with applicable laws and regulatory requirements. The policy further revealed medical records are confidential and protected under the Health Insurance Portability and Accountability Act (HIPAA). The observed practice was inconsistent with the facility's written policy and failed to ensure confidentiality of resident records.Review of the facility policy title, Protected Health Information (PHI), Management and Protection of, dated 04/01/07, revealed it is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release of disclosure.

Based on review of staffing schedules and timecard punches, review of resident census data, and staff interview, the facility failed to ensure a registered nurse worked in the facility for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 107 residents residing in the facility. The census was 107. Findings include: Review of the facility staffing schedules and staff timecard punches dated from 12/25/25 through 12/31/25, revealed there was no registered nurse (RN) working in the facility on 12/25/25 and 12/31/25. Review of the facility census data for 12/25/25 and 13/31/25 revealed 97 were residing in the facility on those dates.Interview on 02/24/26 at 3:18 P.M. with the Director of Nursing (DON) verified there was no RN coverage on 12/25/25 and 12/31/25. She stated she was the only RN in the building on those days.This deficiency represents non-compliance investigated under Complaint Number 2671148 and Complaint Number 2603969.

Based on review of narcotic medication logs, medical record review, staff interview, and facility policy review, the facility failed to ensure all narcotic count sheets were signed, completed, and maintained the accurate receiving, dispensing, and reconciliation of all controlled substance medications, and failed to ensure administered medications were accurately documented within the medical record. This had the potential to affect all 107 residents residing in the facility. The facility census was 107.Findings include:1. Observation on 02/25/26 at 8:00 A.M. of the facility narcotic medication count binders revealed, the Two North (front) narcotic log was missing the second nurse narcotic count verifier on 02/25/26 at 7:00 A.M. The Two North (back) narcotic log was missing signatures on 02/22/26 at 7:00 A.M. and 02/22/26 at 7:00 P.M. The One North narcotic log (East) was missing count signatures on 02/21/26 at 7:00 P.M., 02/22/26 at 7:00 A.M., 02/18/26 at 7:00 P.M., 02/19/26 at 7:00 A.M., 02/24/26 at 7:00 A.M., 02/14/26 at 7:00 A.M., 02/14/26 at 7:00 P.M., 02/15/26 at 7:00 A.M., 02/10/26 at 7:00 P.M., 02/08/26 at 7:00 A.M., 02/08/26 at 7:00 P.M., 02/17/26 at 7:00 A.M., 02/02/26 at 7:00 A.M., 02/02/26 at 7:00 P.M., and 01/31/26 at 7:00 P.M.Interview with the Director of Nursing (DON) on 02/26/26 at 2:45 P.M. verified the missing signatures on the identified narcotic count sheets. The DON stated she would re-educate staff regarding change of shift narcotic counts and the importance of completing documentation verifying the accuracy of narcotic count logs per facility policy. Review of the undated facility policy titled, Best Practice for Medication Dispensing: Scheduled II Narcotics, revealed to decrease costs and increase accountability with scheduled II narcotics, a standard is implemented. Authorized personnel will follow the state and federal regulations regarding schedule II narcotics.2. Review of the medical record for Resident #4 revealed an admission date of 10/29/25 with diagnoses including diabetes mellitus, hypertension, and chronic kidney disease.Review of Resident #4's active physician orders as of February 2026 revealed the resident was ordered atorvastatin 40 milligrams (mg) at bedtime for high cholesterol on 10/29/25; aspirin 81 mg twice daily related to heart disease on 10/29/25; carvedilol 25 mg twice daily for heart disease on 10/29/25; buspirone 10 mg twice daily for anxiety on 10/29/25; gabapentin 300 mg three times a day for pain on 11/03/25; Ramelteon eight (8) mg at bedtime for insomnia on 12/11/25; and insulin glargine solution 40 units inject subcutaneously at bedtime for diabetes mellitus on 01/30/26.Review of Resident #4's medication administration record (MAR) for February 2026 revealed the resident's atorvastatin 40 mg at bedtime was not documented as given on 02/05/26, 02/06/26, 02/10/26, 02/13/26 and 02/19/26. Further review of the MAR revealed aspirin 81 mg at bedtime on 02/05/26, 02/06/26, 02/10/26, 02/13/26, and 02/19/26 was documented as not administered; carvedilol 25 mg at bedtime on 02/05/26, 02/06/26, 02/10/26, 02/13/26, and 02/19/26 was documented as not administered; buspirone 10 mg at bedtime on 02/05/26, 02/06/26, 02/10/26, 02/13/26, and 02/19/26 was documented as not administered; gabapentin 300 mg at 10:00 P.M. on 02/05/26, 02/10/26, 02/13/26, 02/19/26, and at 6:00 A.M. on 02/06/26, 02/11/26, 02/14/26, and 02/20/26 was documented as not administered; Ramelteon 8 mg at bedtime on 02/05/26, 02/06/26, 02/10/26, 02/13/26, and 02/19/26 was documented as not administered; and insulin glargine 40 units at 9:00 P.M. on 02/05/26, 02/10/26, 02/13/26, and 02/19/26 was documented as not administered.Interview on 02/25/26 at 12:51 P.M. with the DON verified the medications listed above for Resident #4 were not documented as administered on the February 2026 MAR. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medication must be administered in accordance with orders, including any require time frame.

Based on observation, resident interview, and staff interview, the facility failed to ensure all hot foods were served at adequate and palatable temperatures. This had the potential to affect 105 residents who received meals from the facility. The facility identified Resident #8 and Resident #67 received no food from the kitchen. The facility census was 107. Findings include: Interview with Resident #11 on 02/23/26 at 1:58 P.M. revealed the food was cold all the time. Interview with Resident #6 on 02/24/26 at 8:50 A.M. revealed the food was never hot.Observation and interview of a test meal tray with Dietary Manager (DM) #526 on 02/24/26 at 12:41 P.M. revealed the tray consisted of a chicken breast filet, rice, peas and carrots, and a grape drink. Temperatures were obtained in the presence of DM #526 with the food temperatures including the chicken breast was 122 degrees Fahrenheit (F), the peas and carrots were 122 degrees F, and the rice was 141 degrees F. The chicken and the peas and carrots were warm but not hot when consumed. DM #526 verified the findings of the test tray at the time of observation.This deficiency represents non-compliance investigated under Complaint Number 2671148.

Based on observation and staff interview, the facility failed to ensure the kitchen environment, kitchen equipment, and food was maintained in a clean and sanitary manner. This had the potential to affect 105 residents who received meals from the facility. The facility identified Resident #8 and Resident #67 who received no food from the kitchen. The facility census was 107.Findings include: Observation of the kitchen area with Dietary Manager (DM) #526 on 02/23/26 between 9:03 A.M. and 9:21 A.M. revealed one loaf of bread on the bread rack was moldy, the oven and stove handles and knobs had accumulated grease and dirt, the floor throughout kitchen had spills and sticky areas and the floor in preparation area across from the steamer had dirt and crumbs, the counter in preparation area around the can opener had grease and a sticky substance on it, and the shelf over the oven had a coating of grease and dust.Interview with DM #526 on 02/23/26 between 9:03 A.M. and 9:21 A.M. confirmed the above findings at the time of discovery.

Based on observation and staff interview, the facility failed to ensure the physical environment was maintained in a clean, sanitary, and homelike manner. This affected 28 (#17, #34, #37, #38, #39, #43, #47, #50, #52, #53, #54, #58, #63, #64, #74, #77, #81, #83, #86, #87, #90, #92, #98, #99, #104, #107, #141, and #162) of 107 residents residing in the facility. The census was 107. Findings Include:1. Observation of Resident #64's room on 02/25/26 at 11:46 A.M. revealed no bathroom door was present.Interview with Licensed Practical Nurse (LPN) #634 on 02/26/25 at 11:50 A.M. verified the lack of a bathroom door in Resident #64's room.2. Observation of the facility environment with Housekeeping Director #700 on 02/26/26 between 1:15 P.M. and 1:45 P.M. revealed the air vent in Resident #50's room was heavily rusted; the privacy curtains in Resident #39, Resident #52, Resident #58, Resident #63, Resident #77, Resident #87, Resident #92, and Resident #107's rooms were visibly stained; the tile flooring in Resident #99 and Resident #162's room contained unidentified substance on the floor and visible staining; Resident #34 and Resident #90's room had thick dust accumulation on the ceiling, Resident #90's supplemental feeding administration pole had a large amount of dried supplement residue; the windowsill in Resident #141's room had a large brown stain; the air conditioning units in Resident #98 and Resident #104's room contained a bird nest and birds could be heard chirping from within the unit; Resident #53's fall mat was torn, worn, and soiled; Resident #54's dresser was missing drawers and the toilet in the room had brown staining; Resident #83's sink in the living area was cracked; Resident #64's light over the bed had a visible crack, and Resident #43's headboard was broken off and was resting beside the bed.Further observation on 02/26/26 between 1:15 P.M. and 1:45 P.M. revealed the closet doors were missing in the rooms for Resident #17, Resident #37, Resident #38, Resident #47, Resident #52, Resident #54, Resident #58, Resident #74, Resident #81, Resident #86, Resident #87, and Resident #92.The above findings were confirmed by Housekeeping Director #700 during the environmental tour on 02/26/26 at the time of discovery. This deficiency represents non-compliance investigated under Complaint Number 2671148 and Complaint Number 2659118.

Based on medical record review and staff interview, the facility failed to accurately code resident Minimum Data Set (MDS) assessments. This affected nine (#11, #29, #32, #52, #53, #62, #64, #87, and #102) of 24 residents reviewed for MDS assessment accuracy. The facility census was 107.Findings include:1. Review of the medical record for Resident #29 revealed the resident was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dementia, and major depressive disorder. Review of the level two Preadmission Screening and Resident Review (PASRR) evaluation dated 03/21/07 revealed Resident #29 had a level two serious mental illness. Review of Resident #29's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses that included delusional disorder, hallucinations, and major depressive disorder. Review of the level two PASRR evaluation dated 06/16/23 revealed Resident #32 had a level two serious mental illness. Review of Resident #32's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 3. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses that included heart failure, schizophrenia, and generalized anxiety disorder. Review of the level two PASRR evaluation dated 08/21/21 revealed Resident #52 had a level two serious mental illness. Review of Resident #52's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 4. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses that included hypoxemia, schizophrenia and acute respiratory failure. Review of the level two PASRR evaluation dated 12/01/15 revealed Resident #53 had a level two serious mental illness. Review of Resident #53's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 5. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses that included mood disorder, intermittent explosive disorder, and bipolar disorder. Review of the level two PASRR evaluation dated 11/14/24 revealed Resident #62 had a level two serious mental illness. Review of Resident #62's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 6. Review of the medical record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses that included mood disorder, intermittent explosive disorder, and bipolar disorder. Review of the level two PASARR evaluation dated 12/02/25 revealed Resident #64 had a level two serious mental illness. Review of Resident #64's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 7. Review of the medical record for Resident #87 revealed the resident was admitted to the facility on [DATE] with diagnoses that included mood disorder, schizophrenia, and schizoaffective disorder. Review of the level two PASRR evaluation dated 12/04/24 (from previous facility that resident transferred from) revealed Resident #87 had a level two serious mental illness. Review of Resident #87's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 8. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE] with diagnoses that included cocaine dependence, schizophrenia, and schizoaffective disorder. Review of the level two PASRR evaluation dated 08/07/24 (from previous facility that resident transferred from) revealed Resident #87 had a level two serious mental illness. Review of Resident #102's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Interview with MDS Nurse #609 on 02/27/26 at 11:00 A.M. verified Resident #29, Resident #32, Resident #52, Resident #53, Resident #62, Resident #64, Resident #87, and Resident #102 all had their PASRR status incorrectly coded on MDS assessments as noted above. 9. Record review for Resident #11 revealed an admission date of 10/30/25. Diagnoses included pain in the left hip, unilateral primary osteoarthritis, left knee, intervertebral disc degeneration, lumbar back pain, and pain in right foot. Review of the MDS assessment dated [DATE] revealed Resident #11 was cognitively intact and did not receive scheduled pain medication. Review of the physician orders for January 2026 revealed Resident #11 had active orders for the narcotic pain medication oxycodone extended release (ER) 12-hour abuse deterrent 10 milligrams (mg) by mouth two times a day for pain initiated on 01/06/26, and the nerve pain medication Lyrica oral capsule 75 mg by mouth three times a day initiated on 11/20/25. Interview and record review on 02/27/26 at 12:05 P.M. with MDS Nurse #609 verified the MDS assessment dated [DATE] was incorrect and confirmed Resident #11 was on routine pain medication in January 2026, including during the five-day look back period the MDS assessment was completed for.

Based on medical record review, business records review, and staff interview, the facility failed to ensure final accounting and conveyance of resident funds was completed within 30 days upon death. This affected three (#126, #127, and #128) of three residents reviewed for final conveyance of trust accounts. The facility census was 107.Findings include:1. Review of the medical record revealed Resident #126 was admitted to the facility on [DATE]. Resident #126 expired at the facility on [DATE].Review of the business records for Resident #126 revealed a check for Resident #126's personal funds balance remaining at the facility in the amount $1,1179.30 was dispensed on [DATE] to the states Medicaid recovery bureau.2. Review of the medical record revealed Resident #127 was admitted to the facility on [DATE]. Resident #127 expired at the facility at the facility on [DATE].Review of the business records for Resident #127 revealed a check for Resident #127's personal funds balance remaining at the facility in the amount $102.42 was dispensed on [DATE] to the states Medicaid recovery bureau.3. Review of the medical record revealed Resident #128 was admitted to the facility on [DATE]. Resident #128 expired at the facility at the facility on [DATE].Review of the business records for Resident #128 revealed a check for Resident #128's personal funds balance remaining at the facility in the amount $2,120.09 was dispensed on [DATE].Interview with the Administrator on [DATE] at 9:45 A.M. verified final accounting and conveyance of Resident #126, Resident #127, and Resident #128's personal funds were not completed within 30 days following their deaths.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure a resident had active orders for use of supplemental oxygen. This affected one (#53) of one residents reviewed for respiratory care. The census was 107.Findings include:Review of the medical record for Resident #53 revealed an admission date of 12/30/15 with diagnoses including paranoid schizophrenia, dyskinesia, asthma, respiratory failure, anxiety, dyskinesia, and nicotine dependence.Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact.Observation and interview of Resident #53 on 02/23/26 at 1:12 P.M. revealed an oxygen concentrator was turned on in the room and set to four liters per minute flow rate. When asked about the usage of his oxygen, Resident #53 stated he wore the oxygen intermittently for shortness of breath or after smoking outside. Resident #53 stated he used the oxygen daily for a long time.Review of Resident #53's current physician orders revealed the resident had no active orders for supplemental oxygen use. Review of completed and discontinued physician orders revealed an order for oxygen was discontinued on 12/13/25 and was only originally ordered for two liters per minute per nasal cannula.Interview with Licensed Practical Nurse (LPN) #519 and Assistant Director of Nursing (ADON) #608 on 02/27/25 at 2:02 P.M. verified there was no active order for oxygen and confirmed Resident #53 had been using the oxygen for months. LPN #519 and ADON #608 did not know the order for oxygen was discontinued on 12/29/25 which was two months earlier.

Based on medical record review and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after hospice services were discontinued for one resident (#3) of three residents reviewed for hospice services. The facility census was 107.Findings include:Record review for Resident #3 revealed an admission date of 07/19/19. The resident had a diagnosis of benign prostatic hyperplasia. Record review revealed a hospice order dated 10/23/24 to admit Resident #3 to hospice services.Review of the progress note dated 11/14/25 at 12:11 P.M., completed by Licensed Practical Nurse (LPN) #543, revealed Resident #3 was transferred to the hospital via stretcher with two paramedics and hospice was aware.Review of the progress note dated 11/25/25 at 3:16 P.M., completed by LPN #552, revealed Resident #3 returned from the hospital. Resident #3 was admitted for hypernatremia, urinary tract infection, and aspiration pneumonia. Record review revealed a hospice order dated 11/20/25 confirming hospice services were discontinued for Resident #3.Review of the Minimum Data Set (MDS) assessment submission log from 11/25/25 through 03/02/26 for Resident #3 revealed there was no significant change MDS assessments completed after discontinuing hospice services.Interview on 03/02/26 at 5:10 P.M. with MDS Nurse #609 confirmed a significant change MDS assessment should have been completed after Resident #3 returned from the hospital on [DATE] with no hospice services.

Based on observation, resident and staff interviews, medical record review, and facility policy, the facility failed to develop and effective means of communication for a resident who spoke limited English to ensure the resident was able to effectively communicate requests and needs. This affected one (#89) of 24 residents interviewed for the provision of care. The facility census was 107.Findings include:Review of Resident #89's medical record revealed an admission date of 07/17/25. Diagnoses included age-related osteoporosis with pathological fracture, adult failure to thrive, protein calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure and alcohol abuse. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with severely impaired cognition and required maximum assistance and cuing for all activities of daily living.Observation and interview with Resident #89 on 02/23/26 at 9:35 A.M. revealed the resident had difficulties in communicating to the surveyor and his roommate (Resident #101) during initial interview due to Resident #89 speaking only Spanish. Resident #89 was not able to respond effectively to questions regarding care or treatment at facility. There was no communication board in room for Resident #89 to use for communicating needs and activities of daily living (ADLs) including pain, bathroom, food, water, and hygiene needs. Resident #89 was able to understand some simple words, but had difficulty expressing thoughts and needs. Attempts with a telephone translation application on the surveyor's telephone provided some additional communication with the resident, however; due to on-going oral problems with Resident #89, he could not speak effectively into the translation application device and have his words translate correctly from Spanish to English. Resident #89 was able to understand some translations from English to Spanish with device.Interview with Resident #101 on 02/23/26 at 9:45 A.M. revealed he, looks out for him (Resident #89). Resident #101 stated he frequently uses the translator application on his telephone to assist Resident #89's needs and will call for assistance from staff for Resident #89. Resident #101 stated staff do not use a communication board or electronic translator when providing care and Resident #89 does not understand what staff are speaking to him about. Resident #101 stated staff do not take the time to ensure Resident #89 understands directions.Additional interview with Resident #89 on 02/25/26 at 12:10 P.M., using the electronic Spanish translator telephone application, revealed he had difficulties communicating with staff. Resident #89 had not been eating well and had lost weight due to his teeth. He did not like the pureed diet and his mouth hurt when he was trying to eat. Resident #89 stated he had not had dental care and was requesting services to improve his oral care and diet. Resident #89 was able to answer yes and no to simple questions but could not appropriately speak his on-going concerns or needs. Communication with the resident was difficult as the Spanish to English translation on the telephone application could not understand all of his words due to oral difficulties and poor annunciation into the device.Interview with Speech Therapist #630 on 02/26/26 at 11:21 A.M. stated Resident #89 understood very simple words and commands such as pain, bathroom, food, water in English, but could not have a conversation with staff. Speech Therapist #630 stated she would supply the resident with a communication board in his room. She also verified Resident #89 had had oral problems and could not annunciate words correctly and had his diet changed from mechanical soft to puree due to oral issues. Speech Therapist #630 stated Resident #89 did not understand most English language but could not answer effectively or communicate all needs and concerns.Interview with Licensed Practical Nurse #556 (LPN) on 02/26/26 at 2:15 P.M. revealed Resident #89 did understand some English but could not speak English except for simple words. She stated Resident #89 did understand what staff are saying to him and LPN #556 verified no communication board or tools were present in the resident's room for Resident #89 to utilize.Interview with Certified Nurse Aide (CNA) #588 on 02/27/26 at 9:47 A.M. confirmed there was no communication board or posted frequently used words for translation from Spanish to English for Resident #89. She stated he did understand English but cannot speak English well. She also stated Intake/admission Director (IAD) #654 was able to translate important concerns for the resident when she was onsite at the facility. Of note, Intake/admission Director #654 was not always available or onsite at facility since she also traveled to another regional facility.Interview with IAD #654 on 03/03/26 at 11:00 A.M. revealed she was fluent in Spanish and was often called upon to translate Spanish to residents at the facility. She stated she had translated and explained pertinent clinical and procedural information to Resident #89 since his admission. IAD #654 stated staff will call when having difficulties communicating with the resident. AID #654 confirmed speech therapy does have communication boards for residents if needed but confirmed she had not seen them used with Resident #89.Review of facility policy titled, Communication for Residents with Limited English Proficiency, dated July 2024, revealed the facility may provide qualified interpreter services when needed, including telephone, video, or in-person interpreters. Staff may use translator applications to assist in communication, and residents will receive safe, effective, and understandable communication regarding their care, rights, and services.

Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure residents needs and preferences were met regarding appropriate linens on beds and maintaining bathing equipment for use to accommodate resident preference. This affected two residents (#105 and #22) of 13 residents reviewed for accommodation of needs. The facility census was 107.Findings include:1. Record review for Resident #105 revealed an admission date of 10/24/24. Diagnoses included dislocation of an unspecified knee, morbid severe obesity, and encounter for orthopedic aftercare. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 was cognitively intact. Resident #105 had impairment on one side of the lower extremities, used a wheelchair for mobility, required set up or clean up assist with toileting hygiene, supervision or touch assist with personal hygiene, and partial/moderate assist with bed mobility and transfers. Observation on 02/24/26 at 10:25 A.M. revealed Resident #105 was lying in bed with her eyes closed. The bed was noted to be a bariatric (larger bed) bed and there was no fitted sheet on the mattress. Resident #105 was resting on the bare mattress.Observation and interview 02/24/26 at 4:33 P.M. revealed Resident #105 was still lying in her bed directly on the mattress with no fitted sheet under her. Resident #105 stated, They do not have a lot of bed sheets, the fitted ones. I have to lay on the bare mattress and I do not like it but they are always running out. Resident #105 revealed she does not refuse the sheet; the facility just does not have them available and revealed they also frequently run out of gowns and towels. Observation and interview on 02/24/26 at 4:46 P.M. with Licensed Practical Nurse (LPN) #637 confirmed Resident #105 was lying on the bare mattress. Observation of the available linens on the south halls where Resident #105 resided confirmed there were no bariatric fitted sheets available. Observation and interview on 02/24/26 at 4:52 P.M. with the Director of Nursing (DON) of the North linen closet and the second floor confirmed there were no bariatric fitted sheets. The DON confirmed there were no bariatric fitted sheets in the residential areas for staff to use. Observation of the laundry area located in the basement of the facility with the DON revealed, after searching, Housekeeping/Laundry Director #540 found two bariatric fitted sheets.2. Record review for Resident #22 revealed an admission date of 12/18/24. Diagnosis included cerebral infarction, cellulitis, type two diabetes mellitus, and morbid, severe obesity. Review of the MDS assessment dated [DATE] revealed Resident #22 was cognitively intact. Resident #22 had impairment on one side of the upper extremities and both sides of the lower extremities and was dependent for bathing and showers. Review of the care plan initiated 12/19/24 revealed Resident #22 had an activity of daily living (ADL) self-care performance deficit. Interventions included Resident #22 required assistance with ADLs (i.e.: dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed and to honor the resident's choices and preferences whenever possible. Record review of the activity interview for daily preference document for Resident #22 dated 12/21/24 revealed for the question asking how important it was to the resident to choose between a tub bath, shower, bed bath, or sponge bath, Resident #22 answered it was very important. Record review of the resident preference evaluation for Resident #22 dated 08/23/25 revealed it was very important to Resident #22 to choose between a tub bath, shower, bed bath, or sponge bath and revealed Resident #22 chose a shower as his preference.Review of the shower records from 12/01/26 through 02/27/26 for Resident #22 revealed Resident #22 only received bed baths during that period.Interview on 02/25/26 at 10:00 A.M. with Resident #22 revealed he had not received a shower in the past two and a half to three months. Resident #22 confirmed he could only take a shower using the shower bed due to his physical condition and revealed he was told by the staff he could not receive a shower because the shower bed was broken. Resident #22 was only able to receive bed baths as he did not feel as clean and preferred showers. Observation and interview on 02/25/26 at 10:06 A.M. with LPN #541 of the shower bed confirmed the bed was missing pins that held the frame together. LPN #541 confirmed Resident #22 was unable to receive showers due to the shower bed being the only shower bed in the facility. LPN #541 revealed the bed had been broke at least a few weeks. Interview on 02/25/26 at 10:26 A.M. with Certified Nurse Aide (CNA) #575 revealed the shower bed Resident #22 used had not been working for at least a couple months.Interview on 02/25/26 at 11:47 A.M. with the Administrator revealed there were issues with the shower bed and stated it was not working a month or so, maybe a little more. This deficiency represents non-compliance investigated under Complaint Number 2710289.

Based on observation, medical record review, and staff interview, the facility failed to label, date, or initial supplemental tube feeding containers to notify when the supplement was hung and by which staff as ordered. This affected one (#70) of two residents reviewed for tube feedings. The census was 107.Findings include:Review of the medical record for Resident #70 revealed an admission date of 12/09/25. Diagnoses included dysphagia, severe protein-calorie malnutrition, and hemiplegia and hemiparesis following cerebral infarction.Review of Resident #70's active physician orders for February 2026 identified orders to change the feeding administration set with each new bottle; label the formula container, syringe, and administrative set with the resident's name, date, time, and the nurse's initials.Observation on 02/23/26 at 11:01 A.M. revealed Resident #70's tube-feeding container was hung but not labeled, dated, or initialed.Interview on 02/23/26 at 11:01 A.M. with Registered Nurse (RN) #571 verified Resident #70's tube feeding container was not labeled, dated, or initialed.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #10 received timely medical intervention for an acute change in condition. Actual Harm occurred on 03/18/25 at 1:49 A.M. when Resident #10 complained of numbness of the right side of the body and requested to go to the hospital. However, the resident was not transferred to the hosptial until 03/18/25 at 4:08 A.M. Hospital documentation revealed the resident was admitted for a cerebrovascular accident due to intracerebral hemorrhage, ischemic stroke. The resident reported he had complaints of right-sided weakness approximately four days ago which he described as a heaviness to his upper and lower extremities. Resident #10 stated his weakness had not improved since the initial onset. The resident reported he suffered a fall yesterday because his leg gave out. The resident had obvious drift to the right upper and lower extremities and an unequal weak grip strength to the right hand in comparison to the contralateral side. Resident #10 had noticeable unilateral weakness to the right upper and lower extremities. Resident #10 stated his symptoms began on 03/15/25 and his symptoms had not improved. At the time the resident arrived to the hospital, Resident #10 was out of the window for significant intervention and a stroke alert was not called. Following the hospitalization , the resident's ability to ambulate had deteriorated and the resident required the use of a wheelchair for mobility. This affected one resident (Resident #10) of three residents reviewed for change of condition. The facility census was 87. Findings include: Review of Resident #10's medical record revealed an admitted [DATE] and a re-entry date of 03/21/25. Resident #10's diagnoses included malignant neoplasm of the pancreas, drug-induced polyneuropathy, and hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side. Review of Resident #10's care plan revised 12/11/24 included Resident #10 needed assistance for ADL's related to cancer, bronchitis, asthma and other diagnoses. Resident #10 was able to ambulate on and off the unit, was alert and oriented times three (time, place, person), was able to voice needs and was able to perform ADL's independently and might require assistance during times of fatigue. Resident #10 would be well groomed and free of odors at all times and would participate as able in ADL self-care. Interventions included to observe for changes in ADL ability and adjust assistance as needed; an intervention initiated on 03/24/25 revealed utilized walker. Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] included Resident #10 was cognitively intact. Resident #10 had no impairment of the upper or lower extremities. Resident #10 did not use a cane, crutch, walker or wheelchair. Resident #10 was independent for toileting hygiene, bathing, upper and lower body dressing, personal hygiene and walking 50 feet. Review of Resident #10's medical record including progress notes dated 03/15/25 through 03/17/25 did not reveal evidence Resident #10 was experiencing numbness or weakness. Review of Resident #10's skilled nursing progress notes dated 03/16/25 at 11:26 A.M. included Resident #10's vital signs were within normal limits. Resident #10 was alert and oriented to time, place and situation. Resident #10 was weight bearing as tolerated, and had a steady gait. Weakness was not noted, able to move all extremities, and had full sensation. The note included Resident #10 did not have changes in ADL capability and did not require assistance with bed mobility. Review of Resident #10's skilled nursing progress notes dated 03/17/25 did not reveal a skilled nursing progress note was completed. Review of Resident #10's progress notes dated 03/18/25 at 1:49 A.M. revealed Resident #10 complained of numbness of the right side of the body, Resident #10 requested to go to the hospital, Resident #10 was alert and oriented times three. Vital signs were blood pressure 117/33, pulse 84, respirations 18 per minute, oxygen saturation was 98 percent on room air. The non-emergency transportation company was contacted and Resident #10 would be picked up on 03/18/25 at 8:00 A.M. Review of Resident #10's progress notes dated 03/18/25 at 1:53 A.M. revealed Resident #10 complained of numbness to the right side of his body. Review of Resident #10's medical record including progress notes dated 03/18/25 at 1:49 A.M. through 03/18/25 at 4:08 A.M. did not reveal evidence Resident #10's weakness and numbness were thoroughly evaluated. Review of Resident #10's progress notes dated 03/18/25 at 4:08 A.M. revealed Resident #10 left the facility via stretcher with two paramedics. Resident #10 was being transported to the local hospital Emergency Department. Review of Resident #10's late entry SBAR Summary for Providers dated 03/18/25 at 2:27 P.M. included on 03/18/25 at 1:49 A.M. Resident #10 had a change in condition and the CIC (change in condition) evaluation was functional decline (worsening function and, or mobility). Outcomes of a physical assessment included Resident #10 had weakness or hemiparesis, decreased mobility. Review of Resident #10's medical record including progress notes dated 03/18/25 through 03/21/25 did not reveal evidence Resident #10's physician was notified Resident #10 was having numbness and weakness and what his recommendations were. Review of Resident #10's physician orders dated 03/18/25 through 03/21/25 did not reveal a physician order to transport Resident #10 to the hospital. Review of Resident #10's medical record including progress notes did not reveal evidence Resident #10's responsible party was notified he was sent to the hospital. Review of Resident #10's hospital records dated 03/18/25 through 03/21/25 included his admission diagnosis was cerebrovascular accident due to intracerebral hemorrhage, ischemic stroke. Resident #10 presented to the ED on 03/18/25 with complaints of right-sided weakness. Resident #10 stated his weakness began approximately four days ago, and he described his right-sided weakness as a heaviness to his upper and lower extremities. Resident #10 stated his weakness had not improved since the initial onset. Resident #10 reported that he suffered a fall yesterday because his leg gave out and he had no injuries from the fall. Resident #10 was not anticoagulated. Resident #10 was chronically ill-appearing and in no obvious distress. Resident #10 had obvious drift to the right upper and lower extremities. Resident #10 had an unequal weak grip strength to the right hand in comparison to the contralateral side. Resident #10 had noticeable unilateral weakness to the right upper and lower extremities. Resident #10 stated his symptoms began on 03/15/25 and his symptoms have not improved. Resident #10 was out of the window for significant intervention and a stroke alert was not called. Review of Resident #10's After Hours Telehealth Consult progress notes dated 03/21/25 at 1:00 A.M. included Resident #10 was readmitted to the facility this evening after a hospitalization for acute CVA (cerebrovascular accident). Review of Resident #10's progress notes dated 03/21/25 at 6:48 P.M. revealed Resident #10 arrived to the facility via a stretcher accompanied by two EMT (Emergency Medical Technician)'s. Review of Resident #10's progress notes dated 03/21/25 at 5:59 P.M. included Resident #10 had right sided weakness due to CVA. Resident #10 was alert and oriented times three. Review of Resident #10's Significant Change in Status assessment dated [DATE] included Resident #10 used a cane, crutch and a wheelchair. Resident #10 did not use a walker. Resident #10 was independent for toileting hygiene, needed setup or clean-up assistance for bathing, and putting on and taking off footwear. Resident #10 required partial to moderate assistance for the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and bed mobility. Resident #10 required supervision or touching assistance for toilet transfers, to walk 10 feet and to walk 50 feet. Observation on 04/09/25 at 8:31 A.M. of Resident #10 revealed he was sitting in a wheelchair in his room. Resident #10 stated the facility needed improvement. Resident #10 indicated if he needed to go to the hospital the nurse had to call the physician and he had to wait for the physician to call back. Resident #10 stated he had a stroke, he told the nurse he needed to go to the hospital, and three hours later he finally went because he insisted. Resident #10 stated he was having a hard time walking, knew something was not right and told the nurse he had to go to the hospital, but he had to really insist because she did not want to send him. Resident #10 stated on 03/14/25 or 03/15/25 he was walking fine, the next day something did not feel right, then he had trouble walking. Resident #10 stated he told the nurse he needed to go to the hospital and she said your vitals are fine. Resident #10 revealed he experienced a fall and his roommate screamed for the nurse. Resident #17 nodded his head yes when Resident #10 stated this, but did not say anything. The nurses came to the room and the nurse told me she would call for transportation to the hospital, but the wait would be four hours and it was non-emergency transportation. Resident #10 could not remember the name of the nurse. Resident #10 stated the facility did not call the physician for three hours. Interview on 04/09/25 at 2:45 P.M. with Licensed Practical Nurse (LPN) #438 revealed she was assigned to care for Resident #10 the night he was transported to the hospital. LPN #438 stated what she knew was Resident #10 said he was not feeling well, and kept saying he did not feel well, and wanted sent out to the hospital. LPN #438 stated she took Resident #10's vital signs and they were fine. LPN #438 indicated she was new to the facility and in orientation and let the nurse manager know Resident #10 wanted sent to the hospital. LPN #438 indicated she asked Resident #10 questions to get more information about how he was feeling, he just came in from smoking and she thought he smoked more than one cigarette and the smoking was what made him not feel well. LPN #438 indicated she asked Resident #10 if he was having pain, and he said he felt numbness, and he was able to squeeze her hand. LPN #438 stated Resident #10 did not experience a fall, and when he came out of the bathroom he was kind of leaning and said his leg felt numb, he needed help (she could not remember which side) and he was assisted back to bed. LPN #438 indicated she called a physician, but she did not remember who she called or when and told the physician Resident #10 was having numbness and was told to send him out to the hospital. Resident #10 was sent to the hospital via non-emergency transportation. Interview on 04/09/25 at 4:06 P.M. wit LPN #417 revealed she was working when Resident #10 was sent to the hospital. LPN #417 stated she arrived to the facility on [DATE] around 1:00 A.M. and LPN #438 already had received orders to send Resident #10 to the hospital via non-emergency transportation. LPN #417 indicated she did not know when the transportation company was due to arrive. LPN #417 stated Resident #10 was fine when she saw him, and she told him transportation was on the way. LPN #417 stated Resident #10 did not experience a fall before he left the facility. Interview on 04/10/25 at 9:32 A.M. with Physician #600 revealed he remembered something about a call regarding Resident #10, but he took care of Resident #10 while he was in the hospital and he could not remember if the calls were before or after Resident #10 was admitted to the hospital. Physician #600 stated he did not always put a physician note in the resident record when he was called. Physician #600 stated if Resident #10 was experiencing weakness and numbness on one side of the body and it was sudden onset like within an hour or so he would definitely order him to be sent out via 911. Interview on 04/10/25 at 10:18 A.M. with Certified Nursing Assistant (CNA) #524 revealed Resident #10 could walk before he went to the hospital and now he was in a wheelchair. CNA #524 stated she thought Resident #10 had a stroke, and he told her he would be able to walk in time. CNA #524 stated Resident #10 told her he fell before he went to the hospital but he did not give details. Interview on 04/10/25 at 11:18 A.M. with the Director of Nursing (DON) revealed LPN #438 called Unit Manager (UM) #442 because Resident #10 said he was not feeling well, had numbness in his right arm, and never told her he had a fall. The DON stated UM #442 said Resident #10 did not know how to describe how he was feeling, said he wanted to smoke a cigarette and wanted to go to the hospital. UM #442 did not think it was serious. UM #442 instructed LPN #438 to call the physician and have Resident #10 sent to the hospital because it was Resident #10's right to go to the hospital if he wanted to. The DON confirmed Resident #10's medical record including progress notes did not have evidence Resident #10's numbness and weakness were evaluated thoroughly while he was at the facility, and confirmed there was no evidence Physician #600 was contacted and Physician #600 did not write a progress note regarding the call. The DON confirmed there was no evidence Resident #10's responsible party was contacted when he was transported to the hospital. Review of the facility policy titled Change in a Residents Condition or Status dated 08/2024 included the facility should promptly notify the resident, physician and representative of changes in a residents medical, mental condition or status. The nurse would notify the resident's physician when there was a significant change in the resident's physical, emotional, mental condition. Unless otherwise instructed by the resident the nurse would notify the residents representative when there was a significant change in a resident's physical, mental or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00163886.

Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent an in-house acquired pressure ulcer for Resident #14. Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility census was 98. Findings include: Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, type II diabetes mellitus, hypertension, altered mental status, neuromuscular dysfunction of the bladder, and paraplegia. A plan of care, dated 10/05/21 included an intervention to encourage resident to turn and reposition every two hours and as needed. However, there was no documented evidence on the administration records of turning and repositioning being provided for the resident. Review of the Braden Scale for predicting pressure sore risk dated 03/16/23 revealed Resident #14 was at a low risk for pressure ulcer development. Review of a skin observation document dated 05/22/23 revealed the resident had no new skin areas noted. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was cognitively intact. The assessment revealed the resident required extensive assistance from two staff for bed mobility, extensive assistance from one staff for hygiene and was dependent on two staff for transfers. The resident had an indwelling (Foley) catheter and an ostomy. The assessment also noted the resident was at risk for skin breakdown and had no behaviors, including refusal of care. Record review revealed no updates to the resident's plan of care until 08/09/23 related to risk for pressure ulcers. Review of a skin grid dated 05/23/23 revealed Resident #14 had a new area to the left heel first identified as an unstageable SDTI measuring 7.0 centimeters (cm) in length by 5.0 cm width with an undetermined depth. The ulcer was noted to have 100 percent (%) necrotic tissue. New orders were received to cleanse the left heel with wound cleanser/normal saline, pat dry, cover with abdominal pad (ABD) and wrap with Kerlix gauze, daily and as needed. Record review revealed no evidence the dietitian was notified of the development of the left heel wound to implement nutritional interventions to promote healing. Review of the skin grid dated 06/06/23 revealed the left heel was not assessed because Resident #14 was on a leave of absence (LOA) with activities. Review of the skin grid dated 06/13/23 revealed to the left heel wound measured 7.0 cm length by 6.0 cm width with an undetermined depth due to the presence of 100% necrotic tissue. The wound was now classified as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 06/20/23 revealed the left heel wound measured 8.0 cm length by 6.0 cm width with an undetermined depth due to the presence of 100% necrotic tissue. There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 06/27/23 revealed the left heel wound measured 7.0 cm length by 4.0 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was debrided sharply manually with curette at this time. There was no evidence the dietitian was notified of the presence of the ulcer at this time. Review of the skin grid dated 07/11/23 revealed the left heel wound measured 8.0 cm length by 5.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was treated with enzymatic debridement (removal of necrotic/dead tissue), Santyl (ointment used to aid in the healing of skin ulcers), calcium alginate (dressing used to repair wounds), ABD (dressing used for wounds with heavy leakage) and Kerlix gauze. Review of the skin grid dated 07/18/23 revealed the left heel wound measured 8.5 cm length by 4.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. The wound was debrided. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. Review of the skin grid dated 07/25/23 revealed the left heel wound measured 7.5 cm length by 5.5 cm width with an undetermined depth due to 50% necrotic tissue and 50% granular tissue. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. Review of the skin grid dated 08/01/23 revealed the left heel wound measured 9.0 cm in length by 7.0 cm width with an undetermined depth due to 75% necrotic tissue and 25% granular tissue. There was no evidence the dietitian was notified of the presence of the left heel wound at this time. The assessment of the wound at this time noted it was larger and had an increase in necrotic tissue. Review of a dietary progress note dated 08/09/23 revealed Registered Dietitian (RD) #1111 was notified of the left heel wound and made recommendations for a multivitamin, Vitamin C 500 milligrams (mg) twice per day (BID) for 30 days, Zinc Sulfate 220 mg every day (QD) for 14 days and liquid protein 30 milliliters (ml) QD for 30 days to promote wound healing. Review of the skin grid dated 08/15/23 revealed the left heel wound measured 6.0 cm length by 5.0 cm width with a measurable depth of 0.3 cm. The wound was assessed to continue to have 75% necrotic tissue and 25% granular tissue. The note revealed the physician was notified of a decline in the wound status. The wound was cleansed, flushed, and irrigated, and prepared for debridement/dressing. A dressing of calcium alginate, ABD pad, and kerlix gauze was applied. The wound was now classified as a Stage IV (full-thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed) pressure ulcer. Record review revealed as of 08/15/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented. Review of the skin grid dated 08/22/23 revealed the left heel wound measured 8.0 cm length by 5.0 cm width with 0.3 cm depth. The wound was noted to have 75% necrotic tissue and 25% granular tissue. The note indicated the physician was notified of a decline in wound status. Review of the wound progress note dated 08/22/23 and completed by Medical Doctor (MD) #1113 revealed the resident's left heel wound was declining and bone was exposed. MD #1113 recommended the resident be sent to the hospital for evaluation with the possible need for amputation; however, Resident #14 declined the recommendation at that time. Record review revealed as of 08/22/23 there was no evidence RD #1111's recommendations (dated 08/09/23) had been implemented. On 08/23/23 new physician orders were obtained for Vitamin C 500 mg BID for 30 days, Zinc Sulfate 220mg QD for 14 days and Pro Stat oral liquid 30 ml QD for 30 days. Review of the skin grid dated 09/05/23 revealed the left heel wound measured 9.0 cm length by 7.0 cm width with 0.3 cm depth. The wound was assessed to have 50% necrotic tissue and 50% granular tissue with bone exposed and an odor. MD #1113 was notified of the decline and recommended a hospital evaluation with the possible need for amputation; however, the resident continued to refuse to go to the hospital. The wound was treated with autolytic bone debridement (breakdown of damaged issue) and calcium alginate, ABD pad, and Kerlix gauze were applied. Review of the skin grid dated 09/12/23 revealed the left heel wound measured 9.0 cm length by 9.0 cm width with a depth of 0.3 cm. The wound was assessed to have 50% necrotic tissue and 50% granular tissue with bone exposed and odor. The wound was assessed to have declined. MD #1113 was notified of the decline and recommended a hospital evaluation with the possible need for amputation; however, the resident continued to refuse. The wound was treated with autolytic bone debridement and calcium alginate, ABD pad, and Kerlix gauze were applied. Review of the skin grid dated 09/19/23 revealed the left heel wound measured 9.0 cm length by 6.0 cm width with 0.3 cm depth and was assessed to show improvement. Interview on 09/26/23 at 8:09 A.M. with the Director of Nursing (DON) revealed when a recommendation from the RD comes in, the facility would implement the recommendation within seven days. She confirmed the orders for Resident #14 for Vitamin C 500 mg BID for 30 days, Zinc Sulfate 220 mg QD for 14 days and Pro Stat oral liquid 30 ml QD for 30 days were implemented 13 days after they were recommended, which was longer than it should have been. Interview on 09/26/23 at 11:09 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Wound Nurse #1109 revealed she could not explain how Resident #14 developed an unstageable STDI on 05/23/23 when no new issues were reported to his skin on 05/22/23. RN #1109 revealed there was no way an injury like that could have developed in one day. Interview on 09/26/32 at 11:31 A.M. with RD #1112 (RD #1111 was not available to interview) revealed the dietician was first notified of the new heel wound for Resident #14 on 08/09/23. Observation on 09/26/23 at 1:33 P.M. of Resident #14's left heel revealed a wound was present with a moderate amount of reddish-brown drainage with no tunnelling. The wound measured 8.0 cm length by 6.0 cm width with no measurable depth. An interview with MD #1113 at the time of the observation revealed the wound was currently showing improvement. The MD did not provide any additional information as to how or why the pressure ulcer developed. Interview 09/28/23 at 9:47 A.M. with Resident #14 revealed the MD #1113 talked to him about needing to go to the hospital for his foot, but stated he never mentioned it might need to be amputated. Resident #14 said he did agree to go to the hospital, but never did because the wound started to get better. Interview with the Administrator on 09/28/23 at 10 45 A.M. revealed a wound culture and or/antibiotic was not ordered when the odor was first identified on 09/05/23 or anytime thereafter. Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated December 2022, revealed the facility would implement nutritional supplements as needed to aid in wound healing. Review of the policy titled Prevention of Pressures/Injuries, dated September 2023, revealed the facility would evaluate, document, and report potential changes in skin conditions. This deficient practice represents non-compliance investigated under Complaint Numbers OH00146813 and OH00146472.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 positivity log, review of facility infection control policies, interviews with staff, observations, interview with the local health department (LHD) and medical record review, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19. This resulted in Immediate Jeopardy on 11/17/22 when Resident #47 tested positive for COVID-19 exposing Resident #33. The facility cohorted exposed COVID-19 negative Resident #33 with COVID-19 positive Resident #47. Resident #33 tested positive for COVID-19 on 11/21/22. On 11/19/22 Resident #44 tested positive for COVID-19 exposing Resident #43. The facility cohorted exposed COVID-19 negative Resident #43 with COVID-19 positive Resident #44. Resident #43 tested positive for COVID-19 on 11/21/22. On 11/21/22 three residents (Residents #16, #18, and #42) tested positive for COVID-19 exposing five residents (Residents #14, #23, #27, #37, and #46). The facility cohorted exposed COVID-19 negative Resident #27 with COVID-19 positive Resident #16; two exposed COVID-19 negative residents (Residents #14 and #23) with COVID-19 positive Resident #18, and two exposed COVID-19 negative residents (Residents #37 and #46) with COVID-19 positive Resident #42. Resident #27 tested positive for COVID-19 on 11/24/22, Resident #46 tested positive for COVID-19 on 11/25/22. Residents #14, #23, and #37 remained negative for COVID-19. On 11/22/22 State tested Nurses Assistant (STNA) #119 was observed walking down hallway wearing a reusable gown and failed to change mask or sanitize eye protection after contact with COVID-19 positive resident; Housekeeper #156 was cleaning a COVID-19 positive room without appropriate personal protective equipment (PPE); Licensed Practical Nurse (LPN) #147 passed medications in a COVID-19 positive room without appropriate PPE, and LPN #148 wore PPE in hallway and did not change mask or sanitize eye protection after exiting COVID-19 positive room. Further observation on 11/22/22 revealed no signage or PPE supplies available for COVID-19 positive Residents #49 and #55 and no signage for COVID-19 positive Resident #18. Resident #33 who was COVID-19 positive was observed to be out of isolation in hallway and on smoking patio. The lack of effective infection control practice affected 16 residents (Resident's #14, #16, #18, #23, #27, #33, #37, #42, #43, #44, #46, #47, #49, #52, #55, #59) and placed all residents at risk for serious life-threatening harm, complications and/or death. The facility census was 82. On 11/22/22 at 5:23 P.M. the Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/17/22 when the facility cohorted COVID-19 exposed negative residents with COVID-19 positive residents, the facility did not implement CDC guidance, and did not implement their COVID-19 policy and procedure for appropriate use of PPE and isolation of COVID-19 positive residents. The Immediate Jeopardy was removed on 11/23/22 when the facility implemented the following corrective actions. On 11/22/22 beginning at identification at 12:15 P.M., the Assistant Director of Nursing (ADON) placed signage indicating type of transmission-based precautions and type of PPE required for COVID-19 positive residents. The ADON also placed isolation cart with supplies for COVID-19 positive Residents #49 and #55. On 11/22/22 at 6:15 P.M. COVID-19 positive Resident #18 was moved to cohort with two other COVID-19 positive residents (Residents #52 and #59). Residents #14 and #23 were tested for COVID-19 with negative results. COVID-19 positive Resident #16 was moved to cohort with COVID-19 positive Resident #42. Residents #37 and #46 were tested for COVID-19 with negative results and moved to other rooms. On 11/22/22 beginning at 6:15 P.M. all facility staff were educated by the LNHA, DON, and ADON on required PPE during outbreak, correct use of PPE, ensuring signage and supplies were available, and who to notify for restock of PPE. On 11/22/22 at 6:30 P.M. the LNHA and DON were educated on cohorting residents and ensuring PPE and signage were available by Regional Director of Clinical Services #155. On 11/22/22 at 7:00 P.M. the Medical Director was notified by LNHA of infection control concerns. On 11/22/22 at 7:16 P.M. the ADON completed repeat observation and verification correct signage and PPE supplies were in place. On 11/22/22 the facility began audits which would be completed by the DON or designee for appropriate use of transmission-based precautions (TBP) including cohorting, appropriate use of isolation signage, and readily available PPE supplies. Additionally, an audit would be completed by the DON or designee for appropriate use of PPE by facility staff on each shift. Audits would be completed daily for four weeks. Results would be reviewed by facility Quality Assurance and Performance Improvement (QAPI) committee for any further recommendations as needed. Although the Immediate Jeopardy was removed on 11/23/22, the facility remained out of compliance at Severity Level 2 (no actual harm with harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of facility documentation revealed a COVID-19 outbreak began on 11/16/22 when Residents #52 and #61 tested positive for COVID-19. On 11/22/22 there were 15 residents, who were positive for COVID-19. Six of 15 residents were residing on Magnolia Unit (Residents #33, #34, #42, #43, #44, and #47). Six of 15 residents were residing on Meadow Wood Unit (Residents #49, #51, #52, #55, #59, and #61). One of 15 residents was residing on Orchard Unit (Resident #67). Two of 15 residents were residing on Glenville Unit (Residents #16 and #18). Two residents had been hospitalized with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of CDC COVID Data Tracker for County Transmission Levels for Cuyahoga County as reported for 11/22/22 revealed the transmission level was high. 1. a.) Review of Resident #14 ' s medical record revealed admission to facility on 08/09/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #14 was vaccinated for COVID-19 on 01/02/21 and 01/23/21 and had booster doses on 01/20/22 and 07/05/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had moderately impaired cognition with Brief Interview for Mental Status (BIMS) score of 09. Review of progress notes dated 11/17/22 and 11/21/22 revealed Resident #14 tested negative for COVID-19. Review of Resident #18 ' s medical record revealed admission to facility on 08/25/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18 was vaccinated for COVID-19 on 09/24/21 and 10/16/21. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #18 had moderately impaired cognition with BIMS score of 10. Review of progress note dated 11/21/22 revealed Resident #18 tested positive for COVID-19 and was displaying no symptoms. The progress note indicated Resident #18 was placed on isolation. Review of physician ' s order dated 11/21/22 revealed Resident #18 required isolation and observation due to positive COVID-19 status. Review of Resident #23 ' s medical record revealed admission to facility on 02/02/07 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 was vaccinated for COVID-19 on 12/21/20 and 01/11/21 and had booster dose on 11/29/21. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #23 did not have cognitive patterns assessed and was on hospice services. Review of progress notes dated 11/17/22 and 11/21/22 revealed Resident #23 tested negative for COVID-19. Review of the facility daily census dated 11/22/22 revealed Resident #14, #18, and #23 remained in same room despite Resident #18 testing positive for COVID-19 and Residents #14 and #23 testing negative for COVID-19 for the time frame 11/17/22 through11/21/22. b.) Review of Resident #16 ' s medical record revealed Resident #16 was admitted to facility on 06/02/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 was vaccinated for COVID-19 on 05/04/21. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #16 was unable to participate in BIMS assessment and had noted short- and long-term memory problems with severely impaired decision making. Review of progress note dated 11/21/22 revealed Resident #16 had tested positive for COVID-19 and was displaying symptoms of runny nose and sneezing. The progress note indicated Resident #16 was placed on isolation. Review of physician ' s order dated 11/21/22 revealed Resident #16 required isolation and observation due to positive COVID-19 status. Review of Resident #27 ' s medical record revealed admission to facility on 10/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27 had no evidence of COVID-19 vaccination. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #27 had severely impaired cognition with BIMS score of 06. Review of progress note dated 11/17/22 and 11/21/22 revealed Resident #27 tested negative for COVID-19. Review of the facility daily census dated 11/22/22 revealed Resident #16 and Resident #27 remained in same room despite Resident #16 testing positive for COVID-19 and Resident #27 testing negative for COVID-19. Further Review of Resident #27 ' s medical record revealed a positive COVID-19 test result on 11/24/22 with symptoms of cough with clear [MEDICATION(S)], low grade fever, watery eyes, and fatigue. c.) Review of Resident #33 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33 was vaccinated for COVID-19 on 01/11/21 and 02/01/21 with booster dose on 11/29/21. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #33 had intact cognition with BIMS score of 13. Review of progress note dated 11/17/22 revealed Resident #33 tested negative for COVID-19. Review of Resident #47 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #47 was vaccinated for COVID-19 on 12/21/20 and 01/11/21 with booster dose on 11/29/21. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had moderately impaired cognition with BIMS score of 11. Review of progress note dated 11/17/22 revealed Resident #47 tested positive for COVID-19 and was displaying no symptoms. Review of physician ' s order dated 11/17/22 revealed Resident #47 required isolation and observation due to positive COVID-19 status. Review of the facility daily census dated 11/22/22 revealed Resident #33 and #47 remained in same room despite Resident #47 testing positive for COVID-19 and Resident #33 testing negative for COVID-19 for the time period of 11/17/22 through 11/21/22. Further Review of Resident #33 ' s medical record revealed a positive COVID-19 test result on 11/21/22 with symptom of dry cough. d.) Review of Resident #37 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #37 was vaccinated for COVID-19 on 12/21/20 and 01/11/21 and had booster dose on 11/29/21. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #37 had moderately impaired cognition with BIMS score of 09. Review of progress notes dated 11/17/22 and 11/21/22 revealed Resident #37 tested negative for COVID-19. Review of Resident #42 ' s medical record revealed admission to facility on 04/28/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #42 was vaccinated for COVID-19 on 03/20/21 and 04/10/21. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #42 had moderately impaired cognition with BIMS score of 08. Review of progress note dated 11/21/22 revealed Resident #42 tested positive for COVID-19 and was displaying no symptoms. The progress note indicated Resident #42 was placed on isolation. Review of physician ' s order dated 11/21/22 revealed Resident #42 required isolation and observation due to positive COVID-19 status. Review of progress note dated 11/22/22 revealed Resident #42 began displaying abnormal lung sounds and a chest x-ray was ordered. Review of progress note dated 11/22/22 revealed Resident #42 ' s chest x-ray results showed bilateral infiltrates and congested lungs. Review of progress note dated 11/24/22 revealed Resident #42 was sent to hospital related to breathing heavily and unresponsiveness. Review of Resident #46 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46 was vaccinated for COVID-19 on 07/01/21 and 07/29/21. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #46 had severely impaired cognition with BIMS score of 06. Review of progress notes dated 11/17/22 and 11/21/22 revealed Resident #46 tested negative for COVID-19. Review of the facility daily census dated 11/22/22 revealed Resident #37, #42, and #46 remained in same room despite Resident #42 testing positive for COVID-19 and Residents #37 and #46 testing negative for COVID-19. Further Review of Resident #46 ' s medical record revealed positive COVID-19 test result on 11/25/22 with no symptoms displayed. e.) Review of Resident #43 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #43 was vaccinated for COVID-19 on 12/21/20 and 01/11/21 with booster dose on 11/29/21. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #43 had intact cognition with BIMS score of 15. Review of progress notes dated 11/17/22 and 11/19/22 revealed Resident #43 tested negative for COVID-19. Review of Resident #44 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 was vaccinated for COVID-19 on 12/21/20 and 01/11/21 with booster dose on 11/29/21. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #44 had intact cognition with BIMS score of 15. Review of progress note dated 11/19/22 revealed Resident #44 tested positive for COVID-19 and was placed on isolation. Review of physician ' s order dated 11/20/22 revealed Resident #44 was on respiratory and droplet precautions for COVID-19 positive status. Review of the facility daily census dated 11/22/22 revealed Resident #43 and #44 remained in same room despite Resident #44 testing positive for COVID-19 and Resident #43 testing negative for COVID-19 for the time frame of 11/19/22 through 11/21/22. Further Review of Resident #43 ' s medical record revealed positive COVID-19 test result on 11/21/22 with symptom of dry cough and sneezing. Interview on 11/22/22 at 11:19 A.M. with LPN #132 and LPN #160 revealed there were two COVID-19 positive residents on Glenville Unit. LPN #132 and LPN #160 confirmed both COVID-19 positive residents had roommates who were negative for COVID-19. LPN #132 indicated they would only wear PPE in room to complete care for the COVID-19 positive resident. LPN #132 indicated they would remove PPE and pull privacy curtain closed when caring for the COVID-19 negative resident. Interview on 11/22/22 at 11:41 A.M. with the LNHA and DON confirmed the list of COVID-19 positive residents was correct as of testing on 11/21/22. The LNHA and DON confirmed the resident room roster was correct. Interview on 11/22/22 at 11:52 A.M. with the DON revealed they were treating all COVID-19 exposed residents as positive. They had found when there was an exposed roommate, they would later test positive for COVID-19 about two days later. In an effort not to spread further they were isolating the COVID-19 positive residents and exposed COVID-19 residents in same room. The DON confirmed Resident #16 was positive for COVID-19 on 11/21/22 and remained in room with exposed roommate Resident #27 despite testing negative. The DON confirmed Resident #18 was positive for COVID-19 on 11/21/22 and remained in room with exposed roommates Residents #14 and #23 despite testing negative. The DON confirmed Resident #42 was positive for COVID-19 on 11/21/22 and remained in room with exposed roommates Residents #37 and #46 despite testing negative. Interview on 11/22/22 at 12:08 P.M. with the ADON revealed the ADON was the facility ' s Infection Preventionist. The ADON indicated they had many three and four person rooms, so their corporate office had advised not to start moving residents when outbreak started. They were to treat each exposed resident despite negative test as COVID-19 positive. They anticipated since the roommates were exposed they would become positive as well. Interview on 11/22/22 at 2:37 P.M. with Medical Director #150 revealed awareness of a few positive cases of COVID-19 at facility. Medical Director #150 indicated unawareness of the facility being in outbreak or having a significant number of positive COVID-19 cases. Medical Director #150 indicated in the past the facility set up an entire unit for outbreaks which was noted to be successful in limiting positive cases. Medical Director #150 indicated when a resident was positive, he would recommend isolating resident and separate from any roommates. Medical Director #150 would then expect the facility to do serial testing of residents and staff. Medical Director #150 confirmed 15 positive cases of COVID-19 was more than he was notified of. Medical Director #150 indicated cohorting positive COVID-19 residents with negative residents should never happen and he was unaware the facility was cohorting COVID-19 positive and COVID-19 negative residents in same room. Interview on 11/22/22 at 3:01 P.M. with Disease Surveillance Specialist (DSS) #151 for LHD revealed the facility had notified them of 15 positive COVID-19 cases in facility. DSS #151 indicated the LNHA had reported cohorting positive COVID-19 residents. DSS #151 indicated the facility had not asked for any guidance on cohorting or infection control. When asked if it was appropriate to cohort positive COVID-19 residents with COVID-19 negative residents, DSS #151 indicated absolutely not. DSS #151 confirmed COVID-19 negative residents should not be in same room as COVID-19 positive residents. DSS #151 indicated the facility should be isolating COVID-19 positive residents and minimizing staff assigned to them. Review of the facility policy Resident Exposure dated 09/28/22 revealed a resident with Confirmed COVID-19 infection should be placed in single-person room with door kept closed. The policy indicated cohorting may only be done with residents with the same respiratory pathogen. Review of the facility policy Transmission-Based (Isolation) Precautions dated 10/12/22 revealed the facility would apply TBP to residents who were known or suspected to be infected with certain infectious agents. Residents could be placed on TBP empirically while awaiting confirmation. TBP would be least restrictive as possible. Residents with empirically initiated TBP were to have the TBP discontinued when additional clinical information, such as confirmatory laboratory result, became available. Review of facility in-service sign-in forms from 05/01/22 to 05/23/22 revealed all departments were trained on COVID-19 transmission, hand washing, appropriate use of PPE, and whom to contact for PPE supplies. Review of CDC guidance: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 09/23/22 revealed patients who had met criteria for empiric TBP based on close contact with someone with COVID-19 infection should not be cohorted with patients with confirmed COVID-19 infection. Patients could only be cohorted with confirmed COVID-19 infection test. The CDC recommendations indicated empiric use of TBP was not required while being evaluated for COVID-19 following close contact with COVID-19 infection. The CDC recommendation was to place a resident with COVID-19 infection in single-person room and door should be kept shut. 2. Review of Resident #42 ' s medical record revealed admission to facility on 04/28/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 11/21/22 revealed Resident #42 tested positive for COVID-19 and was displaying no symptoms. Review of physician ' s order dated 11/21/22 revealed Resident #42 required isolation and observation due to positive COVID-19 status. Review of Resident #52 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 11/16/22 revealed Resident #52 tested positive for COVID-19 with no displayed symptoms. Review of physician ' s order dated 11/17/22 revealed Resident #52 required isolation and observation due to positive COVID-19 status. Review of Resident #59 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 11/21/22 revealed Resident #59 tested positive for COVID-19 with symptoms of malaise. Review of physician ' s order dated 11/21/22 revealed Resident #59 required isolation and observation due to positive COVID-19 status. Observation on 11/22/22 from 7:30 A.M. to 8:00 A.M. revealed facility staff were wearing a variety of PPE. Some staff were wearing an N95 mask with eye protection, some were wearing only an N95 mask, and some were wearing surgical masks. Interview on 11/22/22 at 7:53 A.M. with LPN #148 revealed the rooms with signs and PPE bins were COVID-19 positive. Observation on 11/22/22 at 7:54 A.M. revealed STNA #119 walked down the hallway wearing a reusable gown. STNA #119 walked through the Magnolia Unit to the nursing station. STNA #119 stood at the nursing station wearing the reusable gown and eventually removed the gown and balled it up with her bare hands and discarded the reusable gown in the soiled linen room. Observation on 11/22/22 at 7:56 A.M. revealed Housekeeper #156 cleaning the room of Resident #42 who was COVID-19 positive. There was a stocked PPE isolation cart outside of door and a sign on door that indicated to see nurse before entrance. Housekeeper #156 was wearing a N95 mask that was upside down with the nose piece by her chin and one of two straps at the crown of her head. Housekeeper #156 was wearing gloves, however, was not wearing a gown or eye protection. Interview on 11/22/22 at 7:58 A.M. at the doorway to Resident #42 ' s room with Housekeeper #156 revealed she was unaware of any COVID-19 changes in the facility. Housekeeper #156 believed she should be wearing eye protection glasses; however, could not find any. Housekeeper #156 verified rooms with signs to see nurse before entrance were for COVID-19 and verified she was not utilizing appropriate PPE upon entering the COVID-19 positive room. Following the interview Housekeeper #156 continued to clean in Resident #42 ' s room without donning the additional PPE required. Housekeeper #156 then continued with assigned tasks without replacing the N95 mask or donning eye protection. Observations from 8:00 A.M. to 8:30 A.M. revealed facility staff members filing down to the first floor nursing station to gather N95 masks and eye protection. Continued observation revealed staff members from nursing department, dietary department, and housekeeping department changing into N95 masks and donning eye protection. Observation on 11/22/22 at 8:17 A.M. revealed STNA #119 appropriately donned PPE to enter the room shared by Residents #43 and #44 who were COVID-19 positive. STNA #119 was observed to deliver breakfast meals to Residents #43 and #44. STNA #119 exited room after doffing PPE. STNA #119 did not change N95 mask or sanitize eye protection prior to crossing hallway and again donning PPE to enter COVID-19 positive Resident #42 ' s room. Observation on 11/22/22 at 8:25 A.M. revealed LPN #147 donning PPE at doorway to Resident #34 ' s room who was COVID-19 positive. LPN #147 had on N95 mask, gown, and gloves. LPN #147 did not don eye protection prior to entering Resident #34 ' s room. LPN #147 had on glasses for vision which did not provide coverage for sides of face. Interview on 11/22/22 at 8:50 A.M. with the DON confirmed Residents #34, #42, #43, and #44 were COVID-19 positive. Findings of inappropriate PPE use were reviewed with the DON and confirmed. Interview on 11/22/22 at 10:51 A.M. with LPN #147 verified no eye protection was donned to enter the room of Resident #34 who was COVID-19 positive. LPN #147 indicated she had a pair of goggles, but the goggles were not the kind that fit over eyeglasses. LPN #147 held up a pair of goggles that were in a plastic sleeve. The goggles would not have fit over LPN #147 ' s glasses as indicated. Observation on 11/22/22 at 11:05 A.M. revealed LPN #148 entering the shared room of Residents #52 and #59 who were COVID-19 positive. LPN #148 was observed to don the correct PPE upon entrance to the COVID-19 positive room. Upon exit LPN #148 was observed removing gown and gloves, however, did not change mask or sanitize eye protection. LPN #148 was also wearing foot coverings which were not removed prior to leaving the COVID-19 positive room. LPN #148 walked down the hall towards a housekeeping cart where the foot coverings were removed and disposed of into the trash bag on the housekeeping cart. LPN #148 then sanitized hands and walked down hallway back to nurse ' s station. Interview on 11/22/22 at 11:09 A.M. with LPN #148 confirmed PPE worn in COVID-19 positive rooms should be taken off at doorway upon exiting room. LPN #148 indicated there were bins for disposal of used PPE and another for soiled linens. LPN #148 verified there were extra N95 masks available in PPE bins outside of COVID-19 positive rooms. Interview on 11/22/22 at 12:08 P.M. with the ADON revealed there were face shields available for staff who wore eyeglasses. The face shields were on isolation carts and extra were available in the medication storage room. The ADON confirmed the staff were not following appropriate masking protocol on the morning of 11/22/22. The ADON had instructed nursing staff to check front desk and nurses ' station on second floor for N95 masks and eye protection. The ADON had instructed nursing staff to distribute N95 mask and eye protection to ensure all staff were wearing the appropriate PPE. The ADON reported difficulties with entire boxes of N95 disappearing from nursing stations and indicated they had to limit the amount of N95 masks left out for use by the employee entrance. Review of the facility policy Care for the Patient with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) dated 08/01/22 revealed residents with known or suspected COVID-19 should be cared for in a single-person room with door closed. The policy indicated a sign would be placed on door and PPE equipment would be placed outside of resident room. The policy indicated staff who entered room should use a respirator mask, gown, gloves, and eye protection. The policy indicated reusable eye protection should be cleaned and disinfected prior to re-use. Review of the facility policy Mask and Eyewear dated 09/28/22 revealed when the facility was in high community transmission rates all staff members would be required to wear eye protection. Eye protection was to be disinfected between patient care areas for COVID-19. The policy indicated an N95 face mask was to be worn in the event of an outbreak of COVID-19. Review of facility in-service sign-in forms from 05/01/22 to 05/23/22 revealed all departments were trained on COVID-19 transmission, hand washing, appropriate use of PPE, and whom to contact for PPE supplies. Review of CDC guidance: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 09/23/22 revealed health care professionals entering room of resident with COVID-19 infection should wear NIOSH-approved N95 mask gown, gloves, and eye protection (that covers front and sides of face). 3. Review of Resident #18 ' s medical record revealed admission to facility on 08/25/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 11/21/22 revealed Resident #18 tested positive for COVID-19 and was displaying no symptoms. Review of physician ' s order dated 11/21/22 revealed Resident #18 required isolation and observation due to positive COVID-19 status. Review of Resident #49 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 11/21/22 revealed Resident #49 tested positive for COVID-19 and was displaying no symptoms. Review of physician ' s order dated 11/21/22 revealed Resident #49 required isolation and observation due to positive COVID-19 status. Review of Resident #55 ' s medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 11/21/22 revealed Resident #55 tested positive for COVID-19 with symptom of malaise. Review of physician ' s order dated 11/21/22 revealed Resident #55 required isolation and observation due to positive COVID-19 status. Observation on 11/22/22 at 11:06 A.M. revealed there was no access to PPE outside of Resident #49 and #55 ' s room and no signage to indicate use of isolation precautions. The door to Resident #49 ' s and #55 ' s room was open. Observation on 11/22/22 at 11:15 A.M. revealed there was access to PPE outside of Resident #16 ' s room, however there was no signage to indicate use of isolation precautions. The door to Resident #16 ' s room was open. Interview on 11/22/22 at 12:15 P.M. with the ADON confirmed Residents #49 and #55 were positive for COVID-19 and confirmed there should be access to PPE outside of room and signage. The ADON also confirmed Resident #16 was positive for COVID-19 and should have signage. Review of the facility policy Care for the Patient with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) dated 08/01/22 revealed residents with known or suspected COVID-19 should be cared for in a single-person room with door closed. The policy indicated a sign would be placed on door and PPE equipment would be placed outside of resident room. The policy in

Based on observations, interviews, record review, facility self-reported incident (SRI), police report review, facility policy review, and review of weather information from www.wunderground.com, the facility failed to provide accurate and timely assessment, care planning and supervision to prevent the elopement of one resident (Resident #21) who had diagnoses including anxiety and [CONDITION(S)]. This resulted in Actual Harm that was Immediate Jeopardy when Resident #21 was dropped off at a medical appointment in the community and subsequently left the appointment without facility staff knowledge on 10/11/22. Facility transportation staff had not received a phone call from Resident #21 or the medical office for 2.5 hours and became concerned, drove back to the medical office and discovered Resident #21 was not there. Medical office and building security staff indicated Resident #21 had gotten on a bus alone and left the premises. Facility transportation staff called the facility to report Resident #21 missing at 1:30 P.M. The resident's whereabouts and condition were unknown until he was discovered in the community four days later on 10/15/22 at 4:44 P.M. by nursing staff at a laundromat in a city approximately 7.2 miles away. This affected one resident (Resident #21) of three residents reviewed for elopement. The facility identified one resident (Resident #15) having a Wanderguard (a device that causes the door to alarm upon exit) and identified five additional residents at risk for elopement (Resident #7, Resident #10, Resident #15, Resident #17 and Resident #27). The facility census was 79 residents. Additionally, it was discovered during the complaint survey that Resident #82 had been allegedly selling illegal drugs to staff and residents in the facility during August 2022. The facility failed to further investigate this allegation of illegal drug sales and use, placing all 79 residents in the facility at risk. On 10/24/22 at 2:35 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 10/11/22 at 9:30 A.M. when Resident #21, who had a legal guardian due to known flight risk and delusions about his ability to provide self-care, left the facility to go to a doctor's appointment in the community without a staff escort. At the time of departure from the facility, Transportation Staff (TS) #687 had asked Licensed Practical Nurse (LPN) #623 if Resident #21 needed a staff escort for the medical appointment and she replied, I don't think so. TS #687 took Resident #21 to the medical appointment and left Resident #21 at the medical office alone. TS #687 had written his phone number at the top of Resident #21's appointment paperwork for medical office staff to contact him when the appointment was over for pick up. TS #687 had not heard anything regarding Resident #21 after about 2.5 hours so returned to the medical office and Resident #21 was no longer there. Resident #21 had last been seen by medical building security staff getting on a bus to an undetermined location. Resident #21 ambulated alone and unsupervised throughout a busy [NAME] environment until he was found four days later by Assistant Director of Nursing (ADON)/Registered Nurse (RN) #683 in a city 7.2 miles away on 10/15/22 at 4:44 P.M. Resident #21 was returned to the facility by staff. The Immediate Jeopardy was removed on 10/24/22 when the facility implemented the following corrective actions: On 10/11/22 at 1:45 P.M. TS #687 spoke with Social Service Designee (SSD) #650 who informed DON that Resident #21 had an unauthorized departure from medical appointment. On 10/11/22 at 2:00 P.M. Administrator, RN/ADON #683, Admissions Director (AD) #648 and SSD #650 conducted a full facility headcount with all residents present and accounted for. On 10/11/22 from 2:00 P.M. to 9:00 P.M. DON, RN/ADON #683, MDS/LPN #661, SSD #650 and TS #687 searched the area where Resident #21 was last seen. On 10/11/22 at 5:00 P.M. Administrator completed a SRI with the State Agency (SA). On 10/11/22 at 5:15 P.M. Administrator contacted Resident #21's family listed (Family Members (FM) #706 and FM #707) and left message for Legal Guardian (LG) #698 on voicemail. On 10/11/22 at 5:20 P.M. DON notified Nurse Practitioner (NP) #709 of Resident #21's elopement. On 10/11/22 at 5:30 P.M. DON filed a missing person's report with the police department. On 10/11/22 at 5:45 P.M. Administrator contacted and left message for Guardian Supervisor #712. On 10/11/22 at 6:00 P.M. Administrator spoke with LPN #623 to inquire why she felt Resident #21 did not need an escort. On 10/11/22 Administrator pulled and reviewed Resident #21's Probate Court order from the probate court website. On 10/11/22 Administrator educated SSD #650 and AD #648 regarding ensuring guardianship documents are received, reviewed with any individualized instructions being shared with the interdisciplinary team (IDT) to ensure instructions are implemented, care planned and uploaded within the medical record. From 10/11/22 to 10/12/22 DON and RN/ADON #683 updated all active residents' wandering/elopement assessments. Care plans were also reviewed and updated if resident is identified as elopement risk. No new residents have been identified as high risk for elopement at this time. From 10/11/22 to 10/12/22 DON and RN/ADON #683 updated all active residents' orders to include escort requirement for medical appointments. At this time all current residents have appropriate orders. On 10/11/22 SSD #650 retrieved guardianship paperwork for residents with guardians from website, reviewed and uploaded documentation into electronic medical records. From 10/11/22 to 10/15/22 the Administrator, DON and RN/ADON #683 as well as law enforcement continued to search communities in an effort to locate Resident #21. On 10/12/22 RN/ADON #683 updated Resident #21's elopement/wandering assessment to include need for secured unit and risk for elopement. On 10/12/22 the Administrator educated nursing staff via on-shift on regarding the need for all residents to have escorts for medical appointments. On 10/12/22 at 10:00 A.M. the Administrator notified Medical Director #711 of Resident #21's elopement from medical appointment on 10/11/22. On 10/15/22 at 4:30 P.M. RN/ADON #683 notified the Administrator and the DON that she had spotted Resident #21 at a laundromat and was currently awaiting law enforcement presence to help assist Resident #21 back to the facility. On 10/15/22 at 6:00 P.M. the DON assessed Resident #21 with no negative findings and rehoused on secured unit as stated per probate court paperwork. The DON notified FM #706 and NP #709 that Resident #21 returned to the facility at this time. On 10/17/22 the Administrator notified LG #698 of Resident #21's return. On 10/21/22 RN/ADON #683 updated Resident #21's care plan to include secured unit/elopement risk. On 10/24/22 SSD #650 completed another audit on resident guardianship documentation with no additional findings. SSD #650/designee to complete weekly audits for four weeks on residents identified with guardianship to ensure guardianship documents are received, reviewed updated and shared with IDT for individualized instructions. On 10/24/22 the Regional Director of Clinical Services (RDCS) #702 completed an audit to ensure elopement risk assessments are scheduled on a quarterly basis; schedules activated as needed. Going forward, completion of assessments will be the charge nurses' responsibility and MDS/LPN #661 will be responsible for ensuring completion during MDS timeframes. On 10/24/22 the Administrator educated TS #687 on ensuring residents have an escort for appointments. Activity Director (AD) #646 is back up transportation driver and has also been educated on need for escort according to new policy. Facility does not use outside transportation outside of Cleveland Emergency Medical Services (EMS) for transport in emergent situations. On 10/24/22 RDCS #702 educated the DON, RN/ADON #683 and MDS/LPN #661 on ensuring elopement risk assessments are scheduled/completed on admission/quarterly and as needed. DON/designee to complete an audit on elopement risk assessment on five residents per week for four weeks to ensure elopement risk assessments are completed and scheduled on admission/quarterly and as needed. On 10/24/22 RDCS #702 and [NAME] President of Clinical Services (VPCS) #710 implemented a new formal policy on resident escort requirements. At this time the facility has determined all residents will have an escort for outside medical appointments. Facility will continue current practice for 60 days and will reassess practice after 60-day timeframe. At time of reassessment, the IDT will identify residents who require an escort. On 10/24/22 RDCS #702 educated the DON and Administrator on the new resident escort policy. DON/designee to complete an audit of five resident appointments weekly to ensure residents have appropriate supervision to and from appointments for four weeks. DON/designee will validate residents with upcoming appointments have escorts assigned for next day appointments. On 10/24/22 the Administrator, the DON, RN/ADON #683 and RDCS #702 educated nurses, management staff, and TS #687 on the new escort policy. New nurse orientation will include policy on escort for medical appointments. At this time, as needed (PRN) nurses identified as active have also been educated. On 10/25/22 at 6:00 A.M. Maintenance Director (MD) #639 conducted an elopement drill conducted on night shift and staff responded appropriately. On 10/27/22 a quality assurance performance improvement (QAPI) meeting will review audits for further review as part of the facility's ongoing quality improvement initiative. Although the Immediate Jeopardy was removed on 10/24/22, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses including anxiety, [CONDITION(S)], heart failure and [CONDITION(S)]. Review of Resident #21's census data revealed he resided on the first floor until 10/11/22 where he was marked as hospital less than eight hours. Resident #21 was readmitted to the second floor (secured unit) on 10/15/22. Review of Resident #21's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact and did not display behaviors including wandering or rejection of care. Resident #21 was independent with bed mobility, required staff supervision for ambulation and transfers and required the limited assistance of one staff for personal hygiene and toileting. No restraints or alarms were coded on the assessment. Review of Resident #21's electronic medical record indicated he had a legal guardian and two sisters were listed as emergency contacts. Review of a statement of expert evaluation dated 08/18/21 revealed Resident #21 had [CONDITION(S)] and impairment of orientation, thought process, affect, memory, concentration, comprehension and judgement. The evaluation indicated that guardianship should be established due to Resident #21's disorientation and confusion. Review of a guardianship document from the probate court dated 02/22/22 revealed Resident #21 had [CONDITION(S)] and was delusional about his ability to provide self-care, was a flight risk and was maintained on a locked unit. Legal Guardian (LG) #698 was assigned to be Resident #21's guardian. Review of Resident #21's physician's orders revealed an order dated 11/16/21 for [MEDICATION(S)] (antidepressant) 50 milligrams (mg) daily for anxiety, an order dated 12/14/21 for [MEDICATION(S)] (antipsychotic) 20 milligrams each evening for [CONDITION(S)], an order dated 10/07/22 for dermatology appointment on 10/11/22 at 10:10 A.M. in the community and an order dated 10/13/22 for may go on leave of absence (LOA) with supervision, escort required for all appointments. Review of Resident #21's assessments indicated a wandering and elopement assessment dated [DATE] that classified the resident as not at risk for elopement and stated Resident #21 was cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits or disoriented), pertinent diagnoses and ambulated independently. No elopement history was noted on the assessment. A box was checked at the bottom of the assessment indicating Resident #21 was at high risk for elopement with a listed goal of remaining safe within facility unless accompanied by staff or other authorized persons through next review. Listed interventions included apply Wanderguard to reduce risk of elopement; check device for proper functioning per facility protocol; develop an activity program to divert attention and meet individual needs; discuss with resident/ family risks of elopement/ wandering; if resident is missing from facility, follow elopement protocol, notify physician and family immediately and document; if resident is wandering in potentially unsafe area or situation, redirect to safer area; observe/ record/ report to physician or nurse practitioner risk factors for potential elopement; and take photograph of resident to maintain on file for identification purposes. No further elopement assessments were completed for Resident #21 until 10/12/22 when Resident #21 was still missing from the facility. Review of Resident #21's care plan dated 05/02/22 revealed Resident #21 demonstrated manipulative behavior as evidenced by panhandling; Resident #21 would ask staff, visitors and residents for money, can you stand a little change? being his most common request. Review of Resident #21's care plan dated 09/10/21 revealed Resident #21 was at high risk for elopement and included use of a Wanderguard as an intervention in place. Review of a care plan dated 10/20/22 revealed Resident #21 had a diagnosis of dementia and/or psychiatry diagnosis that required secured observation and exhibited one or more criteria for placement on the secured dementia/behavior unit: elopement risk. Review of a nurses' note dated 10/11/22 at 9:45 A.M. and written by LPN #623 revealed Resident #21 left for his medical appointment at 9:30 A.M. via the facility's transportation with face sheet and medication list, all parties aware. Review of the next available note in Resident #21's medical record revealed a late entry note dated 10/16/22 at 10:39 P.M. originally for 10/15/22 for 5:30 P.M. and written by the DON revealed Resident #21 returned to the facility on this date at 5:30 P.M. accompanied by this nurse and another staff member (not identified). Resident #21 ambulated with cane, placed in his wheelchair and taken to his room now on the second floor secured unit. Resident #21 was assessed and found to have no injuries. Review of an interdisciplinary team note dated 10/17/22 at 10:21 A.M. and written by the Administrator revealed Resident #21 returned to the facility from the community without injuries and verbalized he had been staying with his girlfriend in [city approximately 7.2 miles away from facility] and had contacted his sister, Family Member (FM) #707 and his brother to let them know his whereabouts. Family failed to let facility know Resident #21 had contacted them or of his location. Local law enforcement assisted the DON/ADON with Resident #21's return. Per LG #698, Resident #21 was to reside on the secured unit. Review of historical weather data from www.wunderground.com revealed on 10/11/22 the high temperature was 73 degrees Fahrenheit (F) and the low temperature was 53 degrees F; on 10/12/22 high 71 degrees F and the low temperature was 56 degrees F; on 10/13/22 the high temperature was 61 degrees F and the low temperature was 49 degrees F with 1.59 inches of precipitation noted; on 10/14/22 the high temperature was 61 degrees F and the low temperature was 41 degrees F; and on 10/15/22 the high temperature was 57 degrees F and the low temperature was 42 degrees F. Review of an incident log from April 2022 through October 2022 revealed no elopements or unauthorized absences from the facility were documented. Review of a self-reported incident with the facility's investigation dated 10/11/22 at 5:00 P.M. revealed an allegation of neglect regarding Resident #21's unauthorized departure from medical appointment. At the time of the initial report, Resident #21 was still out of the facility. Resident #21 left the facility in the company of the facility's transportation driver to a medical appointment for dermatology. Resident #21 left the medical appointment after getting a prescription from the dermatologist and left the clinic to go to [chain pharmacy] to fill the prescription. Per security guard at the medical building (not named) Resident #21 was seen getting on a city bus. Dermatology office contacted the facility driver to alert him that Resident #21 had departed the medical office and got onto public transit. Driver contacted facility administration and investigation and search for Resident #21 began. The police were contacted. The facility found the allegation of neglect to be unsubstantiated as at the time of the final submission (10/18/22 9:41 P.M.) Resident #21 was back in the facility and told staff he had told his sister (not identified) he was going to leave his appointment and go to his girlfriend's house. Resident #21 was moved to the secured unit as well. The investigation included an email dated 10/12/22 at 10:23 A.M. to LG #698. A quality assurance form dated 10/11/22 revealed Resident #21 had a dermatology appointment in the community. The transportation driver had asked the nurse if Resident #21 needed an escort and the nurse said an escort was not required for Resident #21. Resident #21 was taken to the appointment, was observed smoking by building staff and then was observed getting on a bus. The facility transportation driver went to get Resident #21 and was notified Resident #21 had left. Police were involved. LG #698 was concerned Resident #21 was sent to his appointment without the appropriate supervision. A text-message was sent to all facility staff on 10/12/22 at 10:48 A.M. indicating all residents leaving the facility for appointments must have an escort. Staff statements were included from TS #687 and LPN #623. Review of TS #687's written statement dated 10/12/22 revealed he had driven Resident #21 to his doctor's appointment in the community on 10/11/22 at 8:50 A.M. When he got to the nurses' station to pick up Resident #21 he asked the nurse (not identified) if the resident needed an escort and was told no. At the facility, Resident #21 was given TS #687's phone number and instructed to call him when his appointment ended. After two hours TS #687 had not heard from Resident #21 so he drove back to the dermatology office and was told by medical office staff (not identified) Resident #21 was taken downstairs to smoke. Building security staff (not identified) and the medical office staff indicated that Resident #21 left and went on a bus. TS #687 drove around looking for Resident #21. Review of LPN #623's written statement dated 10/11/22 revealed she cared for Resident #21 on 10/11/22. Resident #21 had a dermatology appointment at 10:10 A.M. Resident #21 and the driver (not identified) were already aware of the appointment and Resident #21 left the facility at 9:30 A.M. with the driver. Review of a separate incident summary dated 10/17/22 revealed on 10/11/22 at 1:30 P.M. TS #687 alerted the facility Resident #21 was no longer at the medical building he had dropped the resident off at earlier that day for a medical appointment. Resident #21 had not been sent to the appointment with a responsible party per LPN #623's direction. Building security took Resident #21 downstairs to smoke a cigarette when Resident #21 walked away and got on a bus. The DON, ADON/RN #683, MDS/LPN #661, TS #687 and Social Service Designee (SSD) #650 went to the medical center to search for Resident #21 until 4:45 P.M. A police report was filed and an SRI was initiated. Facility staff continued to follow up with local police departments and search the vicinity for Resident #21. Contact was made with Resident #21's sisters. On 10/15/22 at 4:44 P.M. ADON/RN #683 spotted Resident #21 at a laundromat in [city approximately 7.2 miles from the facility] and was waiting for police to arrive. Resident #21 stated with police, the DON and the Administrator present, that he had been at his girlfriend's house and since it was Sweetest Day, he would come back to the facility on Monday 10/17/22. Resident #21 contacted FM #707 for the local police and FM #707 stated she had known Resident #21's whereabouts as Resident #21 had called her to inform her of his location. FM #707 did not tell the facility of Resident #21's whereabouts as she did not believe he needed a guardian. It was noted on Resident #21's probate orders Resident #21 was to reside on the secured unit when originally admitted to the facility. The facility unsubstantiated the SRI for neglect as Resident #21 had a clear plan and had no adverse outcomes. The facility planned to re-evaluate Resident #21's need for a guardian and it would be completed within 90 days. Review of a police report dated 10/11/22 at 4:39 P.M. revealed the DON stated Resident #21 was missing after a dermatology appointment. Resident #21 was seen panhandling in the medical building and was escorted to the first floor by building security who saw Resident #21 get on the bus. Resident #21 was last seen wearing a gray sweater and blue sweatpants and had a blue grocery bag. Resident #21 was ambulatory using a 3-prong cane. Resident #21's appointment was at 10:10 A.M. and they do not know what time he left the medical building. Before leaving he stated to the security office that he needed to pick up his medication from the pharmacy in [city over 12 miles from the medical building]. Police spoke with the Administrator who stated Resident #21 was probated to the nursing home and not free to leave. Interview on 10/20/22 at 12:11 P.M. with TS #687 verified his written statement indicating he asked LPN #623 if Resident #21 needed an escort for his medical appointment and she had replied she didn't think so. TS #687 stated when the current Administrator began working at the facility, all residents that had an appointment required an escort. Prior to this, if staff thought people would be ok they did not need an escort for appointments. TS #687 indicated he wrote his phone number on Resident #21's paperwork and told him or the medical office to call him when the appointment was over. TS #687 took Resident #21 into the building and left the premises. After 2.5 hours TS #687 was concerned he had not heard anything so he drove back to the medical facility. Two receptionists (not identified) indicated Resident #21 went downstairs because he wanted to smoke. A building security guard (not identified) and receptionist (not identified) said Resident #21 acted strange and asked where the bus was. Resident #21 went to the road the medical center was on and got on a bus. Between 1:00 P.M. and 1:30 P.M. TS #687 called ADON/RN #683 or SSD #650 to report that Resident #21 was gone and he did not know where Resident #21 went. TS #687 stated Resident #21 used a wheelchair but could use a cane to walk short distances. TS #687 stated Resident #21 was packing his pockets prior to leaving for the appointment and had a bag but he did not know what was in Resident #21's pockets or bag. Interview on 10/20/22 at 12:47 P.M. with Resident #21 revealed he was seated in his wheelchair with a coat over t-shirt and sweatpants on. Resident #21 asked the surveyor if she was probate court. When asked about leaving the facility recently, Resident #21 stated he had left the facility for three days and was with his girlfriend in [city approximately 7.2 miles from the facility]. Resident #21 verified he had been at a doctor's appointment without a staff escort then abruptly ended the interview. Interview on 10/20/22 at 1:32 PM with the Administrator revealed she was made aware Resident #21 was gone on 10/11/22 at 1:30 P.M. as the front desk had spoken to SSD #650 and she told her and the DON. The Administrator stated the DON and RN/ADON #683 went to the medical facility to see if Resident #21 was there and they could not find him. The Administrator verified LPN #623 was asked how staff determined if an escort was required; LPN #623 could not tell her and she verified TS #687 had even asked LPN #623 regarding an escort but she did not indicate he needed one. Interview on 10/20/22 at 3:25 P.M. with LPN #623 revealed she cared for Resident #21 on 10/11/22, who left around 9:00 A.M. with the facility driver. LPN #623 indicated Resident #21 did not need an escort, there was no physician's order for him indicating that he needed one. LPN #623 stated usually the ADON/RN #683 and Scheduler/STNA #667 would decide if residents needed an escort based on a paper. LPN #623 indicated management notified Resident #21's physician and guardian of his elopement. Phone interview on 10/21/22 at 9:25 A.M. with LPN #697 revealed escorts were to go with residents for all appointments and if the facility could not provide an STNA then TS #687 would stay with the resident. Phone interview on 10/21/22 at 11:27 A.M. with LG #698 revealed he had been Resident #21's guardian since 02/22/22. LG #698 stated he was not aware until Resident #21's elopement that he had not been residing on the facility's locked unit and could not imagine why Resident #21 was not on that locked unit from the very beginning. LG #698 stated he felt Resident #21 should have a Wanderguard as he had eloped from other facilities and was very crafty as he was a known flight risk. LG #698 was first made aware of Resident #21's elopement on 10/13/22 when he spoke with the Administrator. LG #698 checked his phone records and indicated 10/13/22 was the first date he had heard from the facility regarding Resident #21's elopement and stated he was made aware Resident #21 did not have a staff escort for this medical appointment. LG #698 verified he did not feel Resident #21 would be safe in the community without an escort. Follow-up interview on 10/24/22 at 8:29 A.M. with the Administrator revealed on 10/11/22 when the facility pulled Resident #21's probate guardianship documents they learned he was to have been on the secured unit this whole time. The Administrator did not know when the physician was notified. Interview on 10/24/22 at 8:58 A.M. with RN/ADON #683 revealed Resident #21 was alert and oriented but had a guardian. RN/ADON #683 indicated she and the DON helped to search for Resident #21 on 10/11/22 and she also searched for him after work. On 10/15/22 after 3:30 P.M. she saw Resident #21 in [city approximately 7.2 miles from the facility] walking on the street towards the laundromat using a quad cane with a clear garbage bag with laundry detergent and clothes. RN/ADON #683 approached Resident #21 and told him he had to return to the facility; Resident #21 told her he had told his brother and sister where he was and he wanted to come back to the facility on Monday 10/17/22. The police were called and the Administrator and the DON arrived to the scene. Resident #21 returned to the facility in the DON's vehicle. RN/ADON #683 stated LPN #623 was disciplined for the failure to send an escort with Resident #21 to this appointment. RN/ADON #683 verified residents were to be assessed for elopement risk quarterly and after an incident and was made aware during the interview that Resident #21 lacked evidence of routine, quarterly elopement assessments. RN/ADON #683 verified Resident #21 did not have a Wanderguard even though his care plan stated one was in place. Review of LPN #623's personnel file indicated no disciplinary actions. Time punches for LPN #623 revealed no suspensions were noted for the period 10/09/22 to 10/20/22. Interview on 10/24/22 at 9:29 A.M. with SSD #650 revealed Resident #21 had a high BIMS score but he had periods of forgetfulness and did have a legal guardian. SSD #650 verified after reviewing some evaluations previously he was supposed to be on the secured unit and he had been in the facility for some time and had not been on the secured unit. SSD #650 verified Resident #21 was never placed on the secured unit at the time the guardianship was established. SSD #650 verified Resident #21 did not have a Wanderguard and verified his care plan for elopement risk was inaccurate. SSD #650 stated on 10/11/22, early afternoon, TS #687 called the facility and the front desk let her know Resident #21 could not be found. SSD #650 and the DON left the facility to search the area around the medical center. SSD #650 stated building security brought Resident #21 downstairs since he was panhandling in the waiting room and his appointment was over. Resident #21 came down to smoke, then came back inside the building to tell security he did not know where to go now and then ambulated with his cane to the bus stop. SSD #650 stated she had been concerned with him being on his feet for long periods of time since she usually saw Resident #21 in a wheelchair. SSD #650 verified Resident #21 should have had an escort for the appointment and verified due to his history of drug and alcohol use, Resident #21 would not be safe in the community by himself. Interview on 10/24/22 at 10:36 A.M. with the DON revealed she had been employed by the facility since 09/09/22. The DON stated on 10/11/22 in early afternoon SSD #650 came to tell her that TS #687 told them Resident #21 was no longer at his appointment and had been observed smoking then getting on a bus. She, RN/ADON #683, STNA/Scheduler #667 and SSD #650 went to try to locate Resident #21. The DON verified all residents were to have a Leave of Absence physician's order that would reference the need for an escort. The DON verified residents were to be assessed for elopement status quarterly. The DON also stated a progress note indicating doctor and guardian notification of incidents was also required and verified that was not completed for Resident #21. The DON confirmed the facility did not know about Resident #21's guardianship papers indicating he was a flight risk and required the secured unit until pulled during this incident. Interview on 10/24/22 at 10:58 A.M. with medical center Receptionist #699 revealed everyone at the medical facility knew about Resident #21 leaving the medical appointment. Resident #21 was in a wheelchair and must have gotten in one as he had a cane or a walker. Receptionist #699 stated she recalled Resident #21 was asking everyone in the office for money then stated the surveyor needed to talk to a hospital supervisor. Interview on 10/24/22 at 12:04 P.M. with Hospital Nurse Manager (HNM) #700 revealed she had been told Resident #21 was alert and oriented. Resident #21 went to his appointment and medical center staff took Resident #21 downstairs to get his ride and he told them (not identified) he was going to get his prescription. HNM #700 verified Resident #21 was ambulatory but she was not sure if he was using a cane at the time of the appointment. HNM #700 stated this was not the first time Resident #21 had done this and shared he was well known to the medical center's police department. HNM #700 stated the facility's bus did not show up until late afternoon to get Resident #21 but Resident #21 was already gone. Interview on 10/24/22 at 11:15 A.M. with the Administrator revealed when she had asked LPN #623 how the need for a resident escort was determined, her answer was not sufficient so she was disciplined for her failure to send Resident #21 to his doctor's appoin [TRUNCATED]

Based on interview, observation, record review, and policy review, the facility failed to ensure appropriate interventions were implemented to prevent the development of a pressure ulcer for Resident #58. Actual Harm occurred on 10/11/22 at 2:15 P.M. when Resident #58, who was a paraplegic and required total dependence of two staff with transfers, extensive assist of one person with toileting and dressing and limited assistance of one staff with bed mobility, was found to have a Stage three (full thickness tissue loss that may include undermining, tunneling, and slough {dead skin tissue that may be white and/ or yellow in appearance} which does not obscure the depth of the tissue loss) pressure ulcer to his coccyx area during wound rounds that required debridement. No treatment to the pressure ulcer was initiated from the discovery date of 10/11/22 until 10/17/22 (six days). In addition, review of the medical record revealed the facility did not have any evidence Resident #58's coccyx pressure ulcer was re-assessed and measured after 10/11/22 once discoveed until 10/24/22. This affected one resident (Resident #58) of three residents (Resident #58, #61, and #78) reviewed for pressure ulcers. The facility census was 79. Findings included: Review of medical record for Resident #58 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan dated 10/05/21 revealed Resident #58 had actual skin impairment related to his pressure areas on admission to his left heel that resolved on 12/21/21, right dorsal foot that resolved on 10/19/21, sacrum area that resolved on 12/21/21 and his current right ischium pressure ulcer. The care plan contained no evidence of the regarding new facility acquired pressure ulcer to his coccyx area that was found on 10/11/22. Interventions included initiate wound treatment and continue treatment as ordered, limit time out of bed, and skin observation on bath and shower days. Review of Braden Score evaluation dated 08/09/22 and completed by Minimum Data Set 3.0(MDS)/ Registered Nurse (RN) #661 revealed Resident #58 was at moderate risk for skin breakdown due to his sensory perception was slightly limited, he was constantly moist, he was chairbound, his mobility was slightly limited, and he had a problem with friction and shear. Review of annual MDS dated [DATE] revealed Resident #58 had intact cognition and required limited assist with bed mobility and was totally dependent of two people with transfers. He required extensive assist of two people with toileting. Resident #58 was at risk for developing a pressure ulcer and had three unstageable (full thickness tissue loss and the actual depth of the ulcer was completely obscured by slough in the wound bed) pressure ulcers that were not present on admission. Review of October 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Treatment Administration Record (TAR) for October 2022 revealed Resident #58's treatment was documented as first initiated on 10/17/22 7:00 P.M. to 7:00 A.M. to cleanse his coccyx area with normal saline, pat dry, apply calcium alginate to wound bed and cover with foam dressing daily and as needed. The TAR revealed there was no treatments for his coccyx area documented as being completed from 10/11/22 when his coccyx pressure ulcer was first found to 10/17/22 (six days). Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and completed by Wound Physician #713 revealed on wound rounds it was identified Resident #58 had a new facility acquired Stage three pressure ulcer to his coccyx area that measured a length of 2.5 centimeters (cm), width of 1.5 cm and depth of .3 cm. The pressure ulcer contained 75 percent granular tissue, and 25 percent slough. The progress note revealed Wound Physician #713 cleaned the wound, flushed, irrigated, and prepared for debridement. The progress revealed the wound was sharply debrided manually with a curette (a surgical instrument used to remove material by a scraping action) to reduce infection and promote wound healing. The progress note revealed a treatment plan was given to the wound care nurse verbally and written. Review of facility form labeled, Skin Grid Pressure dated 10/11/22 and completed by the Director of Nursing revealed Resident #58 had an unstageable pressure ulcer that was identified on 10/11/22 to his coccyx area that measured a length of 2.5 cm, width of 1.5 cm and depth of .3 cm. The skin grid revealed the pressure ulcer had 75 percent granular tissue, and 25 percent soft yellow slough. The skin grid revealed Wound Physician #713 debrided the wound with a curette. Review of nursing note dated 10/18/22 at 5:44 P.M. and completed by the Director of Nursing revealed Resident #58 was not seen per the Wound Physician #713 because he was out of the facility at an appointment. Review of facility form labeled, Skin Grid Pressure dated 10/18/22 and completed by the Director of Nursing revealed the form was opened in the electric medical record but that there was no assessment documented regarding Resident #58's wound to his coccyx including measurements, and description of his wound. Interview on 10/24/22 at 9:00 A.M. and 10/26/22 at 10:58 A.M. with Assistant Director of Nursing (ADON/ Registered Nurse (RN) #683 revealed she completed wound rounds weekly with Wound Physician #713. She revealed on 10/11/22 during wound rounds they found Resident #58 to have a pressure ulcer to his coccyx area that was not previously reported and/ or documented. She verified Wound Physician #713 staged his coccyx pressure area as a Stage three wound and the wound had contained slough inside the wound bed that needed debrided by Wound Physician #713. She verified there was a discrepancy in documentation as the facility Skid Grid Pressure form dated 10/11/22 and completed by the Director of Nursing revealed the coccyx pressure ulcer was unstageable but Wound Physician #713's progress note revealed the wound to his coccyx area on 10/11/22 was a Stage three. She also verified Wound Physician #713 had given her a treatment order verbally for Resident #58's coccyx that included to cleanse his coccyx area with normal saline, pat dry, apply calcium alginate to wound bed and cover with foam dressing daily and as needed. She revealed there was a lot going on that week and she verified she did not initiate the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She verified the treatment was not documented on the TAR as being completed until 10/17/22 . ADON/ RN) #683 verified she had no documentation a treatment was completed to Resident #58's coccyx area from 10/11/22 to 10/17/22 (six days). She revealed wounds were to be assessed and measured weekly and that Wound Physician #713 came into the facility on [DATE] but Resident #58 was at an outside appointment. ADON/RN) #683 verified the documentation per the facility form, Skin Grid Pressure dated 10/18/22 was blank and that she did not have any documentation that the coccyx wound was measured and/ or documented on appearance of the wound from 10/11/22 to 10/24/22. ADON/RN) #683 verified Resident #58 was a paraplegic and required total dependence of two staff with transfers, extensive assist of one person with toileting and dressing and limited assist of one staff with bed mobility. She verified staff should have found and reported the pressure ulcer to his coccyx area prior to the wound being found as a stage three on wound rounds and stated, I really can not explain why it was not found earlier as it should have been. Observation and interview on 10/24/22 at 1:00 P.M. of wound care for Resident #58's coccyx area completed by Wound Physician #713 and ADON/ RN #683 revealed Wound Physician #713 measured the wound as a length of 3 cm, width 2.5 cm and depth of .2 cm. He revealed the wound continued to be a Stage three and had 85 percent granulation and minimal slough. He recommended the same order to continue. Wound Physician #713 verified the wound to Resident #58's coccyx area was found on 10/11/22 during wound rounds and was discovered as a Stage three wound. Wound Physician #713 verifed the wound was larger in length and width from 10/11/22. Review of facility policy labeled, Pressure Injury Prevention and Management dated 08/22/22 revealed the facility was committed to the prevention of avoidable pressure injuries and was to provide treatment and services to heal pressure ulcers. The unit manager and/ or designee would review relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly. The policy revealed nursing assistants would inspect skin during bath and would report any concerns to the resident's skin immediately after the task. This deficiency represents non-compliance investigated under Complaint Number OH 176.

Based on interview, observation, and open and closed record review, the facility failed to ensure tube feedings were ordered and implemented appropriately to prevent gastrointestinal symptoms including severe abdominal pain, nausea, and vomiting. Actual Harm occurred on [DATE] when Dietician #677 wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 4:00 A.M. Resident #35 had a large emesis, and abdominal pain causing her to cry out in pain. On [DATE] Hospice RN #727/ Hospice Physician #729 ordered to discontinue the continuous tube feeding and only administer the bolus tube feeding order. The facility failed to transcribe the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 expired on [DATE]. In addition, the facility failed to ensure Resident #35 and #39 had an annual comprehensive nutritional assessment completed monitoring their tube feeding status. This affected two residents (Resident #35 and #39) of three residents (Resident #23, #35, and #39) reviewed for tube feedings. The facility had a total of three residents with orders for tube feedings (Resident #23, #35, and #39) residing at the facility. Findings included: 1. Review of closed medical record for Resident #35 revealed an admitted [DATE] and the resident expired on [DATE] under hospice services. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical record revealed Resident #35 had a guardian of person. Review of facility form labeled, Comprehensive Medical Nutrition Therapy Assessment- V1 dated [DATE] revealed Former Dietician #724 completed the admission comprehensive nutritional evaluation. There were no other Comprehensive Medical Nutrition Therapy Assessments in the resident's medical record until [DATE]. Review of the care plan dated [DATE] revealed Resident #35 was dependent on tube feeding for nutrition and hydration. She was at risk for aspiration and other complications related to the tube feeding. Interventions included administer tube feeding and flushes as ordered, check residuals as ordered, and notify physician of any complications. Review of care plan dated [DATE] revealed Resident #35 and Resident' #35's family elected hospice services as Resident #35 desired to be kept comfortable and not receive life sustaining measures. Interventions included communicate to hospice regarding changes in condition, and coordinate plan of care with resident, family, and hospice. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #727 revealed Resident #35 was readmitted to hospice services with a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The order revealed to contact hospice prior to initiating any treatments, after a fall, or with any change in status. Review of Significant Change Minimum Data Set 3.0 (MDS) dated [DATE] revealed Resident #35 had impaired cognition. She was totally dependent on one person with eating, and she had a tube feeding. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #35 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 6:00 A.M., 12:00 P.M., and 6:00 P.M) The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 12:00 P.M. due to resident being nauseated, [DATE] at 12:00 P.M. and 6:00 P.M. with no indication provided, and on [DATE] the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ., and 6:00 A.M. and the tube feeding was held at 6:00 P.M. Resident #35 had an order that started on [DATE] at 11:00 P.M. for Diabetisource continuous at 40 ml per hour through peg tube. The nurses documented every shift that Resident #35 received this as ordered beginning [DATE] through [DATE] except on [DATE] 7:00 A.M. to 3:00 P.M., [DATE] 3:00 P.M. to 11:00 P.M., [DATE] from 11:00 P.M. to 7:00 A.M., [DATE] 7:00 A.M. to 3:00 P.M., and [DATE] 3:00 P.M. to 11:00 P.M. as the tube feeding was held. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #677 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order discontinuing the previous tube feeding order of Diabetisource 240 ml bolus per peg tube every six hours. Review of nursing note dated [DATE] at 7:25 P.M. and completed by Licensed Practical Nurse (LPN) #657 revealed the tube feeding was held for Resident #35 because it was not continuous but there was no further documentation. Review of facility form labeled, Comprehensive Medical Nutrition Therapy Assessment- V1 dated [DATE] and completed by Dietician #677 revealed the assessment was in progress and the only things completed on the assessment were name, room number, admitted , date of birth, age, physician, assessment type (significant change), diagnoses, and medications as all the other areas were left blank. There was no further documentation including meal intake, impairments, tube feeding order including calories, protein, and water flushes, body type, laboratory data, nutritional needs, nutritional risks, plan of care and how Resident #35 was tolerating the tube feeding. Review of nursing note dated [DATE] at 4:00 A.M. and completed by RN #679 revealed Resident #35 had a large emesis that appeared to be tube feeding material. The nursing note revealed Resident #35 was grimacing and crying in pain when moved or when her abdomen was palpated. Hospice was notified and was refusing to come see Resident #35. Primary Care Physician #725 was notified and stated he would contact hospice. Review of nursing note dated [DATE] at 4:23 A.M. and completed by RN #679 revealed Resident #35 was grimacing in pain and yelling out when abdominal area was touched. Review of Hospice Visit Note Report dated [DATE], untimed and completed by Hospice RN #727 revealed Resident #35 was seen earlier than scheduled due to Resident #35 was having emesis and stomach pain. The note revealed when Hospice RN #727 arrived LPN #657 had stated Resident #35 was having stomach pains, nausea, and vomiting over the last few days. Hospice RN #727 requested a printout of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice RN #727 questioned LPN #657 regarding the orders which she was not aware of the reasoning of, and LPN #657 had stated Resident #35 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice RN #727 questioned LPN #657 further regarding who had ordered the continuous tube feeding and was told Dietician #677 had written the order. The Hospice RN #727 noted that there was no progress note or anything else in the medical record regarding why there was a change in order. Hospice RN #727 wrote a clarification order to discontinue the continuous tube feeding due to patients' current symptoms that had started on [DATE] after the continuous tube feeding order had been started and to continue only the bolus tube feedings as ordered. Hospice RN #727 spoke with LPN #657 regarding the new order. Review of Prescriber's telephone order dated [DATE] and completed by Hospice Physician #729/ Hospice RN #727 revealed the order stated to please clarify enteral feed order that was changed on [DATE] due to patient's history of not tolerating continuous tube feeding and with her being hospice recommended promoting comfort. The telephone order ordered to discontinue continuous tube feeding at 40 ml per hour and to continue Diabetisource bolus 240 ml every six hours. The order was in Resident #35's medical record but was never transcribed by the facility. Review of nursing note dated [DATE] at 12:35 P.M. and completed by Director of Nursing revealed Resident #35's tube feeding was held because she had a residual of 60 ml. Review of nursing note dated [DATE] at 3:39 P.M. and completed by the Director of Nursing revealed Primary Care Physician #725 was notified due to Resident #35 having a large emesis and residual. Primary Care Physician #725 ordered to place tube feeding and water flushes on hold for four hours and use as needed [MEDICATION(S)] (medication for vomiting and nausea) to address issues with vomiting. Hospice and Resident #35's guardian were updated. Review of a nursing note dated [DATE] at 11:14 P.M. and completed by LPN #602 revealed Resident #35's tube feeding was held due to 60 ml of residual and severe stomach pain. Review of nursing note dated [DATE] at 7:09 P.M. and completed by Agency LPN #726 revealed the tube feeding was held due to Resident #35 had increased residual of 60 ml. Review of nursing note dated [DATE] at 3:01 P.M. and completed by LPN #631 revealed Resident #35 had absence of vital signs and Primary Care Physician #725 was at the facility and pronounced her death. Hospice and Resident #35's guardian were notified. Interview on [DATE] at 9:20 A.M. with Hospice Director of Clinical Service revealed on [DATE] they received a call from the facility that Resident #35 was having severe abdominal pain, vomiting, and was nauseated. She revealed Hospice RN #727 had come to the facility and verified Resident #35 had severe abdominal pain with vomiting. She revealed Hospice RN #727 had found after she completed a record review that Resident #35 was ordered on [DATE] Diabetisource continuous tube feeding at 40ml per hour and hospice had not been notified of the new order. She revealed it was in best practice to ensure the facility notified hospice of any order changes. She also revealed Hospice RN #727 had discovered not only was Resident #35 receiving the new continuous tube feeding order but that she was still receiving the old tube feeding order of Diabetisource 240 ml bolus every six hours and most likely the reason of the abdominal pain, emesis, and nausea. She revealed Hospice RN #727 had received an order on [DATE] from the Hospice Physician #729 to discontinue the continuous tube feeding order and just to continue the previous bolus tube feeding order. She revealed Hospice RN #727 had checked through the medical record and there was no documentation as to why the continuous tube feeding was ordered and that staff and Resident #35's guardian had stated that Resident #35 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She verified she was not aware Resident #35 continued to receive both the continuous tube feeding and the bolus tube feeding after [DATE] when Hospice RN #727 had written the order to discontinue the continuous tube feeding order. Interview on [DATE] at 9:43 A.M. and 11:15 A.M. with the Administrator verified Dietician #677 had placed the order for Resident #35 into the electronic medical record to receive the continuous Diabetisource 40 ml per hour and had forgot to discontinue the previous tube feeding order of Diabetisource 240ml bolus every six hours. She verified on review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She verified on [DATE] Resident #35 had severe abdominal pain with nausea and vomiting requiring a call to hospice due to her symptoms. She verified Hospice RN #727 had left an order in Resident #35's medical record to discontinue the continuous Diabetisource 40 ml per hour and to continue only the Diabetisource bolus 240 ml every six hours. She verified this order was never transcribed and Resident #35 continued to receive both tube feeding orders including Diabetisource bolus 240 ml every six hours and Diabetisource 40 ml every hour continuously. She verified from [DATE] to [DATE] Resident #35 continued to have abdominal pain, nausea, vomiting and increased residuals of tube feeding when checked. She revealed she was unsure why the order was not transcribed. She also verified that there was a comprehensive admission nutritional assessment completed on [DATE] but that there were no further comprehensive nutritional assessments completed as the one dated [DATE] was almost completely blank. She verified a comprehensive nutritional assessment should be completed at least annually and on any significant change. She verified hospice and Resident #35's guardian were not notified regarding the Diabetisource 40ml per hours continuous tube feeding order change dated [DATE] and that they both should have been notified. Interview on [DATE] at 9:54 A.M. and 10:33 A.M. with Dietician #677 revealed she had felt Resident #35 would tolerate better from a continuous tube feeding rather than a bolus so she had changed the tube order to Diabetisource 40 ml per hour continuous on [DATE] but that she had forgot to discontinue the Diabetisource bolus 240 ml every six hours as both tube feeding orders should not have been administered at the same time. She verified Resident #35's last comprehensive nutritional assessment was completed on [DATE] and that an annual had not need completed in [DATE]. She verified she had only started the comprehensive significant change nutritional assessment on [DATE] with basic information but had not gotten a chance to complete the assessment before the resident passed away. She verified she had not contacted Resident #35's guardian or hospice regarding the change in tube feeding order on [DATE] and could not remember if she had passed it along to nursing. She verified she was not aware Resident #35 was having abdominal pain, vomiting, and nausea after she had added the continuous tube feeding order and she was not notified regarding hospice consulting and recommending discontinuing the continuous tube feeding and only maintaining the bolus tube feeding order. She revealed she was not aware the order from hospice on [DATE] was never transcribed. Interview on [DATE] at 12:17 P.M. with Resident #35's guardian revealed she was never contacted on [DATE] regarding Resident #35's tube feeding order change for continuous tube feeding. She revealed if she would have been contacted, she would have not approved the order change because Resident #35 in the past was not able to tolerate continuous tube feeding and only could tolerate bolus tube feedings. She revealed in the past on continuous tube feeding Resident #35 would have sever abdominal pain, vomiting and nausea that was why it was changed to bolus. She revealed she was not notified to ensure this did not happen until [DATE] and then was told by hospice that the continuous tube feeding would be stopped on [DATE] but then she had found out that it continued despite Resident #35 having severe abdominal pain. 2. Review of medical record for Resident #39 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility form labeled. Comprehensive Medical Nutrition Therapy assessment dated [DATE] and completed by Former Dietician #724 revealed Resident #39 was evaluated upon admission and continued on tube feedings per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no other comprehensive nutritional assessments completed in her medical record. Review of care plan last revised [DATE] revealed Resident #39 had altercation in her nutrition and hydration status. She received enteral feedings and was on hospice. Interventions included collaborate with the hospice team, provide enteral nutrition per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of quarterly MDS dated [DATE] revealed Resident #39 was cognitively impaired as she was rarely and/ or never understood. She was totally dependent of one person for eating as she received tube feedings. Observation and attempted interview on [DATE] at 9:06 A.M. revealed Resident #39 was receiving tube feeding per order and was unable to be interviewed due to impaired cognitive ability. Interview on [DATE] at 9:54 A.M. and 10:33 A.M. with Dietician #677 verified the last comprehensive nutritional assessment for Resident #39 was completed on [DATE]. She verified comprehensive nutritional assessment were to be completed at least annually and upon any significant change. She revealed Resident #39's comprehensive assessment must have been missed in [DATE]. Review of facility policy labeled, Enteral Nutrition dated [DATE] revealed the dietician with input from the physician, nurse, and resident representative would determine the calorie, protein, nutrient, fluid needs and evaluate whether the resident's current intake was adequate. The policy revealed the dietician was responsible for routinely assessing residents who received enteral feedings. Review of facility policy labeled, Nutritional Management dated [DATE] revealed a comprehensive nutritional assessment would be completed by the dietician on admission, annually, and upon significant change in condition. This deficiency represents non-compliance investigated under Complaint Number OH 986.

Based on interview, record review and policy review, the facility failed to implement interventions to prevent the development of an unstageable pressure ulcer for one resident (Resident #73). Actual Harm occurred on [DATE] when Resident #73's significant weight loss was not addressed timely, he was not routinely turned and repositioned, and he developed a pressure ulcer to the left ischium first discovered as an unstageable ulcer (Full-thickness skin and tissue loss which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed). This affected one (Resident #73) of three residents reviewed for pressure ulcers. The facility census was 71. Findings include: Review of Resident #73's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 had severe cognitive impairment and required extensive assistance with bed mobility. Resident #73 was transferred to the hospital on [DATE] and expired on [DATE]. Review of Resident #73's medical record revealed he experienced a significant weight loss of 17.5 percent over less than three months, from [DATE] (157.8 pounds) through [DATE] (130.1 pounds). Further review revealed Resident #73 experienced a significant weight loss from [DATE] (151.2 pounds) through [DATE] (132.2 pounds) of 12.5 percent for six months. Review of the physician's orders revealed an order dated [DATE] for a monthly weight. Review of the Braden Scale for predicting pressure sore risk dated [DATE] revealed Resident #73 was at a low risk of developing a pressure ulcer. The assessment included Resident #73's nutrition intake was adequate, and he ate over half of most meals. The assessment included there was no apparent problem for friction and shear, indicating Resident #73 moved in chair independently and had sufficient muscle strength to lift-up. However, the MDS 3.0 assessment dated [DATE] stated he required extensive assistance for bed mobility. The assessment included sensory perception was slightly limited, indicating Resident #73 responded to verbal commands but could not always communicate discomfort or the need to be turned. Review of Resident #73's Braden Score Assessment on [DATE] revealed Resident #73 was a high risk for development of a pressure ulcer included Resident #73's nutrition intake was probably inadequate, indicating he rarely ate a complete meal and generally only ate one half of any food offered. The assessment included friction and shear was a problem, indicating Resident #73 required moderate to maximum assistance in moving. Sensory perception was slightly limited, but Resident #73 responded to verbal commands but could not always communicate discomfort or the need to be turned. Review of Resident #73's Skin Grid Pressure assessment dated [DATE] revealed Resident #73 had an unstageable pressure ulcer to the left ischium measuring 5.3 centimeters (cm) in length by 3.1 cm in width and a depth unable to be determined. The wound bed was 50 percent necrotic, 25 percent slough and 25 percent granular tissue. The wound edges were attached. This was a new problem area. Resident #73 did not have a documented pressure ulcer prior to [DATE]. Review of Resident #73's Skin Grid Pressure assessment dated [DATE] revealed Resident #73 had an unstageable pressure ulcer to the left ischium 5.4 cm in length by 4.0 cm in width by 1.5 cm in depth. The wound bed was 75 percent black necrotic tissue. The area was debrided (removal of necrotic tissue) by the wound doctor. Resident #73 tolerated the procedure well. After debridement, the depth was 3.0 cm. An observation of the wound was unable to be completed due to the resident expired prior to the survey. Review of Resident #73's care plan, revised [DATE], included interventions initiated on [DATE] to monitor and record consumption of food, and an intervention initiated [DATE] to monitor weights every month and as needed, and notify the physician or nurse practitioner of a significant weight change. Review of Resident #73's MDS 3.0 assessment dated [DATE] included Resident #73 had a loss of five percent or more weight in the last month, a ten percent or more in six months and documented resident was not on a prescribed weight loss regimen. Interview on [DATE] at 3:42 P.M. with MD #218 revealed MD #217 was no longer working on the hospital nursing unit that Resident #73 was admitted to, and he did not know where she was now. MD #218 did not care for Resident #73 before he expired. MD #218 checked the records and stated Resident #73 was septic from urine or his pressure ulcer. Review of Resident #73's physician's orders revealed an order dated [DATE] to turn and reposition every two hours and as needed while in bed as tolerated. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #227 marked an E on the bi-weekly skin checks on Wednesdays and Saturdays. The E stood for Resident #73 had an existing area of concern on his skin. Review of the record revealed Resident #73 had no documented evidence of bed mobility and turning every two hours for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the medical record revealed Resident #73 had no documented evidence of bed mobility and turning every two hours one or two shifts each day for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the record revealed Resident #73 had no documented evidence of bed mobility and turning every two hours for [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Interview on [DATE] at 12:18 P.M. with State tested Nurse Aide (STNA) #220 revealed when Resident #73 was transferred to the nursing unit she worked on (before he developed the pressure ulcer) he did not walk, was usually in the wheelchair and required a stand-up lift or a Hoyer (mechanical lift) for transfers. Interview on [DATE] at 3:24 P.M. with STNA #211 revealed she took care of Resident #73 after he was transferred to the nursing unit she usually worked on. STNA #211 stated Resident #73 had a reddened area on his buttocks which she brought to the attention of the Assistant Director of Nursing (ADON). STNA #211 stated it was a small reddened area and was not an open wound at the time. STNA #211 could not remember the month she noticed the reddened area or the ADON she told about the reddened area. STNA #211 further stated she needed to remind Resident #73 to eat, he would just stare at his food unless she prompted him. STNA #211 stated she fed him at times because he wouldn't eat. Interviews on [DATE] between 11:26 A.M. and 11:35 A.M. with ADONs #210 and #219 revealed they denied they were notified Resident #73 had a reddened area on his buttocks by a STNA. Interview on [DATE] at 3:55 P.M. with Registered Dietitian (RD) #209 revealed a nutrition assessment was completed on [DATE]. No further assessment was completed until [DATE]. RD #209 stated she was training a new dietitian which was why her name was on the assessment dated [DATE]. RD #209 stated Resident #73 had a significant weight loss over 90 days. RD #209 stated every Thursday the facility conducted a resident risk meeting, and resident weights were reviewed at the meetings. RD #209 stated [DATE] through [DATE] was a busy time, she was aware Resident #73 had a significant weight loss and needed a nutrition assessment, but she thought his intake was fairly good and his weights would get better. RD #209 stated obviously that's not an intervention, and his weight did not get better. Interviews on [DATE] at 10:04 A.M. and 2:20 P.M. with STNA #225 revealed she noticed Resident #73 had a reddened area on his bottom on [DATE] and reported the reddened area to Licensed Practical Nurse (LPN) #221. STNA #225 stated the area was reddened but was not an open wound. STNA #225 stated there were two residents she reported having reddened areas on [DATE] and she was 100 percent certain Resident #73 had a reddened area, and she reported it to LPN #221. Interview on [DATE] at 10:35 A.M. with LPN #221 stated she did not remember being told Resident #73 had a reddened area on his buttocks by a STNA. Interview on [DATE] at 11:03 A.M. with LPN #229 revealed residents on the first-floor nursing unit do not get the care they need. LPN #229 stated Resident #73 was left sitting in his wheelchair for long periods of time and when he was in bed, he did not get repositioned or changed when he was wet or had a bowel movement. Interview on [DATE] at 3:12 P.M. with Nurse Practitioner (NP) #208 revealed he did not recall if he was notified about a weight loss for Resident #73. NP #208 stated a lot of factors could contribute to the development of a pressure ulcer and weight loss could be one of the factors. An Interview was attempted on [DATE] of Resident #73's primary care physician, Medical Doctor #226. A voice message was left, and no return call was made. Interview on [DATE] at 9:14 A.M. with STNA #228 revealed the facility did not always have enough STNAs to get all the work done, and the nurses did not want to help. STNA #228 stated she did not get residents turned every two hours because she was too busy. STNA #228 stated Resident #73 did not always get turned every two hours when he was in bed because she had too much work to do. Attempts on [DATE] to contact LPN #227 by phone were unsuccessful. Review of the undated facility policy titled Resident Care included residents confined to bed or wheelchair will be routinely encouraged and assisted to be turned and repositioned and body alignment maintained. Review of the facility policy titled Weight Policy, dated ,d+[DATE], included obtaining accurate weights is important for the nutritional assessment of each resident and is used as the basis for Medical Nutritional Therapy interventions. Weights will be obtained upon admission and documented. Do not use the hospital weight. The resident will be weighed every week for the following three weeks, then monthly unless ordered otherwise by MD/NP or dietitian. This deficiency substantiates Complaint Number OH 461.

Based on observation, resident and staff interview, medical record review and review of the facility suicide policy, the facility failed to consistently implement comprehensive and individualized interventions and provide adequate supervision for one resident (Resident #41) with known suicidal ideation, to prevent self-harm. This resulted in Immediate Jeopardy on 06/12/19 when Resident #41, who had a history of [REDACTED]. In addition the facility failed to implement fall interventions for one resident (Resident #42) who was assessed at high risk for falls and sustained multiple falls. This affected two of six residents reviewed for accidents, hazards and supervision. The facility census was 103. The Administrator and Regional Administrator were notified on 06/13/19 at 2:21 P.M. that Immediate Jeopardy began on 06/12/19 at 7:00 A.M. when staff members did not implement every fifteen-minute checks of Resident #41 as previously ordered. The Immediate Jeopardy was removed on 06/14/19, when the facility implemented the following corrective action. · On 06/13/19 at 8:15 A.M. Resident #41 was placed on one-to-one monitoring to ensure she was safe and unable to attempt actions that could result in harm. She was seen by psychiatric service and was started on a new anti-psychotic medication, [MEDICATION NAME] 5 milligrams (mg) twice daily. The order for the one-to- one monitoring was written as an order to be in place until discontinued by a physician. The care plan was updated to indicate the one-to-one supervision starting 06/13/19. · The policy on Suicide Threats was updated on 06/13/19 by 7:30 P.M. and renamed Suicidal ideation and self-harm attempts. The policy was revised to ensure the facility administrator would be responsible for notification of the regional team of any threats of suicide made by a resident, and a staff member was to remain with the resident until otherwise directed by the administrator or director of nursing (DON). The resident room would be assessed for safety and monitored for risk. The supervisor or DON would assess the resident in more detail and notify the physician for further direction. The facility would proceed as indicated with a psychiatric consultation or transfer for emergency psychiatric evaluation. The record would contain documentation of assessments, interventions, one-to-one monitoring and notes and responses of notification until the physician deemed the resident was no longer in danger of harming self or others. The record would also contain supporting documentation of any interdisciplinary team discussion and care plan updates. · On 06/13/19 at 8:00 P.M. Licensed Social Workers (LSW) #403 and #416 began assessing all residents for thoughts of self-harm or self-harm behaviors. Residents who were able were interviewed, and residents who were not interviewable were reviewed by the interdisciplinary team for behaviors and discussed by the interdisciplinary team to determine if they were at risk. All 68 residents were assessed by 10:45 P.M. No additional residents were assessed as having thoughts of self-harm or suicidal ideation. Seven residents were assessed as feeling sad, and care plans were reviewed and updated as needed to ensure appropriate interventions for behaviors were in place. · The new supervision policy for residents with suicidal ideation or self-harm attempts indicated residents who expressed suicidal ideation, threats of suicide or threats of self-harm would be provided with one-to-one supervision until the physician determined the resident was no longer at risk to self. · On 06/13/19 starting at 8:00 P.M., the Director of Regional Operations (DRO) in-serviced the Administrator and all managers on the warning signs of suicide and interventions to take if a resident was threatening suicide or self-harm. The Administrator, DRO, Assistant Director of Nursing (ADON) / Licensed Practical Nurse (LPN) #408, and Assessment Nurse (LPN #452) in-serviced all nurses starting on 06/13/19 at 8:30 P.M. and continuing until 06/14/19 at 12:00 P.M. This included two registered nurses (RN), and 26 LPNs. The Vice President of Operations, ADON, Medical Records Supervisor (MR)/ State tested Nurse Aide (STNA) #445 and Scheduler/ STNA #453 in-serviced 31 STNAs starting on 06/13/19 at 8:30 P.M. All managers for housekeeping and laundry, dietary and therapy in-serviced their staff members starting on 06/13/19 at 8:00 P.M. Clinical staff members were educated on the new and revised policies, recognizing suicidal and self-harm behaviors and interventions for staff to implement if the behaviors were witnessed by staff, to include prompt reporting of the behaviors to the charge nurse. Non-clinical staff were educated on warning signs of suicide and actions to take, to include notification of the charge nurse of any witnessed behaviors or statements. As of 06/14/19 at 12:00 P.M., all facility staff had been in-serviced, either in person or by phone. · Beginning on 06/14/19 RNs and LPNs were in-serviced by the Administrator, LSWs #403 and #416 and LPN #452 regarding shift to shift report and communication to staff. This was completed by 06/14/19 at 12:00 P.M. · On 06/14/19 from 3:15 PM to 3:46 P.M. interviews were conducted of 16 staff members including LPN #405, #444 and #446, STNA #434, #437, #438, #440, #441 and #442, Housekeeper #427, Scheduler #435, Activity Director #436, Physical Therapist #439, Medical Records Director #445 and Maintenance Director #443. All employees verified they had been in-serviced and had knowledge of new suicide policy procedures, warning signs of suicidal ideation, what to do if a resident expressed suicidal ideation, one-to-one procedures and notification procedures. · On 06/14/19, audits were instituted to verify all staff understood the policy regarding one-to-one monitoring, self-harm and suicidal ideation. The Administrator called at shift change on 06/15/19 and 06/16/19 to verify current staff had previously received the in-servicing. Residents on one-to-one monitoring would be observed by a manager each shift to verify the monitoring was in place starting on 06/14/19, with coverage in case of a call off, and to ensure documentation of the one-to-one was current. Observations and audits would be conducted three to five times a week by the DON or designee, verifying the one-to-one care was implemented per the policy for 90 days, with findings reviewed once a week for four weeks then monthly. Clinical managers would read 24-hour report and report any behaviors to the Administrator each shift starting 06/14/19. The Administrator, Nurse Manager or Social Services staff member would complete an audit of all residents to ensure they were not having feelings of self-harm or exhibiting behaviors twice a day between 7:00 A.M and 1:00 P.M. and again between 1:00 P.M. and 8:00 P.M. to ensure behaviors were assessed and interventions were put in place as appropriate. This was completed on 06/15/19 and 06/16/19 and would be completed three to five times a week starting 06/17/19 for one month then monthly. Ambassador rounds would be conducted to assess resident concerns three to five times a week by management staff routinely/ongoing. Results of the audits would be reviewed by the monthly Quality Assurance (QA) committee monthly with recommendations for changes to be made as needed. Audit documentation was reviewed as completed through 06/16/19. Although the Immediate Jeopardy was removed on 06/14/19, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing on-going monitoring of the corrective actions. Findings include: 1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 required extensive assistance of two staff to total dependence on staff with all activities of daily living. Resident #41 was cognitively intact but felt down and tired frequently with trouble concentrating. The assessment indicated the resident had seven to eleven days of the 14-day assessment reference period of feeling she would be better off dead or of hurting herself in some way. Review of the care plan for depressive behaviors dated 12/04/18 and revised on 03/31/19 indicated the resident exhibited depressive behaviors evidenced by episodes of suicidal ideation and would place objects (pants, socks, bra strap and oxygen tubing) around her neck and state she was attempting self-harm. Interventions were to administer medications as ordered, including as needed medications and monitor for side effects, attempt non-pharmacological interventions such as one-to-one supervision, change in position or scenery, offer food and fluids, redirect with activity of choice, toileting and diversional activities. The resident was to be encouraged to verbalize feeling and fears and have a psychological consult as needed. All interventions were dated 12/04/18 with no evidence of any new interventions added to the plan. Review of a care plan for the risk of self-directed violence dated 12/17/18 and revised on 03/31/19 indicated the resident was at risk for self-directed violence related to suicidal ideation and would state that a male voice would tell her to kill herself, which would cause her to become upset. The care plan indicated Resident #41 had attempted to keep the knife from her food tray. The resident would request to go to the emergency room when she was upset and would attempt to wrap oxygen tubing, pants, socks, and bra straps around her neck. The plan also indicated she would say she wants to kill herself to gain the one-to-one attention from staff. Interventions included to administer medications as ordered, interview resident to evaluate potential for self-directed violence, asking if the resident had a present plan. Document all assessments, interactions and interventions, remove any sharp items, belts and plastic bags from the resident room, and contact the Administrator, DON and Social Services of the resident's intent. All interventions were dated 12/17/18 with no evidence any interventions were added to the plan. Review of a nursing note dated 12/13/18 at 7:21 P.M. revealed Resident #41 was found holding a knife from her tray in her hand, stating a male voice was telling her to hurt herself. In addition, Resident #41 placed calls to the suicide hot line. Resident #41 was then was put on fifteen-minute checks. Review of a note by Consulting Psychologist #501 dated 12/14/18 revealed the resident had suicidal ideation and intent and was encouraged in the use of texting crisis services. Review of a nurse's note dated 12/15/18 at 2:36 P.M. indicted after several more statements regarding the voices, Resident #41 agreed to be sent to the hospital. The resident was sent to the hospital on [DATE] at 8:30 P.M. and returned on 12/16/18 at 1:45 A.M. The medical record did not indicate an assessment of her thoughts regarding hurting herself or any new orders concerning her thoughts of self-harm. Review of a physician note dated 12/17/18 indicated Resident #41 stated she was having suicidal ideation and had a plan. The note indicated the resident was placed on fifteen-minute checks, placed near the nurse's station and instructed to call the suicide hot line. Review of a nursing note dated 01/29/19 at 10:45 P.M. revealed the resident was having suicidal thoughts after hearing of a friend's death. Resident #41 was placed on fifteen-minute checks. A nursing note dated 01/29/19 at 11:06 P.M. revealed after one of the checks, the nurse was notified the resident had torn open a soda can and tried to slit her wrists with the sharp edge. Resident #41 had an abrasion measuring 1.5 centimeters (cm) by 0.1 cm and was sent out to hospital on [DATE] at 12:41 A.M. The resident returned on 01/30/19 at 5:00 A.M. and was again put on fifteen-minutes checks. Review of a psychiatric note dated 01/30/19 revealed Resident #41 had been voicing [MEDICAL CONDITION] and had attempted to cut herself and presented as anxious and restless. An application for an emergency psychiatric admission was completed, and a nursing note dated 01/30/19 at 2:41 P.M. revealed Resident #41 was sent to the emergency room for a psychiatric evaluation. A nursing note dated 02/04/19 at 7:42 P.M. revealed the resident returned to the facility on [DATE] at 5:15 P.M. The note indicated Resident #41 had a [DIAGNOSES REDACTED]. There was no evidence in the medical record of new interventions put in place to prevent suicidal behaviors. Review of a social work note dated 02/05/19 at 1:00 P.M. revealed Resident #41 was feeling much better, denied thoughts of self-harm and was encouraged to contact nursing or social services if feelings of sadness or self-harm arose. Review of psychiatric notes dated 02/22/19, 02/27/19 and 03/20/19 indicated the resident had fleeting thoughts of suicide without intent, plan or means and the psychologist worked with her on coping and safety strategies. Review of a nurse's note dated 04/15/19 at 6:29 P.M. revealed the resident continued to say she did not feel needed. The note also indicated an agency nurse walked in the resident's room and found cord wrapped loosely around neck. The note indicated the resident was placed on fifteen-minute checks. The record did not indicate when these checks were discontinued, although there was no further mention of the checks after that documentation. Review of a psychologist note dated 04/16/19 revealed Resident #41 had suicidal and homicidal ideations and coping mechanism were discussed. The note indicated the resident did not have the means to implement the homicidal plan and would not identify potential victims. The note also indicated fifteen-minute checks were to continue and a behavior management plan was discussed with the nurse. Review of a psychologist progress note dated 04/22/19 revealed the resident's wheelchair had been broken and she was hoping it would be fixed soon so she could be out of bed more and spend less time thinking of things that made her depressed and suicidal. Another psychiatric note dated 04/25/19 revealed she was again having fleeting thoughts of suicide and auditory hallucinations. The progress note indicated the nurse will monitor. Review of a nurse's note dated 04/26/19 at 7:06 P.M. indicated Resident #41 verbalized suicidal ideation and was put on fifteen-minute checks. Although the next note on 04/27/19 at 3:19 A.M. indicated the checks were in place, there was no further mention of the fifteen-minute checks or when the fifteen-minute checks were discontinued. Review of a nurse's note dated 04/30/19 at 8:21 P.M. (late entry) revealed the resident said she took an overdose of medication. The nurse practitioner was contacted with an order given for fifteen-minute checks and for two nurses to be in the room when giving medication. Resident #41 called Emergency Medical Services (EMS) on her personal phone and was sent to the emergency roiagnom on [DATE] at 8:25 P.M. The resident returned on 05/01/19 at 3:30 P.M. with an order to stay on fifteen-minute checks for twelve hours. A physician order [REDACTED]. Review of the psychiatric service note dated 05/02/19 revealed Resident#41 was melancholy with a sad facial expression and low energy. The note indicated the resident was distressed by fleeting suicidal ideation with no intent, plan or means, and the psychologist indicated they worked on coping and safety strategies. The resident also complained of visual hallucinations and was provided with reassurance. The psychiatric note indicated Resident #41 was demonstrating some progress, so sessions would continue in a week. Resident #41 was sent to the hospital on [DATE] for exacerbation of [MEDICAL CONDITION] and [MEDICAL CONDITION] and returned on 05/28/19. Resident #41 was short of breath on 05/31/19 and again sent to the hospital, returning on 06/09/19. Review of the LSW note dated 06/10/19 at 7:04 P.M. revealed LSW #403 was informed the resident was suicidal. After speaking with the resident, who told her she was hearing a male voice commanding her to hurt herself, and Resident #41 planned to carry out this plan with her oxygen tubing, LSW #403 told the Unit Manager, RN #404, about the plan. Review of a note by Unit Manager, RN #404, dated 06/10/19 at 7:27 P.M., revealed Resident #41 would be placed on fifteen-minute checks and the oncoming nurse would follow-up with psychiatric services as needed for additional orders if necessary. Review of a nurse's note by LPN #415 dated 06/10/19 at 10:04 P.M. indicated Resident #41 talked about wanting to hurt herself but after talking, the resident felt better and slept. Review of Resident #41's fifteen-minute check observation sheet revealed initials in place from 7:00 P.M. through 11:45 P.M. on 06/10/19, all day on 06/11/19 and through 7:00 A.M. on 06/12/19. There was no evidence the checks continued after that. Review of Certified Nurse Practitioner (CNP) #500's note dated 06/11/19 revealed the resident did admit to voices telling her to hurt herself. The note indicated Resident #41 was on every fifteen-minute checks. On 06/12/19 at 11:50 A.M. During an interview with Resident #41 the resident stated staff had not answered her call light earlier in the morning. The resident stated she put the light on at 7:15 A.M. to let staff know she had been incontinent, and no one came until 8:00 A.M. Resident #41 said she did not think the call light worked and put it on again at 11:55 A.M. to check the function of the call light and to ask for more water. The call light was observed lit above the door signaling the call light was functioning. While waiting for someone to answer the call light, the resident told the surveyor she sometimes heard the voice of a male that told her to hurt herself. The resident said she did not want to do so but was afraid because she sometimes was weak. The resident said staff asked her if she wanted to go to the hospital, but she said no because staff at the hospital just made her wait and then would send her back to the facility. She said the staff at the hospital felt she should be on one-to-one, but they don't have enough staff to sit with her all the time. Resident #41 said she was hearing the voice at that time and didn't feel comfortable. The surveyor looked for staff in the hall, but none were observed initially, so the surveyor waited with the resident in the room, since the call light had been activated. While waiting for staff to respond to the call light, the resident used her phone to call her phone company. She was overheard talking loudly and was angry that her phone was not working correctly. LPN #405 came into the room at 12:20 P.M. and asked what Resident #41 needed. The resident was still on phone but told the nurse that she needed more water and she needed to be changed. The nurse turned off the call light and left room to get water. An interview with LPN #405 and LPN #406 when she returned with the water on 06/12/19 at 12:25 P.M. revealed the nurses were not aware of any special precautions regarding the care of Resident #41. STNA #411 approached and was also asked if she was aware of any special precautions regarding Resident #41. She indicated she was not assigned to the resident but was also was not aware of any special precautions for the resident. All three employees denied they had any knowledge of orders to check the resident every fifteen minutes. LPN #405 and #406 were made aware Resident #41 had stated she was hearing a male voice and had said she did not feel safe. Resident #41 was heard ending her phone conversation, so the surveyor entered the room with LPN #406 at approximately 12:30 P.M. The resident had completely removed her oxygen tubing and had loosely tied the tubing around her neck. The circled end of the tubing with the nasal cannula prongs and the tightening connector (slide bolo) was lying to the left side of her chest, with the actual hose tubing for the oxygen around the back her neck and looped over itself. LPN #405 untied the tubing, put the oxygen back on the resident and as she did so, the resident put her arms out to hug the nurse. The nurse hugged her back and the resident appeared tearful. STNA #412 was interviewed on 06/12/19 at 12:35 P.M. and revealed she had not been assigned to the resident lately, although she did care for her at times. She was unaware of any special precautions. STNA #410 was assigned to care for Resident #41 and was interviewed on 06/12/19 at 12:40 P.M. She said she was giving another resident a shower at the time of the resident putting the oxygen tubing around her neck. STNA #410 stated she was unaware of the need to do fifteen-minute checks on Resident #41. STNA #410 said she had not received a form to record the fifteen-minute checks at the start of her shift. STNA #410 verified she had checked Resident #41 on 06/12/19 but had not completed fifteen-minute checks. An interview with RN #404 on 06/12/19 at 12:45 P.M. revealed she had gone in the resident's room around 8:00 A.M. On 06/12/19. RN #404 said the resident asked about being cleaned up for the day, and she stated she would be able to help with that after the breakfast trays were passed. RN #404 stated she went back in the room around 9:30 A.M. to check on the resident. She stated the resident was emotional at times. RN #404 said she knew the resident should be on fifteen-minute checks but had not checked for a form to make sure the checks were done. Resident #41 was observed in her room with a staff member sitting in her room on all observations on 06/12/19 after 12:45 P.M. until she was observed leaving the facility for the hospital at 3:53 P.M. with seven ambulance attendants assisting. Review of the medical record did not contain documentation of the incident when Resident #41 was found in her room at 12:30 P.M. on 06/12/19 with the oxygen tubing around her neck or that physician notification was made. review of the nurse's notes on 06/12/19 at 4:00 P.M. by LPN #405 indicated the resident's power of attorney was notified of the resident's transfer to the hospital. A note timed 4:04 P.M. indicated Resident #41 was sent to the hospital per physician order [REDACTED]. An interview with the Administrator and Regional Nurse, RN # 402, on 06/12/19 at 4:50 P.M. verified on 06/12/19 at 11:50 A.M. Resident #41 was not on every fifteen-minute checks as ordered, and her call light was not responded to promptly when the surveyor observed the call light activated from 11:55 A.M. until 12:20 P.M. The Administrator and Regional Nurse, RN # 402, also verified the observation of the resident with oxygen tubing around her neck at 12:30 P.M. on 06/12/19. Review of a nurse's note dated 06/12/19 at 10:40 P.M. revealed Resident #41 returned to the facility with no new orders. The note indicated the resident was alert and oriented but did not contain any information regarding if the resident had thoughts of hurting herself. Review of a nurse's note dated 06/13/19 at 12:07 A.M. indicted LPN #400, went into the resident's room to answer the call light. The resident had pulled the call light cord from the wall and wrapped it around her neck. When asked why, the resident stated she did not know. When LPN #400 asked what she could do to help the resident, the resident asked for some snacks. Snacks were given, and the resident was placed on fifteen-minute checks. The note also indicated the Administrator, Assistant Director of Nursing/ LPN #408 and CNP #500 were made aware. Interview with LPN #400 on 06/13/19 at 8:30 A.M. by phone revealed she went in the room with Resident#41 when she returned from the hospital around 10:40 P.M. LPN #400 stated the resident did not mention any thoughts of self-harm and the LPN did not ask her if she had any. LPN #400 stated she stayed in the room briefly, returned with snacks, then said she thought the nursing assistant may have gone in the room. LPN #400 said she went in the room at about 11:30 P.M. when the call light was ringing and saw the call light cord around the resident's neck. LPN #400 stated she started the resident on every fifteen-minute checks and called the Administrator, Assistant Director of Nursing/ LPN #408 and CNP #500, and left them text messages. She stated Assistant Director of Nursing/ LPN #408 called her back after just a couple of minutes and told her to make sure she had charted, and to keep the resident on the fifteen-minute checks. She said the Administrator and CNP #500 did not call back. An observation and interview with Resident #41 on 06/13/19 at 8:13 A.M. revealed the resident was in her in bed. There was no staff in her room with her at the time the surveyor entered her room. The resident told the surveyor, I knew it was a waste of time to go to the hospital. I came back and tried to hurt myself again. The resident said the Administrator had been in her room and had moved her fan, so she could be seen from the doorway, and she stated she was happy that she might get a shower on that day. An interview with the Administrator on 06/13/19 at 8:15 A.M. revealed she did not see the phone call or text until early on 06/13/19 and called the facility regarding the incident with Resident #41. She then came into the facility to further review the incident. An interview with Assistant Director of Nursing/ LPN #408 on 06/13/19 at 9:45 A.M. revealed she got the text and saw the phone call at 4:00 AM. on 06/13/19 but did not call the facility or talk with LPN #400. An interview with Regional Nurse/ RN # 402 at 06/13/19 at 10:00 A.M. verified the resident was sent to the hospital on [DATE] at approximately 4:00 P.M. but returned at approximately 10:40 P.M. RN #402 verified there was no evidence of an assessment of Resident #41's emotional status or potential for inflecting harm to herself. RN #402 verified Resident #41 was found at 11:30 P.M. with a call light cord wrapped around her neck. RN #402 indicated Resident #41 was put on every fifteen-minute checks through the night, until 06/13/19 at 9:00 A.M. when she was placed on one-to-one monitoring. An interview with CNP #500 on 06/14/19 at 11:00 A.M. revealed he had worked with the resident since her admission. CNP #500 stated he usually managed her medical concerns but knew of her suicidal ideation. He stated he saw the resident on 06/11/19 and knew she was on fifteen-minute checks but stated he did not know that she had an actual plan to hurt herself by using her oxygen tubing. He stated he had not been involved in discussion of interventions regarding her psychiatric care, stating he knew she followed with psychiatric services. An interview with Consulting Psychologist #501 on 06/17/19 at 12:20 P.M. revealed she saw the resident several times a month. She stated the resident had self-injurious behaviors. She indicated she would assist the resident with coping mechanisms such as relaxation techniques, challenging her cognitive distortions and reality testing. Consulting Psychologist #501 stated Resident #41 was also encouraged at times to use the suicide hot line, as she was familiar with staff there and could talk with them at any hour using her phone, which gave her some control. Consulting Psychologist #501 stated she would be willing to be involved in team meetings to discuss interventions that would be helpful to try to prevent some of the harmful behaviors exhibited by Resident #41. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the quarterly comprehensive assessment (MDS 3.0) dated 04/05/19 revealed he was severely cognitively impaired, had continuous inattention, displayed physical behaviors and rejection of care on one to three days of the seven-day assessment reference period. He required the extensive assistance of one person for dressing and personal hygiene and extensive assistance of two staff for transfers and toileting. He required the total assistance of one staff for bathing and was always incontinent of bowel and bladder. He sustained two falls with no major injury. Review of the fall risk evaluations indicated he had been a high risk for falls since 02/03/18. Evaluations for actual falls occurred on 03/26/18, 06/25/18, 08/26/18, 02/17/19, 03/14/19 and 03/16/19. Review of the fall plan of care revised 03/15/19 indicated the interventions were to assist with transfers and ambulation as needed. On 08/26/18, a non-skid pad was applied to the top of the wheelchair cushion; 04/18/18 to have appropriate non-skid footwear on at all times; 04/02/18 educate staff to turn on the call light and call for help without leaving the resident unattended; 03/26/18 to have non-skid pad to chair while seated in the dining room; 04/18/18 low bed with grab bars; and 02/17/19 to have low bed to help prevent falls. The resident had three falls since (MONTH) 2019 and failed to implement new and effective interventions. Review of the nurses note, incident report and post fall evaluation indicated on 02/17/19 at 3:37 A.M. Resident #42 was found on the floor on his left side after trying to toilet himself. No new interventions were implemented. Review of the nurses note, incident report and post fall evaluation indicated on 03/14/19 at 5:52 A.M. State tested Nurse Aide (STNA) #433 called Licensed Practical Nurse (LPN) #420 to Resident #42's room. LPN #420 documented that she observed Resident #42 lying on the floor, face down, positioned partially on his left side, on top of the half side rail and the bed was standing up on its left side. The nurse noted he had no apparent injury. The nurse noted Resident #42 was tense and resistive. Neurological evaluations were initiated. No new interventions were implemented. Review of the nurses note, incident report and post fall evaluation dated 03/16/19 at 6:58 A.M. indicated two staff were at the nurse's station along with the resident. Resident #42 attempted to get out of the chair and sat back down on command from the staff. The resident then stood up and fell to the floor hitting his head on the right side of his face. The resident sustained [REDACTED]. The resident was assisted back to his chair. The resident was sent to the hospital for an evaluation. No new fall interventions were implemented. Resident #42 was observed on 06/12/19 at 08:45 A.M. in bed eating breakfast. The bed was in the high position, and no staff were present. On 06/13/19 at 08:25 A.M., he was in the dining room sitting in a standard chair. After breakfast at 9:00 A.M. two staff were observed transferring him from the standard chair to his wheelchair. There was no non-skid mat on the standard chair. Resident #42 was obse (TRUNCATED)

Based on observation, record review, Self-Reported Incident review, policy review and interview, the facility failed to ensure Resident #1 and Resident #87 were free from abuse. This affected two residents (Resident #1 and Resident #87) of three residents reviewed for abuse. Actual harm occurred when Resident #1 and Resident #87 had a physical altercation which resulted in both residents being sent to the hospital. Resident #1 was treated at the hospital for a laceration on the head, puncture on the right hand, metacarpal [MEDICAL CONDITION] hand and dislocation of the first metacarpal joint on the left hand. Resident #87 was treated at the hospital for a closed head injury and needed three staples to the top of the head. Findings include: Review of Resident #87's medical record indicated an original admission date of [DATE] with [DIAGNOSES REDACTED].#87 resided on the secured dementia unit. Review of the 01/18/18 Minimum Data Set (MDS) 3.0 quarterly assessment indicated Resident #87 was cognitively intact, had no behaviors and used a wheelchair. Review of Resident #1's medical record indicated an original admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 resided on the secured, dementia unit. Review of the 03/22/18 MDS 3.0 quarterly assessment indicated Resident #1 was severely-cognitively impaired, had no behaviors and walked independently in his bedroom. Review of the 05/02/18 nursing progress note timed 10:47 P.M. indicated staff heard a commotion coming from down the hall, upon entering Resident #1's and Resident #87's room, Resident #1 and Resident #87 were both observed in Resident #1's bed and a large volume of blood was noted. Both residents were separated, assessed for injury and questioned what happened. Resident #87 stated he thought Resident #1 had Resident #87's bag and Resident #87 wanted it back. When Resident #87 went to take the bag, Resident #1 hit Resident #87 with a cane and both residents started to fight. Resident #87 had a laceration to the top of his head and was sent to the hospital. Review of the 05/02/18 nursing progress note timed 11:00 P.M. indicated Resident #87 had bleeding coming from a facial mole by right side of his nose. Review of the 05/03/18 nursing progress note timed 5:11 A.M. indicated Resident #87 was admitted to the hospital with [REDACTED]. Review of the 05/04/18 after visit summary from the hospital indicated Resident #87 sustained a closed head injury at the facility with a laceration over the right parietal area and to remove the staples on 05/09/18. Review of the 05/03/18 Self-Reported Incident (SRI) sent to the State Agency indicated a resident-to-resident physical altercation occurred between Resident #1 and another resident. Resident #1 had injuries to the head and hand. Review of the 05/02/18 witness statement by State tested Nurse Aide (STNA) #7 indicated she heard yelling around 8:45 P.M. coming from Resident #1 and Resident #87's room, STNA #7 and another STNA entered the room and saw Resident #1 and Resident #87 on the bed holding on to each other. The STNAs immediately separated both residents. Review of the 05/02/18 witness statement by STNA #8 indicated at approximately 9:00 P.M., she heard yelling and commotion coming from the East wing. When we arrived in the resident's room, Resident #87 was on top of Resident #1 and they were bear hugging each other. Review of the 05/02/18 witness statement by Licensed Practical Nurse (LPN) #6 indicated at approximately 8:40 P.M., commotion was heard from the East wing of the second floor, noise coming Resident #1 and Resident #87's room. Upon entering the room, Resident #1 and Resident #87 were observed in Resident #1's bed and blood was noted on the bed. Residents were lying side-by-side each one had a strong grip on the other. A cane was in the hand of Resident #1. Resident #1 verbalized he was trying to take my bag, so I hit him in the head with my cane, we started to fight and he bit me on my right hand. Resident #87 verbalized Resident #87 was trying to get his bag because Resident #1 had taken the bag and they started to fight. Observation on 05/07/18 at 9:49 A.M. revealed Resident #87 was sitting in his wheelchair in the dining room on the secured, dementia unit, asleep. Resident #87 had an approximate two-inches by one-inch closed laceration, with three staples, to the top of his head. During an interview with Resident #87 he stated Resident #1 was hitting me and I was hitting him, Resident #1 was trying to take some of my stuff. Resident #87 also stated the top of my head hurts and left leg hurts because of what happened. Interview on 05/07/18 at 10:36 A.M. with Resident #85 (roommate to Resident #1 and Resident #87) revealed Resident #1 was lying in bed talking when Resident #87 got up and scared the (expletive) out of Resident #1. Resident #85 told Resident #87 to leave Resident #1 alone. Resident #87 said to Resident #1, I'm going to do something to you then Resident #87 hit Resident #1 four times with his fist and a cane on Resident #1's head. Resident #1 was lying there taking it and holding his hands up to protect himself. Interview on 05/07/18 at 11:13 A.M. with Hospital Licensed Social Worked (HLSW) #5 indicated Resident #1 was admitted to the hospital on [DATE] and was treated for [REDACTED]. Interview on 05/07/18 with LPN #6 indicated Resident #1 had periods of being the alpha male and made sure no one touched his belongings. Resident #1 always carried around a grocery bag with him which Resident #1 believed had $14,000 in it. Review of the facility (YEAR) freedom from abuse, neglect and exploitation policy indicated residents must not be subjected to abuse by anyone, including, other residents. This violation substantiates complaint number OH 777.

Based on observation, record review, interview, and the reasonable person concept, the facility failed to prevent sexual abuse for Resident #115. Harm occurred when Resident #115 was unable to physically or verbally consent to, or refuse, the sexual aggressive behaviors of Resident #116. This affected one (Residents #115) of two residents reviewed for abuse. The facility census was 120 residents. Findings include: Review of the medical record for Resident #115 revealed an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 11/03/17, revealed the resident had impaired cognition (BIMS Score 7). The resident required supervision and limited assistance of one staff for bed mobility, transfers, ambulation. Review of behavior and mood did not identify any current behaviors were present. Review of the nurse progress note dated 01/09/18 revealed Resident #116 was observed kissing and touching Resident #115 in her room. Review of the medical record for Resident #116 revealed he was admitted on [DATE]. His medical history included dementia without behaviors, hypertension, diabetes, [MEDICAL CONDITIONS] infarction, and altered mental status. Review of the 30-day admission MDS dated [DATE] revealed Resident #116 was assessed with [REDACTED]. Review of the progress notes revealed Resident #116 was transferred to the hospital on [DATE] did not return until 01/09/18, being readmitted at 11:43 A.M. On 01/09/18 at approximately 1:45 P.M., Resident #116 was found in Resident #115's room. He was removed, and transferred to the hospital. At 7:20 P.M., Resident #116 returned from the hospital and ordered to be one on one observation. Review of the care plans revealed those initiated for Resident #116 on 11/18/17 included history of sexual offense; required supervision for activities of daily living; impaired cognitive process related to dementia; and elopement risk requiring secured unit. A new care plan added as of 01/10/18 included resident unable to conform/understand socially accepted boundaries and increased behaviors of verbally threatening others. Review of a self-reported incident (SRI) dated 01/09/17 (# 1) revealed at approximately 1:45 P.M., Resident #116 was observed in Resident #115's room, kissing her with his hand on her person. Both residents resided on the dementia secured unit and were immediately separated by staff. At the time of this survey, the facility was in the process of conducting their investigation and provided information gathered as of 01/11/17. A statement from the charge nurse, Licensed Practical Nurse (LPN) #400, revealed when she entered the room, both residents were observed completely dressed and Resident #116 was observed kissing Resident #115 who was eating. Resident #116's hand was observed placed in the front of Resident #115's pants, between her pants and incontinent brief. No skin to skin contact was observed. Review of local law enforcement participation indicated the police arrived at the facility on 01/09/18 and filed a police report #2018- . Their report was directed to the detectives from the Police Abuse Unit who arrived at the facility on 01/10/18 at 4:00 P.M. On 01/11/18 between 10:30 A.M. and 11:00 A.M., an interview was conducted with Interim Administrator (IA) #300 and Corporate Administrator (CA) #302. IA #300 reported that an SRI was submitted and that an investigation was in progress for an allegation of sexual abuse. IA #300 explained that both residents, Resident #115 and Resident #116, reside on the secured dementia unit. Both residents were fully dressed. Resident #116 was observed kissing Resident #115 and his hand on her person. The family of Resident #115 requested she be sent to the hospital and was transferred. Resident #116 was taken to the hospital by police and returned the same day with one-on-one monitoring. CA #302 verified that Resident #116 was identified on the sexual abuse database and the facility implemented their Sexual Offender Policy (dated September 2014) obtaining clinical and medical assessment prior to admission, and care plans developed and implemented. On 01/11/18 at 1:35 P.M., Stated tested Nursing Assistant (STNA) # 402, was assigned to provide one-on-one observation for Resident #116 who had just finished the lunch meal. STNA #402 was interviewed and reported Resident #116 was compliant with care, pleasant, and did not present with any negative behaviors. She confirmed that Resident #116 was on one-to-one observation 24 hours a day. Resident #116 was interviewed at 1:40 P.M. He said, I am doing okay. I had chicken for lunch, it was good. Resident #116 was well groomed, dressed in clean, appropriate day clothing, clear speech, alert, pleasant, and cooperative with staff. On 01/11/18 at 2:30 P.M., a telephone interview was conducted with Housekeeper (HK) #500. HK #500 reported she observed Resident #116 kissing and touching Resident #115 and called out for the nurse, LPN #400 to address. HK #500 confirmed both residents were dressed. On 01/11/18 at 3:55 P.M. LPN #400 was interviewed, and explained (HK #500) called me down to Resident #115's room where I observed Resident #116 kissing Resident #115 who was sitting in her chair eating lunch. Resident #116 was standing at the side of her chair, leaning in towards her face, kissing her, right hand on back of chair and left hand in the front of her pants. I directed him to remove his hands and step away from her, and he did. She had thin pants on, an incontinence brief, and I did see his hand impression against the front of her pants (she demonstrated with her hand and clothing during interview). He did not have skin to skin contact. I conducted head to toe assessment. There were no concerns. I checked her pad, she was continent the pad was dry and the brief was intact, secured to her body. Her shirt was tucked into her pants. It had not been pulled out or removed. Clothing was in place. I directed staff to remained with each resident in their separate room and proceeded to notify the administrator, called the police, called the families, and the doctors per our policy. Both residents were fully dressed, clothing was in place with no type of clothing disturbance. Both residents went out to the hospital. LPN #400 went on to explain that Resident #115 had a prison like behavior. He does not let anyone walk behind him, and he remembers his past offense. His short-term memory is impaired. He can be a bully at times and will argue with men and women. He talks about his time in prison and talks tough. He is re-directable most times. Review of facility policy titled Freedom from Abuse, Misappropriation, Involuntary Seclusion, Neglect, and Exploitation, dated November 2017 revealed the facility fail to prevent sexual abuse which includes any non-consensual sexual contact of any type for Resident #115. This deficiency substantiates Master Complaint Number OH 763 and Complaint Number OH 540.

Based on observation, record review, incident report review, personnel record review, policy review and interview, the facility failed to ensure staff were properly trained on how to use a mechanical lift, failed to ensure Resident #35 was safety transferred with a mechanical lift and failed to ensure Resident #35 was appropriately assessed by a nurse after a fall. This affected one of three residents reviewed for accidents (Resident #35). Actual harm occurred when Resident #35 slid out of the mechanical lift pad while being transferred and landed on the floor. Resident #35 experienced a headache and was transferred to the emergency department where Resident #35 underwent X-ray's and was diagnosed with [REDACTED]. Findings include: Record review of Resident #35 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 03/11/17 fall risk assessment revealed Resident #35 was at moderate risk for falls. Review of the 04/03/17 Minimum Data Set (MDS) 3.0 quarterly assessment revealed Resident #35 was cognitively intact, had no behaviors and was totally dependent on staff for transfers. Review of the fall care plan, revised on 04/04/17, revealed Resident #35 had the potential for injury and was at risk for falls due to quadriplegia and lift transfer with inventions which included Resident #35 was a Hoyer (mechanical) lift transfer with two-person assistance. Review of the 05/17/17 nursing notes timed 5:20 P.M. revealed Registered Nurse (RN) #10 was called to Resident #35's room by State tested Nurse Aide (STNA) #11 and #13 and asked Resident #35 if he wanted to go to the hospital. Resident #35 refused; his physician was contacted. Review of the 05/18/17 physician's orders [REDACTED]. Resident #35 stated that he had pain on the left side of his head. Resident #35 had a Computerized Tomography (CT) scan of his cervical spine and brain ordered. Resident #35's final emergency department [DIAGNOSES REDACTED]. Review of the 05/17/17 fall incident report timed 5:20 P.M. revealed the nurse was informed by a STNA Resident #35 fell from the Hoyer during transfer. While RN #10 was walking to Resident #35's room, Resident #35 was sitting in his motorized wheelchair. Resident #35 stated the aides were lifting me from one chair to another when I slid from the Hoyer to the floor on my left side. Review of the 05/19/17 witness statement by STNA #11 revealed they were transferring Resident #35 and while the Hoyer was on the correct color transfer, Resident #35 was complaining and yelling of pain and asked them to put it on a different color. They did the color he wanted, and as they did, they noticed the Hoyer pad was very twisted and Resident #35 fell as they were transferring and slide out of the sling. They picked him up and got him in his chair and contacted the nurse. Review of the undated electric portable patient lift user manual revealed do not use this product or any available optional equipment without first completely reading and understanding these instructions and any additional instructional material such as owner's manuals, service manuals or instruction sheets supplied with this product or optional equipment. Special care must be taken with people with disabilities who cannot cooperate while being lifted. Review of the November, 2014 fall response and interventions policy revealed when a resident is observed on the floor, do not get the resident up until the charge nurse assesses the resident. Review of STNA #11's personnel record of the 05/05/17 mechanical lift transfer competency assessment revealed STNA #11 acknowledged with her signature that she was incompetent with the step in the transfer of once the resident is sitting, keep raising the lift until the resident is up six to twelve inches from the surface. The machine lift transfer competency assessment was absent of a reviewer signature acknowledging STNA #11 was incompetent in that area of a mechanical lift transfer. There was no evidence STNA #11 had read and understood the electric portable patient lift user manual. Observation on 05/26/17 at 9:40 A.M. revealed Resident #35 way lying in bed with his breath/air activated call light close to his mouth. Interview at the time of the observation with Resident #35 revealed he did fall from the Hoyer lift when two STNAs used the Hoyer lift to transfer him to his wheelchair. Resident #35 stated he hit his head when he fell and had a headache after the fall then was sent to the hospital. Another interview on 05/26/17 at 10:52 A.M. with Resident #52 revealed the Hoyer pad was connected incorrectly when he fell and he had asked STNA #11 and #13 to put him in his wheelchair however the two STNAs did not tell him the nurse needed to assess him first. Interview on 05/26/17 at 11:15 A.M. with RN #10 revealed RN #10 couldn't say what happened with Resident #35 on 05/17/17 due to everything was already over with. Resident #35 was coming towards RN #10 in his wheelchair since STNA #11 and STNA #13 had put Resident #35 in his wheelchair after he fell from the Hoyer lift. RN #10 also revealed STNAs are not supposed to pick up residents off the floor until a nurse assesses the resident. Interview on 05/26/17 at 11:22 A.M. with STNA #11 revealed it was STNA #11's first day on the floor at the facility. STNA #11 and STNA #13 went into Resident #35's room due to Resident #35 wanting to be transferred from his Broda chair to his electric wheelchair. STNA #11 stated she noticed the Hoyer pad was twisted underneath Resident #35 and the Hoyer pad wasn't underneath Resident #35 all the way. STNA #11 and STNA #13 attached the bottom or second Hoyer pad hook-up straps and lifted Resident #35 up and Resident #35 kept yelling to use the top hook-up strap however STNA #11 and STNA #13 knew the top hook-up strap would be too loose. Resident #35 stated, they always use the top hook-up strap so STNA #11 and STNA #13 used the top hook-up strap and when Resident #35 was lifted in the air, Resident #35 slipped out of the front of the Hoyer pad and laid on his left shoulder. STNA #11 revealed STNA #13 instantly stated pick him up which was not the proper protocol and STNA #13 went to get RN #10. STNA #11 stated Resident #76 and Resident #76's family member witnessed Resident #35's fall from the Hoyer lift. STNA #11 also revealed she had not been educated on how to use a Hoyer lift and had not really ever used a Hoyer lift prior to that. Attempted interview on 05/26/17 at 11:43 A.M. and at 1:15 P.M. with STNA #13 was unsuccessful. Interview on 05/26/17 at 12:20 P.M. with Resident #76's family member, who was in the room at the time of the fall, revealed on 05/17/17, Resident #35 fell out of the Hoyer lift and landed on his left side and hit his head. STNA #11 and STNA #13 lifted Resident #35 off the floor and Resident #35 asked if he was bleeding. Interview on 05/26/17 at 2:20 P.M. with the Director of Nursing, with the Regional Registered Nurse (RRN) #12 present, revealed STNA #11 and STNA #13 should have went to get the nurse if they thought the Hoyer straps were too loose to transfer Resident #35 and should have not picked Resident #35 off the floor without a nurse assessing him first. This deficiency substantiates Complaint Number OH 355. This deficiency is evidence of continued non compliance from the annual survey completed 0309/17.

Based on record review and interviews, the facility failed to ensure two pressure ulcers (sacrum and left ischium) for Resident #30 were promptly identified. Resident #30 experienced actual harm when the wounds deteriorated to unstageable (full-thickness skin and tissue loss which the extent of tissue damage within the ulcer cannot be confirmed because is it obscured by dead tissue) before treatment was implemented. This affected one of two residents reviewed for pressure ulcers. Findings include: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #30 was moderately impaired for cognition based on a brief interview for mental status (BIMS) score of 11 out of a possible 15 points. The MDS assessment indicated Resident #30 was totally dependent on staff for bed mobility, transfers, toilet use and hygiene. The assessment revealed the resident was frequently incontinent of bowel and was at risk for the development of pressure ulcers. The Potential for alteration in skin integrity plan of care initiated on 10/24/16 revealed Resident #30 was at risk related to incontinence, decreased mobility, history of previous skin breakdown, impaired cognition, co-morbidities including anorexia with weight loss and skin desensitized to pressure and/or pain. Interventions included inspecting for any reddened areas during daily care. A Wound/Skin Healing Record dated 01/16/17 revealed a new, facility acquired unstageable pressure ulcer to Resident #30's sacrum measuring 9.0 centimeters (cm) by 5.0 cm with a depth of 0.3 cm. The record indicated the wound had a copious amount of serosanguineous exudate with a foul odor. The wound bed was covered with slough (dead tissue in the process of separating from the viable portions of the body). The surrounding wound edges were documented as macerated (the softening and breaking down of the skin caused by excessive amounts of fluid remaining in contact with the skin or the surface of a wound for extended periods). The Wound/Skin Healing Record dated 01/16/17 also revealed a second new, facility acquired unstageable pressure ulcer to Resident #30's left ischium measuring 8.0 cm by 5.0 cm with a moderate amount of odor. The wound bed was described as black/brown eschar ( thick, leathery, frequently black or brown in color, dead or devitalized tissue that has lost its usual physical properties and biological activity). The surrounding wound edges were documented as macerated. There was no documentation in the Nurses Notes as to the aforementioned pressure ulcers identified on 01/16/17. Arrangements were made with the facility's wound nurse/Licensed Practical Nurse (LPN) #303, to observe the wound care on 03/08/17 after breakfast. On 03/08/17 at 8:50 A.M., LPN #303 indicated that she forgot that Resident #30 had his wound care provided during the night shift, at 6:00 A.M. The Director of Nursing (DON) was notified, who assured the surveyor that night shift would be notified not to complete the treatment prior to 6:00 A.M. on 03/09/17. On 03/09/17 at 5:55 A.M., LPN #307 reported Resident #30's wound treatment had been completed at approximately 4:00 A.M. LPN #307 indicated the message had not been relayed to her. During an interview on 03/09/17 at 10:01 A.M., the facility's wound nurse/LPN #303 verified two unstageable pressure ulcers were identified on 01/16/17, one each on Resident #30's sacrum and left ischium. LPN #303 acknowledged both wounds had deteriorated to unstageable before discovery, with the sacrum wound having a depth of 0.3 cm and a large left ischial wound covered with eschar. LPN #303 revealed she did not know who discovered the wounds. During an interview on 03/09/17 at 10:26 A.M., Unit Manager, Registered Nurse (RN) #308 verified that two, facility acquired pressure areas were not identified until they were unstageable for Resident #30. RN #308 acknowledged there was no documentation on 01/16/17 regarding the discovery of the pressure ulcers for Resident #30. RN #308 revealed she did not know who first identified the wounds. RN #308 indicated it was the expectation of the state tested nurses' aides (STNAs) to inspect the skin during daily care and to notify the nurses when any alterations in skin integrity were identified.

Based on clinical record review, resident interview, staff interviews, and review of the facility's abuse investigation reports, Self-Reported Incident reports and policies on Abuse, and staffing records, the facility failed to prevent staff to resident abuse resulting in Immediate Jeopardy for one Resident (#117) who voiced fear for his safety and was physically abused by a staff member and two additional residents, (#107 and #135) who were verbally abused and expressed emotional harm by State tested Nurse Aide (STNA) #10. In addition, this had the potential to affect all ten to 13 additional residents who were provided care by this same staff member (number of residents varied according to the census of the assignment). On 09/03 /13 at 1:30 P.M., the Administrator was notified that Immediate Jeopardy began on 05/14/13 when Resident #107 reported to a nurse that STNA #10 was verbally abusive and refused to provide him assistance. The Director of Nursing (DON) was not notified until 05/16/13. The facility did not complete an investigation of the allegation of abuse, and STNA #10 continued to provide direct care to residents in the facility. Registered Nurse (RN) #57 identified during an interview on 07/30/13 that STNA #10 was named on or about 06/30/13 in an alleged incident of verbal abuse and refusal to care for Resident #135. The facility provided no evidence that this allegation of abuse was investigated or reported to the State agency as required. Finally, review of the facility investigation summary dated 07/30/13 for an incident that occurred on 07/22/13 revealed STNA #10 was involved in a verbal and physical altercation with Resident #117 that included rough physical treatment. Interview of Resident #117 on 07/29/13 revealed he feared for his safety during the incident. The facility substantiated that STNA #10 physically and verbally/emotionally abused Resident #117. The Immediate Jeopardy was removed on 07/30/13 when STNA #10 was terminated from employment. 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). The facility provided training to all staff on the immediate reporting of all allegations of abuse to the State agency. However the training did not include the need to conduct thorough investigations of all allegations of abuse and the need to ensure the protection of residents during investigations. Findings include: 1. Resident #117 was readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. During an interview on 07/29/13 at 6:15 P.M., the alert and oriented Resident #117 reported that he had been treated roughly by STNA #10 in the recent past. He did not provide an exact date, but indicated that it had happened during 11:00 P.M. to 7:00 A.M. shift. Resident #117 stated STNA #10 had grabbed him by both of his legs, picked him up, spun him around and pulled him over to the top of his bed rail. He stated STNA #10 also had made faces at him. Resident #117 stated he told STNA #10 to stop it. He stated, "I can't voice how strongly I repeatedly told her to stop and put me down. I was afraid she was going to hurt me." Resident #117 stated he understood that someone could have a bad day, but this treatment went way beyond that. Review of the facility investigation of the incident revealed a handwritten statement from Human Resources Director (HR) #78 dated 07/29/13. HR #78 wrote that STNA #30 reported to her that Resident #117 was upset at STNA #10 because she made faces at him and argued with him. HR #78 informed the charge nurse, Licensed Practical Nurse (LPN) #59, of STNA #30's allegations and together they interviewed Resident #117. HR #78 then notified the Director of Nursing (DON) of Resident #117's allegation of abuse via a written statement that was signed by Resident #117 and LPN #59. On 08/20/13 at 4:00 P.M., HR #78 stated that she contacted the DON by telephone on 07/25/13 to inform her of Resident #117's allegation of abuse. This information conflicted with what was contained in her written statement. HR #78 stated that the DON was out of the facility at a meeting, but had instructed her by telephone to start an investigation into Resident #117's allegation of abuse. The DON instructed her to make sure that STNA #10 was not on the schedule and to obtain statements from staff and residents. This was confirmed by the DON on 08/20/13 at 4:05 P.M. Review of a statement dated 07/25/13 and signed by Resident #117 and LPN #59 revealed the following: Resident #117 stated that STNA #10 made faces at him and his roommate. STNA #10 pulled Resident #117's legs over the bed rails when she tried to turn him over. Resident #117 stated that STNA #10 was too rough and he told her to put the side rail up, but she kept it down. Resident #117 indicated that he did not have to take that kind of treatment from anyone, and that if STNA #10 was mentally unstable, she should not work at this facility. The facility's Resident Abuse Investigation Report Form dated 07/30/13 for the incident that occurred on 07/22/13 revealed STNA #10 was involved in a verbal and physical altercation with Resident #117 that included rough and rude treatment. The facility substantiated that physical and verbal/emotional abuse occurred for Resident #117. STNA #10 was terminated from employment on 07/30/13. 2. Review of facility investigation reports and interviews of staff revealed there were two alleged abuse incidents involving STNA #10 that occurred prior to the 07/22/13 incident. a. Review of a facility investigation report dated 05/17/13 revealed on 05/14/13, Resident #107 reported an incident to "staff" about a concern he had with STNA #10 not getting him a blanket and getting him off the bedpan. The staff person was not identified. There were no further details in the facility investigation regarding Resident #107's specific concerns. The facility investigation report dated 05/17/13 revealed the Director of Nursing (DON) spoke with STNA #10 on 05/16/13 about Resident #107's "remarks." STNA #10 stated she had given a blanket to Resident #107 and helped him get off of the bedpan. She denied knowledge of any issues with the resident. The investigation report dated 05/17/13 revealed it contained a typed statement dated 05/14/13. LPN #24's name was typewritten at the end of the statement, but there was no signature. The statement indicated that Resident #107 complained to LPN #24 about the care that was provided to him by STNA #10. He stated he waited on the bedpan for 45 minutes after he called for help. When STNA #10 entered his room, Resident #107 told her that he had been waiting for a long time, and he was uncomfortable. STNA #10 told Resident #107 he was "lucky" that she came in, "because your nurse will not come to wipe your ass." Resident #107 told LPN #24 that he then became tearful and reported the incident to the second shift nursing supervisor, Nurse #43. Nurse #43 was not able to be contacted by phone for interview during the complaint investigation. An interview with LPN #24 on 07/30/13 at 11:00 A.M. revealed she was a Minimum Data Set (MDS) assessment nurse. She indicated that her job duties included conducting face to face interviews with residents. LPN #24 stated she interviewed Resident #107 on 05/14/13. She produced a copy of the same typewritten statement that was found in the facility investigation report dated 05/17/13, in which she described Resident #107 's allegation of verbal intimidation and neglect by STNA #10. When interviewed on 08/01/13 at 12:15 P.M., the DON confirmed that Resident #107 reported abuse on 05/14/13, but no investigation was started until 05/17/13. She confirmed the investigation was incomplete and did not include any information about the written statement from LPN #24 that was dated 05/14/13. She confirmed the abuse allegation was not reported to the State agency, as required. On 08/20/13 at 10:45 A.M., the DON confirmed that STNA #10 continued to work in the facility after the allegation of abuse was made on 05/14/13. Review of the facility staffing records as worked revealed STNA #10 provided direct care for ten to 13 residents during each of 37 shifts she worked, from the date the first allegation of abuse was made on 05/14/13 until she was terminated from employment on 07/30/13. b. Resident #135 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required the extensive assistance of at least two other persons for transfers and toilet use. He required the extensive assistance of at least one other person for dressing and ambulating in the hall. Resident #135 was discharged from the facility on 08/05/13. On 07/30/13 at 10:40 A.M., Registered Nurse (RN) #57 was interviewed. She stated she recalled an incident that occurred on or about 06/30/13 between STNA #10 and Resident #135. RN #57 indicated STNA #40 had reported to her that STNA #10 was behaving in an abusive manner to Resident #135. STNA #10 refused to help Resident #135 get off the toilet, and she told the resident to walk down the hall to get his own clothes. RN #57 stated she and STNA #40 spoke with Resident #135 and wrote statements. They both then reported the incident to the DON and presented her with their statements. An interview with STNA #40 on 08/20/13 at 10:20 A.M. revealed that she recalled an incident that occurred between Resident #135 and STNA #10 approximately two months ago (on or about 06/20/13). STNA #40 stated she had spoken with Resident #135 soon after she arrived at the facility to start her shift at 7:00 A.M. Resident #135 reported to STNA #40 that STNA #10 was getting him ready to go out to an appointment, but would not help him get off the toilet, and told him that he would have to get up and go down the hall himself to get his clothing. STNA #40 indicated that Resident #135 was crying and was "terrified" of STNA #10. He "begged" STNA #40 to go with him to his appointment, because he did not want to go with STNA #10. STNA #40 indicated she told LPN #58 that Resident #135 did not want STNA #10 to escort him to his appointment. A telephone interview with LPN #58 on 08/20/13 at 4:20 P.M. revealed she was familiar with Resident #135 and recalled an incident that occurred approximately one and one half to two months ago. LPN #58 stated she had worked night shift on the second floor. She passed by the nursing station on the first floor at the end of her shift, and saw Resident #135 sitting in his wheelchair at the nursing station. She indicated the resident was not upset or crying. She stated that Resident #135 was getting ready to leave the building for an appointment, and he stated he did not want STNA #10 to accompany him. He indicated he wanted anyone but STNA #10. LPN #58 instructed another STNA to escort Resident #135 to his appointment. She denied that any STNA or any staff reported to her that STNA #10 refused to help Resident #135 off of the toilet, or that STNA #10 had told him to go down and get his own clothes. There was no evidence that this allegation of abuse was investigated by the facility or reported to the State agency as required. This was confirmed with the DON on 08/20/13 at 12:16 P.M. Review of the facility Abuse policy and procedure, revised January 2008 revealed allegations of abuse must be reported immediately to the employee's supervisor, the administrator and the DON. The alleged perpetrator must immediately be removed from resident care areas in order to protect the resident. The alleged perpetrator would be suspended pending conclusion of the investigation. This deficiency substantiates Master Complaint Number OH 087.

Based on clinical record review, staffing records, resident interview, staff interviews, review of the facility's abuse investigation reports, Self-Reported Incident (SRI) reports and policies on Abuse, the facility failed to ensure staff immediately reported all allegations of abuse and neglect, failed to investigate all allegations of abuse and neglect and failed to protect residents once abuse and neglect were alleged. This resulted Immediate Jeopardy for one Resident (#117) and who feared for his safety when the staff member verbally and physically abused him during care and two other residents, Residents #107 and #135, who were verbally abused and expressed emotional harm from State tested Nurse Aide (STNA) #10. In addition, this had the potential to affect ten to 13 additional residents who lived in the facility and that STNA #10 provided care (the number of residents varied according to the census and the assignment). The facility also failed to immediately report all allegations of abuse and neglect immediately to the State Agency as required. This occurred in four of seven SRI reports reviewed during the complaint survey, of eight SRIs submitted in July 2013. On 09/03/13 at 1:30 P.M., the Administrator was notified that Immediate Jeopardy began on 05/14/13 when Resident #107 reported to a nurse that STNA #10 was verbally abusive and refused to provide him assistance. The Director of Nursing (DON) was not notified until 05/16/13. The facility did not complete an investigation of the allegation of abuse, and STNA #10 continued to provide direct care to residents in the facility. Staff interview on 07/30/13 revealed STNA #10 was named on or about 06/30/13 in an alleged incident of verbal abuse and refusal to care for Resident #135. The facility provided no evidence that this allegation of abuse was investigated or reported to the State agency as required. Finally, review of the facility investigation summary dated 07/30/13 for an incident and that occurred on 07/22/13 revealed STNA #10 was involved in a verbal and physical altercation with Resident #117 that included grabbing him by both of his legs, picking him up, spinning him around and finally pulling him over to the top of his bed rail. Interview of Resident #117 on 07/29/13 revealed he feared for his safety during the incident. The facility substantiated that STNA #10 physically and verbally/emotionally abused Resident #117. STNA #10 was terminated from employment. The Immediate Jeopardy was removed on 07/30/13 when STNA #10 was terminated from employment. 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). The facility provided training to all staff on the immediate reporting of all allegations of abuse to the State agency. However the training did not include the need to conduct thorough investigations of all allegations of abuse and the need to ensure the protection of residents during the investigations. Findings include: 1. Resident #117 was readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. During an interview on 07/29/13 at 6:15 P.M., the alert and oriented Resident #117 reported that he had been treated roughly by STNA #10 in the recent past. He did not provide an exact date, but indicated that it had happened during 11:00 P.M. to 7:00 A.M. shift. Resident #117 stated STNA #10 had grabbed him by both of his legs, picked him up, spun him around and pulled him over the top of his bed rail. He stated STNA #10 also had made faces at him. Resident #117 stated he told STNA #10 to stop it. He stated, "I can't voice how strongly I repeatedly told her to stop and put me down. I was afraid she was going to hurt me." Resident #117 stated he understood that someone could have a bad day, but this treatment went way beyond that. Review of the facility investigation of the incident revealed a handwritten statement from Human Resources Director (HR) #78 dated 07/29/13. HR #78 wrote that STNA #30 reported to her that Resident #117 was upset with STNA #10 because she made faces at him and argued with him. HR #78 informed the charge nurse, Licensed Practical Nurse (LPN) #59, of STNA #30's allegations and together they interviewed Resident #117. HR #78 then notified the Director of Nursing (DON) of Resident #117's allegation of physical abuse via a written statement that was signed by Resident #117 and LPN #59. On 08/20/13 at 4:00 P.M., HR #78 stated that she contacted the DON by telephone on 07/25/13 to inform her of Resident #117's allegation of abuse. This information conflicted with what was contained in her written statement. HR #78 stated that the DON was out of the facility at a meeting, and instructed her by telephone to start an investigation into Resident #117's allegation of abuse. The DON instructed her to make sure that STNA #10 was not on the schedule, and also to obtain statements from staff and residents. This was confirmed by the DON on 08/20/13 at 4:05 P.M. Review of a statement dated 07/25/13 and signed by Resident #117 and LPN #59 revealed the following: Resident #117 stated that STNA #10 made faces at him and his roommate. STNA #10 pulled Resident #117's legs over the bed rails when she tried to turn him over. Resident #117 stated that she was too rough. He told her to put the side rail up, but she kept it down. Resident #117 indicated that he did not have to take that kind of treatment from anyone and that if STNA #10 was mentally unstable, she should not work at this facility. The facility's Resident Abuse Investigation Report Form dated 07/30/13 for the incident that occurred on 07/22/13 revealed STNA #10 was involved in a verbal and physical altercation with Resident #117 that included rough and rude treatment. The facility substantiated that physical and verbal/emotional abuse occurred for Resident #117. STNA #10 was terminated from employment on 07/30/13. 2. Review of five additional facility investigation reports and interviews of staff revealed there were two alleged abuse incidents involving STNA #10 that occurred prior to the 07/22/13 incident. a. Review of a facility investigation report dated 05/17/13 revealed on 05/14/13, Resident #107 reported an incident to "staff" about a concern he had with STNA #10 not getting him a blanket and getting him off the bedpan. The staff person was not identified. There were no further details in the facility investigation regarding Resident #107's specific concerns. The facility investigation report dated 05/17/13 revealed the Director of Nursing (DON) spoke with STNA #10 on 05/16/13 about Resident #107's "remarks." STNA #10 stated she had given a blanket to Resident #107 and helped him get off of the bedpan. She denied knowledge of any issues with the resident. The investigation report dated 05/17/13 revealed it contained a typed statement dated 05/14/13. LPN #24's name was typewritten at the end of the statement, but there was no signature. The statement indicated that Resident #107 complained to LPN #24 about the care that was provided to him by STNA #10. He stated he waited on the bedpan for 45 minutes after he called for help. When STNA #10 entered his room, Resident #107 told her that he had been waiting for a long time, and he was uncomfortable. STNA #10 told Resident #107 he was "lucky" that she came in, "because your nurse will not come to wipe your ass." Resident #107 told LPN #24 that he then became tearful and reported the incident to the second shift nursing supervisor, Nurse #43. Nurse #43 was not able to be contacted by phone for interview during the complaint investigation. An interview with LPN #24 on 07/30/13 at 11:00 A.M. revealed she was a Minimum Data Set (MDS) assessment nurse. She indicated that her job duties included conducting face to face interviews with residents. LPN #24 stated she interviewed Resident #107 on 05/14/13. She produced a copy of the same typewritten statement that was found in the facility investigation report dated 05/17/13, in which she described Resident #107 's allegation of verbal intimidation and neglect by STNA #10. When interviewed on 08/01/13 at 12:15 P.M., the DON confirmed that Resident #107 reported abuse on 05/14/13, but no investigation was started until 05/17/13. She confirmed the investigation was incomplete and did not include any information about the written statement from LPN #24 that was dated 05/14/13. She confirmed the abuse allegation was not reported to the State agency, as required. On 08/20/13 at 10:45 A.M., the DON confirmed that STNA #10 continued to work in the facility after the allegation of abuse was made on 05/14/13. Review of the facility staffing records as worked revealed STNA #10 provided direct care for ten to 13 residents during each of 37 shifts she worked, from the date the first allegation of abuse was made on 05/14/13 until she was terminated from employment on 07/30/13. b. Resident #135 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required the extensive assistance of at least two other persons for transfers and toilet use. He required the extensive assistance of at least one other person for dressing and ambulating in the hall. Resident #135 was discharged from the facility on 08/05/13. On 07/30/13 at 10:40 A.M., Registered Nurse (RN) #57 was interviewed. She stated she recalled an incident that occurred on or about 06/30/13 between STNA #10 and Resident #135. RN #57 indicated STNA #40 had reported to her that STNA #10 was behaving in an abusive manner to Resident #135 by refusing to help Resident #135 get off the toilet. STNA #10 told the resident to walk down the hall to get his own clothes. RN #57 stated she and STNA #40 spoke with Resident #135 and wrote statements. They both then reported the incident to the DON and presented her with their statements. An interview with STNA #40 on 08/20/13 at 10:20 A.M. revealed that she recalled an incident that occurred between Resident #135 and STNA #10 approximately two months ago (on or about 06/20/13). STNA #40 stated she had spoken with Resident #135 soon after she arrived at the facility to start her shift at 7:00 A.M. Resident #135 reported to STNA #40 that STNA #10 was getting him ready to go out to an appointment, but would not help him get off the toilet, and told him that he would have to get up and go down the hall himself to get his clothing. STNA #40 indicated that Resident #135 was crying and was "terrified" of STNA #10. He "begged" STNA #40 to go with him to his appointment, because he did not want to go with STNA #10. STNA #40 indicated she told LPN #58 that Resident #135 did not want STNA #10 to escort him to his appointment. A telephone interview with LPN #58 on 08/20/13 at 4:20 P.M. revealed she was familiar with Resident #135 and recalled an incident that occurred approximately one and one half to two months ago. LPN #58 stated she had worked night shift on the second floor. She passed by the nursing station on the first floor at the end of her shift, and saw Resident #135 sitting in his wheelchair at the nursing station. She indicated the resident was not upset or crying. She stated that Resident #135 was getting ready to leave the building for an appointment, and he stated he did not want STNA #10 to accompany him. He indicated he wanted anyone but STNA #10. LPN #58 instructed another STNA to escort Resident #135 to his appointment. She denied that any STNA or any staff reported to her that STNA #10 refused to help Resident #135 off of the toilet, or that STNA #10 had told him to go down and get his own clothes. There was no evidence that this allegation of abuse was investigated by the facility or reported to the state agency as required. This was confirmed with the DON on 08/20/13 at 12:16 P.M. Review of the facility Abuse policy and procedure, revised January 2008 revealed allegations of abuse must be reported immediately to the employee ' s supervisor, the administrator and the DON. The alleged perpetrator must immediately be removed from resident care areas in order to protect the resident. The alleged perpetrator would be suspended pending conclusion of the investigation. 3. Review of SRI report tracking number revealed a resident to resident altercation occurred on 07/01/13 at 8:30 A.M. The facility first reported the incident to the state agency on 07/01/13 at 9:55 P.M., 13.5 hours after the incident occurred. 4. Review of SRI report tracking number revealed an allegation of staff to resident abuse was made on 07/06/13 at 8:00 P.M. The facility first reported the incident to the state agency on 07/07/13 at 4:09 P.M., more than 20 hours after the incident occurred. 5. Review of SRI report tracking number revealed a resident to resident altercation occurred on 07/15/13 at 10:00 A.M. The facility first reported the incident to the state agency on 07/15/13 at 5:09 P.M., more than seven hours after it occurred. 6. Review of SRI report tracking number revealed a resident to resident altercation occurred on 07/17/13 at 9:15 P.M. The facility first reported the incident to the state agency on 07/18/13 at 12:25 P.M., more than 15 hours after it occurred. This deficiency substantiates Master Complaint Number OH 087.

Based on observation, interview and record review, the facility failed to ensure residents received adequate fluids as ordered resulting in significant weight loss and abnormal laboratory values indicative of dehydration. This affected six of seven residents reviewed that were on therapeutic diets requiring thickened liquids (Resident #16, #18, #22, #24, #26 and #28) and Resident #30 who had an order for [REDACTED]. Findings include: 1. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/04/12 at 5:15 P.M., Resident #30 was observed with four ounces of juice on her dinner tray. Resident #30's daughter revealed the resident's laboratory work showed signs of dehydration and the doctor wanted her to drink more fluids. The daughter indicated Resident #30 had an order for [REDACTED]. The daughter stated the resident was also to have jello at each meal and the resident did not receive the jello as ordered. The daughter stated she had talked to multiple staff members including Licensed Practical Nurse (LPN) #9 and the director of nursing (DON). Review of the signed November 2012, physician orders [REDACTED]. Review of the monthly weights indicated the following: 11/01/11 weight was 152 pounds, on 03/01/12 weight was 160 pounds, on 08/01/12 weight was 140 pounds and on 10/01/12 weight was 145 pounds. Review of the "condition change form" in the physician orders [REDACTED]. Review of the dietary note dated 08/14/12, revealed the resident had significant weight loss of 14.1 percent in 30 days, 12.5 percent in 90 and 180 days. The plan was to change milk to whole whole with meals and Resource fruit juice at lunch. Review of the dietary note dated 10/10/12, revealed the resident had a significant weight loss of 11 percent in 90 days. The family requested increased fluids on meal trays. The plan was to change juice to 12 ounces with breakfast lunch and dinner. The note did not assess the laboratory values for signs of dehydration as per plan of care. There was no documented evidence the fluids were monitored to ensure the resident received adequate fluids. Review of the nutrition/hydration plan of care revealed the resident was at increased risk for weight loss with significant weight loss noted on 08/14/12, 09/11/12 and 10/10/12. Interventions included monitor meal intake and record, offer substitution if less than 50 percent of meals eaten, monitor for signs and symptoms of fluid imbalance, encourage fluids at bedside, eight ounces of whole milk with every meal, increase fluids, jello with lunch, dinner and night snack, eight ounces of juice and Resource fruit juice at lunch, and 12 ounces of juice with every meal. Review of nursing assistant flow record for September, October and November 2012, did not indicate any fluid intake was monitored nor were any supplements recorded, despite the physicians order and the plan of care to push or encourage fluids. The meal records were incomplete. On 11/05/12 at 4:00 P.M., interview with the DON verified no plan was put into place to ensure the resident received the ordered fluids on each tray. 2. The facility had eight residents on nectar thick liquids and one resident on honey thick liquids. On 11/04/12 at 11:50 A.M., interview with Dietary Aid #15 verified the dietary staff did not thicken any liquids but liquids came pre-thickened for juice and milk. If residents who were on thickened liquids wanted water or coffee it would be thickened by the nursing staff. On 11/04/12 at 1:00 P.M., Resident #16 was observed during the lunch meal with six ounces of thickened cranberry juice but no other liquids were provided. Review of the meal card revealed Resident #16 was to be provided with four ounces of nectar prune juice, eight ounces of other nectar juice, and four ounces of nectar milk. On 11/04/12 at 1:05 P.M., interview with State tested Nursing Assistant (STNA) #11 verified the above. STNA #11 verified all thickened liquids were provided by the kitchen and the STNAs did not thicken any liquids but only provided residents with the thickened liquids provided by the kitchen. STNA #11 verified residents on thickened liquids did not receive coffee or water. 3. On 11/04/12 at 5:10 P.M., observation of the dinner meal in the Collanade dining room revealed Resident #22 had four ounces of thickened lemonade and no other liquids. Review of the meal card revealed Resident #22 was to be provided four ounces of nectar juice and eight ounces of nectar milk. On 11/04/12 at 5:30 P.M., interview with the administrator verified the above findings. On 11/05/12 at 12:15 P.M., lunch observation revealed Resident #22 was observed feeding himself without any liquids available. On 11/05/12 at 12:20 P.M., the lunch observation was verified by Licensed Practical Nurse (LPN) #7. 4. On 11/05/12 at 12:15 P.M., lunch observation revealed Resident #18 was observed with her meal in front of her that did not include any fluids. On 11/05/12 at 12:20 P.M., the lunch observation was verified by the LPN #7. 5. On 11/04/12 at 2:45 P.M., observation of the kitchen with the dietary manager verified the facility did not have any mighty shakes in stock. On 11/04/12 at 5:10 P.M., observation of the dinner meal in the Collanade dining room revealed Resident #24 was observed to have eight ounces of lemonade. Review of the meal card revealed Resident #24 was to be provided eights ounces of nectar juice and a mighty shake. On 11/04/12 at 5:15 P.M., the lunch observation was verified by LPN #7. Review of Resident #24's admission sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of weights revealed on 01/01/12 Resident #24's weight was 155 pounds and on 10/01/12 the residen'ts weight was 144 pounds. Review of the dietary note dated 07/27/12 revealed per nursing the resident seemed to need more to eat at breakfast and more fluids every meal. Review of the dietary note dated 10/22/12 revealed the residents received supplements due to a history of weight loss and was to receive 12 ounces of juice every meal, eight ounces of milk with breakfast and dinner and mighty shakes with lunch, dinner and bedtime. Review of Resident #24's nutrition and hydration plan of care revealed a history of significant weight changes. The plan of care dated 07/27/12 indicated the resident needed more to eat and drink. Interventions included monitor meal intake and record, honor likes/dislikes, offer substitutions if consumes less than 50 percent of meals, monitor for signs and symptoms of fluid imbalance, encourage fluids at bedside, and participate in the red napkin program. On 11/05/12 at 11:45 A.M., interview with Registered Nurse (RN) #17 verified the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RN #17 was in the dining room during the dinner observation and verified the resident did not receive the mighty shake. RN #17 verified the MAR indicated [REDACTED]. Review of the nursing assistant flow record for October and November, 2012 revealed the record was incomplete. No fluid intake was documented, no supplements were documented and when the resident ate less than 50 percent no snacks or supplements were offered as per plan of care. On 11/05/12 at 4:00 P.M., interview with the DON verified the above findings. 6. On 11/04/12 at 5:10 P.M., observation of the dinner meal in the Collanade dining room revealed Resident #26 had eight ounces of nectar lemonade. Review of the meal card revealed Resident #26 was to be provided a nectar Resource fruit juice and eight ounces of nectar juice. On 11/04/12 at 5:15 P.M., the lunch observation was verified by the LPN #7. 7. On 11/04/12 at 5:10 P.M., observation of the dinner meal in the Collanade dining room revealed Resident #28 had four ounces of thickened fluids. On 11/04/12 at 5:15 P.M., interview with LPN #7 verified the resident only had four ounces of thickened fluids. Review of the signed November 2012, physician orders [REDACTED]. An order initiated on 09/24/12, indicated the resident was to receive increased fluids every shift. Review of the residents weights revealed on 04/01/11, the resident's weight was 134.6 pounds, and on 10/01/12, the weight was 129 pounds. Review of the dietary quarterly note dated 05/15/11, indicated the resident was to receive pudding at lunch and dinner, eights ounces of juice at breakfast, four ounces of juice at lunch and dinner. Review of the dietary note dated 08/01/12, indicated the plan was to increase the amount of food provided including yogurt at dinner. Review of the dietary note dated 11/01/12, indicated the resident required cueing for multi swallowing, received multiple extra items to ensure adequate calorie intake and the physician ordered to increase fluids every day to promote improved labs. Review of the nutrition/hydration plan of care initiated 02/24/12, revealed the resident was at increased risk for weight loss and had drooling/coughing with meals. The plan of care dated 11/01/12, indicated the resident was at risk for aspiration and interventions included honey thick liquids, monitor meal intake and record, monitor laboratory values as needed, monitor for signs and symptoms of fluid imbalance, encourage fluids at bedside, fed by staff with swallow guidelines per speech therapy, pudding at lunch and dinner, eight ounces juice at breakfast, four ounces of juice at lunch and dinner, and yogurt at dinner. On 11/05/12 at 5:30 P.M., interview with the DON, administrator and director of operations revealed the above concerns were reviewed and verified. This deficiency substantiates Complaint Number OH 883.

Based on record review and interviews, the facility failed to prevent the development, deterioration and infection of a deep tissue injury that progressed to a Stage four pressure ulcer with osteo[DIAGNOSES REDACTED] for Resident #140. This affected one of three residents reviewed with pressure ulcers. The facility's census was 139. Findings include: Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] indicated Resident #140 required extensive assistance of two persons for bed mobility, transfers and toileting and total dependence for personal hygiene. The resident had short term memory deficits and some cognitive difficulty in making decisions in new situations only. The MDS assessment revealed Resident #140 entered the facility with intact skin, i.e. no pressure ulcers. The admission skin risk assessment dated [DATE] identified Resident #140 at moderate risk for the development of pressure ulcers. One risk factor revealed Resident #140 had very limited mobility, including the inability to change and control his body position (frequent or significant changes) independently. The admission skin integrity care plan confirmed Resident #140 was at risk for skin breakdown due to decreased mobility and incontinence. The care plan gave no specific interventions to reduce the pressure to his heels. Condition Change Form dated 11/01/10 revealed Resident #140 had a 7.4 centimeter (cm) by 5.5 cm deep tissue injury (DTI) to his left heel. The area was described as dark purple with no drainage. Deep tissue injury is a term proposed by the National Pressure Ulcer Advisory Panel (NPAUP) to describe a form of pressure ulcers. These ulcers have been described by clinicians for many years with terms such as purple pressure ulcers and ulcers that were likely to deteriorate. NPAUP's proposed definition was "A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. DTI represents a dangerous lesion due to its potential for rapid deterioration. DTIs appear innocent yet conceal a deep, potentially fatal lesion." Source: National Pressure Ulcer Advisory Panel. Weekly Pressure Ulcer Progress Report dated 11/01/11 confirmed Resident #140's pressure area of deep tissue injury and indicated the treatment was for [MEDICATION NAME]. [MEDICATION NAME] is a protective covering to promote healing of decubitus ulcers. Manufacturers' recommendation indicated the cream was to be applied at least twice daily, or as often as necessary. Source: Drugs.com. Review of the treatment administration records (TARs), revealed the [MEDICATION NAME] cream was ordered and provided one time per day. Weekly Pressure Ulcer Progress Reports from 11/11/10 through 12/23/10 indicated the dark purple area of DTI remained, and the treatment remained [MEDICATION NAME] cream once a day. Weekly Pressure Ulcer Progress Report dated 12/30/10 revealed the pressure area opened and measured 5.5 cm by 6.0 cm with a depth of 0.1 cm. The wound treatment was changed on 12/30/10. Resident #140 was sent out for a consultant appointment to the wound care center on 01/07/11. The wound consultant physician wrote Resident #140 had an ulceration of the left heel. He wrote, the nursing home "sent him for an evaluation and examination with no notes and/or reason given." He indicated the resident was unable to provide any history, but complained of burning pain in the left leg. The physician's examination revealed Resident #140 had an ulceration to the left heel that measured 7.5 by 7.4 by 0.1 cm. His examination indicated the wound was macerated, necrotic and foul smelling. The wound had macerated edges with a dusky discoloration around the ulcerative site. The wound care physician indicated the left heel pressure ulcer was infected. Resident #140 was admitted to the hospital for the infected left heel pressure ulcer. Vascular surgeon's progress note dated 01/08/11 indicated the wound on Resident #140's left heel was unstageable, but likely a Stage four based on radiology findings. Hospital physician assessment dated [DATE] revealed Resident #140's left heel wound infection had progressed to the bone, as evidenced by his [DIAGNOSES REDACTED]. Hospital wound care service progress noted confirmed the left heel ulcer infection and indicated Resident #140 was a full assist with turning in bed. Resident #140 returned to the facility on [DATE] with the Stage four pressure ulcer that measured 6.2 cm by 8.4 cm with a depth of 0.3 cm, with the wound bed yellow and brown. The resident received intravenous antibiotic therapy for treatment of [REDACTED]. Resident #140 was discharged from the facility on 02/28/11. During an interview on 03/22/11 at 3:05 P.M., the wound care nurse, Licensed Practical Nurse (LPN) #12, verified Resident #140 was admitted to the facility with intact skin and no pressure areas. LPN #12 indicated Resident #140 developed a deep tissue injury to his left heel on 11/01/10. LPN #12 verified that based on assessment data, Resident #140 was dependent for care, including bed mobility. LPN #12 confirmed there were no specific interventions to reduce pressure to Resident #140's heels until after the area of DTI developed. LPN #12 indicated that heel protectors and an air mattress were ordered after the DTI was identified. LPN #12 verified Resident #140 went out to the wound treatment center for a consultation on 01/07/11 and was immediately admitted to the hospital for a infection of the left heel wound, returning to the hospital on [DATE], with intravenous antibiotics continuing. This deficiency substantiated Complaint Number OH 087.