Every finding on record at Heritage Healthcare of Euclid

Based on observation, interview, and review of the facility policy and procedure, the facility failed to ensure a homelike environment. This affected six residents (#1, #4, #14, #16, #41, and #54) of six residents reviewed for environment and had the potential to affect all 68 residents residing in thee facility. The facility census was 68.Findings include:Observation on 12/03/25 at 11:03 A.M. of Resident #4 in his room sitting in his wheelchair wearing a coat and hat. Interview at this time with Resident #4 stated it was cold in the building, and they needed to turn on the heat.Interview on 12/03/25 at 11:16 A.M. with Resident #54 stated it was cold at night in his room and staff would get him another blanket that helped. Observation of Resident #54's room revealed long black marks and gashes in the wall near the entrance into the room. Resident #54 stated they were supposed to paint the walls and stated they had re-did the bathroom. Observation of the bathroom revealed it appeared to have been updated but was missing the baseboard along the wall. Interview on 12/03/25 at 11:24 A.M. with Resident #14 (Resident #54's roommate) revealed they were supposed to paint the wall next to his bed but was not sure when. Observation of the wall next to Resident #14's bed was a very long patched area that needed to be painted that ran near the ceiling down to the resident's bed. Interview on 12/03/25 at 2:02 P.M. with Resident #41 stated it was always cold in her room and stated she was told they fixed the heat, but it still felt cool. Observations on 12/04/25 between 10:16 A.M. and approximately 10:30 A.M. during tour with Maintenance Staff (MS) #491 of the residents' rooms. MS #491 stated he had to point the laser temperature gun at a surface to get the temperature because there were no thermostats in the resident rooms. Observation in Residents #14 and #54's room the temperature from the vent was 75 degrees Fahrenheit, the wall by window was 70 degrees Fahrenheit, and the back wall across from beds was 70 degrees Fahrenheit, and the wall by the beds was 71 degrees Fahrenheit. MS #419 verified the walls needed painting and the baseboards placed in the bathrooms. MS #419 stated he was in the process of updating the room but was moved to the assisted living building about a month ago. Observations of the temperature of Resident #4's room revealed from the vent it was 83 degrees Fahrenheit, back wall and the wall by window was 73 degrees Fahrenheit, and the back wall where the television was located was 63 degrees Fahrenheit. Resident #4 stated the room felt cold to him. Observation of Residents #1 and #41's room revealed the temperature from the vent was 56 degrees Fahrenheit, the wall by the window and the wall across from the beds was 61 degrees Fahrenheit, and wall by the beds was 64 degrees Fahrenheit. Both Resident #1 and #41 stated that their room was cold. MS #491 verified it felt cold in Resident #1 and #41's room, even with him wearing a jacket. Observation of Resident #16's room revealed the temperature from the vent was 91 degrees Fahrenheit, but it was blowing out very little and did not spread throughout room. The temperature from the wall by the window was 63 degrees Fahrenheit, the back wall by the bed was 65 degrees Fahrenheit, and the wall across from the bed was 60 degrees Fahrenheit. Further observation of Resident #16's room revealed a large area of wallpaper. During the tour, MS #491 verified the above findings and stated in regards to the repairs, that he and the maintenance director were in the process of completing the rooms, but he was then sent to the assisted living facility and that was about a month ago. MS #491 stated he was not sure what the maintenance director was doing.Observations on 12/04/25 between approximately 11:00 A.M. and 11:15 A.M. with Regional Director of Operations (RDO) #615 of Resident #1 and #41's room verified it was cool. Residents #1 and #41 stated to RDO #615 that it was cold in their room. Observation of Resident #16's room stated he could feel the heat coming from vent when he touched the vent but verified it didn't seem to move around the room. RDO #615 verified the peeling wallpaper near the window and the flooring that was in disrepair near the side of the room by the window. Observation in Resident #14 and #54's room, RDO #615 checked the vent stated he felt heat coming through. At this time Resident #54 stated to RDO #615 that it gets cold in the room at night. RDO #615 verified the walls needed painted, and the baseboard for the bathroom needed installed. Observation of Resident #4's room with RDO #615, Resident #4 stated he was cold and was wearing a coat and hat. RDO #615 stated he felt the heat from the vent but will have it looked at. During the observations RDO #615 verified the findings and stated they recently had someone out regarding the heat but would have someone back out to investigate the heat for Residents #1, #4, #14, #16, #41, and #54. Review of the undated facility policy titled Homelike Environment revealed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment; and comfortable and safe temperatures (71 degrees Fahrenheit - 81 degrees Fahrenheit). This deficiency represents non-compliance in Complaint Numbers 2667099 and 1356067 (OH00165144).

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #29 received timely incontinence care and was free from skin breakdown. This affected one resident (Resident #29) out of three residents reviewed for incontinence care. The facility census was 66. Findings include: Review of Resident #29's medical record revealed and admitted [DATE] and diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, major depressive disorder, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident #29's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed A Brief Interview for Mental Status was not completed due to resident was rarely or never understood. Resident #29 was dependent for toileting, bathing, and personal hygiene. Resident #29 was frequently incontinent of urine and always incontinent of bowel. Review of Resident #29's care plan revised on 09/11/24 included Resident #29 had a history of CVA (cerebrovascular accident) with functional impairment. Resident #29 was dependent on staff for activities of daily living (ADL) and exhibits with incontinence. Resident #29's ADL needs would be met through the next review. Interventions included Resident #29 was a total assist with activities of daily living; Resident #29 was a two person assist with a mechanical lift. Resident #29 had bladder and bowel incontinence. Resident #29 would be comfortable, clean, dry and free from skin breakdown through the next review. Interventions included to monitor peri-area and rectal area for redness, irritation, and skin excoriation, breakdown; provide peri-care after each incontinent episode. Review of Resident #29's medical record revealed the resident did not have skin break down as of 12/10/24. Observations on 12/10/24 from 8:30 A.M. revealed Resident #29 was sitting in a padded wheelchair by a table in the common area. Observation on 12/10/24 at 9:21 A.M. revealed Resident #29 was sitting in a padded wheelchair by the same table in the common area. Resident #29's head was laying on the table. Observation on 12/10/24 at 11:16 A.M. revealed Resident #29 was sitting in a padded wheelchair by the same table in the common area and an aide was placing a garment to protect her clothes from food spills around her neck and across her chest. Observation on 12/10/24 at 12:43 P.M. of Resident #29 revealed Resident #29 was sitting in the wheelchair by the same table in the common area and Certified Nursing Assistant (CNA) #400 pushed Resident #29's wheelchair from the table to the nurses station and stated she was getting ready to assist Resident #29 to bed, but she needed a mechanical lift and was waiting for a second aide to help her. Observation on 12/10/24 at 1:12 P.M. revealed Registered Nurse (RN) #401 assisted CNA #400 to use a mechanical lift to place Resident #29 into her bed and have incontinence care provided. RN #401 stated he was not assigned to care for Resident #29 but was helping CNA #400 because the other aide was at lunch. CNA #400 proceeded to remove Resident #29's incontinence brief and a large amount of yellow urine and a large amount of feces were observed on the brief. CNA #400 began cleaning Resident #29's perineal area using a wash cloth and warm basin of water. CNA #400 wiped down with the wash cloth then back up and when the wash cloth wiped up feces could be seen on the wash cloth. CNA #400 folded the washcloth with the feces on it and kept wiping the perineal area multiple times down and then back up and each time she wiped upward a moderate amount of feces could be seen on the wash cloth. After cleaning Resident #29's perineal area CNA #400 turned Resident #29 on her right side and cleaned her rectal area. A nickel size discolored pink area could be seen in the crease of the right thigh and buttock and in the center of the discolored pink area was a small open area with a reddish-pink wound bed. CNA #400 stated the area was not open and rubbed her finger over the area, but when she rubbed her finger over the open area Resident #29 cried out in pain. CNA #400 and RN #401 confirmed Resident #29 had a small open area in the right crease of her buttock and thigh. After confirming Resident #29's open area CNA #400 took a towel and wet one side of it with water from the basin and used it to wipe Resident #29's buttocks and dry them with the end of towel not placed in water. CNA #400 and RN #401 placed a clean incontinence brief on Resident #29 and CNA #400 stated she would tell the nurse assigned to Resident #29 about the open area, have it evaluated and get treatment orders. CNA #400 stated Resident #29's incontinence brief was dry when she put her in the wheelchair before breakfast and this was the first time Resident #29 received incontinence care since she was placed in her wheelchair. CNA #400 indicated Resident #29 usually stayed in the common area until after lunch because there were activities and there was more stimulation in the common area than in her room. Interview on 02/10/24 at 3:46 P.M. of the Director of Nursing (DON) confirmed CNA #400 did not provide incontinence care correctly. Review of Resident #29's progress notes dated 12/10/24 at 5:34 P.M. included the nurse was notified by staff that Resident #29 had a small area to the right buttocks, the wound team was made aware, MASD (moisture associated skin damage) was present and new orders were received. Resident #29's son and physician were aware. The interdisciplinary team met, reviewed report, updated Resident #29's care plan, and treatment implemented. Review of Resident #29's physician orders dated 12/10/24 at 5:47 P.M. revealed cleanse right and left buttocks with soap and water, pat dry, apply Triad paste and leave open to air every shift and as needed for treatment. Review of the facility policy titled Perineal Care undated included it was the practice of the facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. If the perineum was grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. Cleanse buttocks and anus, front to back, vagina to anus in females using a separate wash cloth or wipes. Thoroughly dry. Re-position the resident in the supine position, change gloves if soiled and continue with perineal care. For females separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus). Repeat on opposite side using separate section of the washcloth or a new disposable wipe. Clean urethral meatus and vaginal orifice using clean portion of the washcloth or new disposable wipe with each stroke. Pat dry with towel. Always note any skin changes such as rash, red pr pink areas or any discolorations to skin. Report to nurse when applicable. This deficiency represents non-compliance investigated under Master Complaint Number OH00160445 and Complaint Number OH00159858.

Based on record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance for water management, the facility failed to provide evidence of water testing conducted to monitor and prevent the growth of Legionella (a bacteria that causes Legionnaire's disease) in the building water system. This had the potential to affect all 65 residents in the facility. The census was 65. Findings Include: During the entrance conference, the facility was asked to provide a copy of the Legionella water management program and evidence of water testing being conducted. The facility provided the policy titled, Legionella Water Management Program, revised September 2022; however, the facility had no evidence to support that regular testing for Legionella was being done in the building. Interview on 06/27/24 at 12:50 P.M. with the Administrator verified the facility had no documented evidence of water testing related to Legionella prevention. During a follow up interview on 06/27/24 at 1:00 P.M., Maintenance Director (MD) #915 indicated the facility did conduct water testing from different water sources in the facility and send the samples out; however, the results do not return for two to three weeks. MD #915 stated the facility had been unable to locate the previous maintenance director's records and were unable to provide evidence of routine water testing. Review of the CDC document titled, Overview of Water Management Programs, dated 03/15/24, revealed water management programs require regular monitoring of key areas for potentially hazardous conditions. 36307

Based on observation, staff interview, review of a State Fire Marshal report, and policy review, the facility failed to maintain a safe, clean, sanitary, and well maintained environment and equipment. This had the potential to affect all 65 residents residing in the facility. The facility census was 65. Findings Include: 1. An environmental tour was conducted on 06/26/24 between 9:30 A.M. and 9:45 A.M. with Maintenance Director (MD) #915. Observation of the carpeting throughout the facility was significant discolored and stained. The ceiling in the 400 hall dining room area was completely ripped off and plastic sheeting was covering the ceiling to prevent debris from falling. One of the walls of the dinning room was completely taken down to the wooden studs. Observation of the 300 and 400 Hall tub room had drilled out holes in the shower room that were directly in front of the room. The holes exposed rusted pipes and numerous cob webs. Observation of the ceiling light about the 100 and 200 Hall nurses' station did not have a cover. The 100 and 200 Hall tub room had a noted brown substance on the floor that was not easily removed and various other debris on the floor including an open ketchup packet. Further observation of the 100 and 200 Hall tub room revealed numerous other towels that were discolored and wet were thrown about in the room. Observation of the laundry area revealed multiple ceiling tiles completely off the ceiling along with other water damaged areas exposing the piping above the ceiling. Lights covers observed throughout the facility contained numerous dead insects inside the light covers. Further observation during the tour on 06/24/24 between 9:30 A.M. and 9:45 A.M. revealed the tube feeding pole used by Resident #4 had significant amount of dried and caked on residual tube feeding supplement at the bottom of the pole. The stand up closet next to Resident #48's bed had the back panel half off and exposing multiple nails. The room occupied by Resident #6 and Resident #21 had a large hole in the bathroom door and a significant area of stained black and brown substances on the bathroom floor. Resident #58's bathroom also had black and brown substances on the bathroom floor. The privacy curtains in the rooms occupied by Resident #11, Resident #20, Resident #25, Resident #30, and Resident #211 were stained with various unknown substances. The base board behind Resident #37 and Resident #45's beds was hanging off the wall exposing the drywall. Interview with MD #915 during the tour stated the facility had a major flood related to pipes breaking in January 2024 causing the ceiling to collapse. MD #915 further explained that repairs were just approved on 06/20/24 and work was expected to begin on sometime in July 2024. MD #915 verified all the environmental concerns at the time of discovery during the tour. Review of the State Fire Marshal report from 06/20/24 revealed (regarding the 300 hall dinning room area) the area had a water leak earlier this year and needs to be repaired as soon as possible (ASAP). There is a shock risk because there are many open junction boxes with exposed wires. The missing drywall also will allow smoke and flame spread if they would have a fire. 2. Observation on 06/24/24 at 8:35 A.M. revealed Resident #12's electric wheelchair was in the hallway and the wheelchair had food debris and dust covering the arm rests, seat, and footrest. Interview on 06/24/24 at 8:47 A.M., with the Director of Nursing (DON) verified the observation of Resident #12's wheelchair and directed staff to clean the wheelchair. 3. Observation on 06/25/24 at 3:52 P.M. revealed Resident #56's wheelchair was missing the right armrest and the vinyl on the left armrest was cracked exposing the padding underneath. Interview on 06/25/24 at 3:55 P.M., with the DON verified the observations and directed staff to replace the wheelchair. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 2024, revealed direct staff were responsible for cleaning single-resident equipment when visibly soiled. 35768

Based on observation, staff interview, and policy review, the facility failed to ensure insulin was dated when opened, was stored in the container for the resident it was ordered for, and was disposed of once expired. This affected five (#13, #15, #26, #33, and #40) of thirteen residents who receive insulin. The census was 65. Findings include: 1. Observation on [DATE] at 3:14 P.M. revealed a used injector pen of Humalog insulin for Resident #33 was stored in a medication cart. The pen was open and in use with no date written when use began. Interview during the observation with Licensed Practical Nurse (LPN) #905 stated all insulin pens should be dated when initially opened and verified Resident #33's insulin injector pen was not dated. 2. Observation on [DATE] at 3:23 P.M. revealed a used injector pen of Lispro insulin for Resident #13 and Resident #15 were stored in a medication cart. The pens were open and in use with no date written when use began. Further observation of the medication cart revealed an open vial of Lispro insulin for Resident #26 that was dated [DATE], and an opened vial of Humalog insulin for Resident #40 that was stored in a box labeled for Resident #15. Interview during the observation of the medication cart on [DATE] at 3:23 P.M., Assistant Director of Nurse (ADON) #930 stated all insulin pens should be dated when initially opened and insulin generally expires 28 days after opening and should be removed from the medication cart. ADON #930 verified Resident #13 and Resident #15's insulin was not dated, verfiied Resident #26's Lispro insulin was past expiration, and verified Resident #40's vial of Humalog insulin was stored in a box labeled for Resident #15. Review of the facility policy titled, Insulin Storage and Dispensing Information, dated 2021, revealed Lispro and Humalog insulin is good for 28 days.

Based on observation, staff interview, and policy review, the facility failed to store food in a safe and sanitary manner. This affected six (#3, #10, #44, #48, and #172) of 31 residents residing on the 300 and 400 units. The census was 65. Findings include: Observation on 06/24/24 at 3:14 P.M. revealed four containers of applesauce that were not dated and a container of pudding dated 06/20/24 were sitting in the top drawer of the medication cart. The containers were warm to the touch. Another container of applesauce dated 06/20/24 was currently provided to residents who had difficulty swallowing medications. Interview on 06/24/24 at 3:20 P.M. with Licensed Practical Nurse (LPN) #905 stated the containers of applesauce and pudding were in the medication cart when she arrived, so she used them. LPN #905 removed all containers from the cart and stated the containers should have been dated. The facility identified six (#3, #10, #44, #48, and #172) residents who utilized applesauce or pudding with medication administration on the 300 and 400 units. Review of the facility policy titled, Dating for Food Storage, dated 2021, revealed staff were to date foods that were time and temperature controlled (applesauce and pudding) when made and document the use by date as well. The foods should also be kept for designated days and be stored at 41 degrees Fahrenheit or lower.

Based on observation, staff interview, and medical record review, the facility failed to treat residents with dignity while feeding. This affected one resident (#48) of three residents who were provided assistance with feeding. The facility census was 65. Findings Include: Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included cerebral infarction, seizures, dementia, and dysphasia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/17/24, revealed Resident #48 had severely impaired cognition. Review of Resident #48's physician orders for June 2024 revealed an order for feeding assist with all meals on 01/24/24 and the resident was ordered a dysphasia puree texture diet on 04/22/24. Observation on 06/25/24 at 12:29 P.M. revealed Resident #48 in was in a Broda chair (a chair designed to tilt and recline for comfort and mobility) with a plate of puree food on the table. Observation and interview on 06/25/24 at 12:41 P.M. revealed State tested Nurse Aide (STNA) #909 was standing beside Resident #48 while feeding her. STNA #909 confirmed she was standing and stated she knew she should sit to feed residents.

Based on medical record review, review of resident funds accounts, and staff interview, the facility failed to make final dispersal of resident funds within 30 days of a resident's death. This affected one (#219) of one residents reviewed for final dispersal of resident funds. The facility census was 65. Findings Include: Review of Resident #219's medical record revealed the resident was admitted to the facility on [DATE] and expired on [DATE]. Review of Resident #219's resident funds account revealed a check dated [DATE] for $90.56 was sent to the Attorney General and a check dated [DATE] for $1,768.00 was sent to to cover the balance due on the resident's account. Interview on [DATE] at 2:25 P.M. with the Administrator verified Resident #219's personal funds were not disbursed within 30 days after the resident's death as required. The Administrator stated they were aware there was a problem getting the checks out within the 30 day timeframe.

Based on medical record review, review of self-reported incidents, staff interview, and review of a facility policy, the facility failed to report an allegation of abuse, neglect, or injury of unknown origin to the State Survey Agency as required. This affected one (#67) of two residents reviewed for abuse. The facility census was 65. Findings Included: Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), congestive heart failure, high blood pressure, and nicotine dependence. Resident #67 discharged from the facility against medical advice (AMA) on 04/17/24. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact and required one person physical assistance for completing activities of daily living. Review of a progress note dated 04/16/24 at 8:00 A.M. revealed Resident #67 was observed in room during tray pass for breakfast and it was observed that Resident #67's nose and lips were swollen surrounded with small amount of dry blood. Resident #67 was asked what happened and the resident stated that a lighter was lit in his room and it blew up in his face at about 2:00 A.M. or 3:00 A.M. Resident #67 indicated he was not a snitch and refused to give staff any information Review of self-reported incidents (SRIs) submitted to the Ohio Department of Health's Enhanced Information Dissemination Collection System (EIDC) (database used for facilities to report required instances of abuse, neglect, injuries of unknown origin, and misappropriation) revealed no report was filed related to Resident #67's claim on 04/16/24 that an unknown person lit a lighter in his room and caused injuries to his face. Interview with Administrator on 06/26/24 at 10:00 A.M. verified the facility did not file a report with the State Survey Agency for Resident #67's allegations on 04/16/24 as required. Review of the policy titled, Abuse, Neglect, Exploitation, & Misappropriation of Resident Property, dated 10/01/20, revealed all incidents and allegations of abuse, neglect, and exploitation, mistreatment of a resident, or misappropriation of resident property, and all injuries of unknown source must be reported immediately to the Administrator or designee. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Ohio Department of Health immediately, but not no later than two (2) hours after the allegation is made.

Based on medical record review and staff interview, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) assessment data to the Centers for Medicare and Medicaid (CMS) system within 14 days of completing the assessment. This affected one (#2) of three residents reviewed for discharge. The facility census was 65. Findings: Review of the medical record for Resident #2 revealed a discharge MDS assessment dated [DATE] had been completed but not transmitted as of 06/24/24. Resident #2 was discharged from the facility after he failed to return from an authorized leave of absence (LOA) on 01/01/24. During interview on 06/26/24 at 1:15 P.M., the Director of Nursing (DON), Licensed Practical Nurse (LPN) #905, and Social Worker #922 confirmed Resident #2 left on an authorized leave of absence and did not return. Follow up interview on 06/26/24 at 1:40 P.M., the DON confirmed Resident #2's discharge MDS assessment had not been transmitted until 06/26/24.

Based on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screen was completed after a resident remained in the facility longer than 30 days as required. This affected one (#13) of two residents reviewed for PASARR. The facility census was 65. Findings Include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact and required minimum assistance for completing his activities of daily living. Review of the medical record revealed a PASARR was completed for Resident #13's stay in the facility on 04/09/24. Social Worker (SW) #922 verified Resident #13's PASARR was not completed timely as required in an interview on 06/26/24 at 1:30 P.M.

Based on medical record review and staff interview, the facility failed to timely act upon pharmacist recommendations to address any medication irregularities in the medical record. This affect one (#40) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included visual hallucinations, repeated falls, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired and required the assistance of one staff person for completing her activities of daily living. Review of a pharmacist recommendation dated 03/04/24 revealed Resident #40 had a physician's order dated 03/16/23 for the medication carvedilol (medication used to treat high blood pressure) with instructions to give 6.25 milligrams (mg) by mouth two times a day for hypertension (high blood pressure) and hold for systolic blood pressure (SBP) below 100 millimeters of mercury (mmhg) and/or a heart rate below 60 beats per minute. The pharmacist noted nursing was no longer taking and documenting blood pressure and pulse prior to administration as required. The pharmacist further documented for Resident #40's physician to updated the order entry in the facility's medical record system to force nursing to document the blood pressure and pulse with each dose, and also educate nursing staff that any order with a parameter attached to it required the parameter to be checked, and the dose to be held, when the parameter(s) fall outside of the stated range. Review of Resident #40's medication administration record (MAR) for March 2024 revealed blood pressure monitoring was added and completed, but no pulse monitoring was completed as recommended by the pharmacist. Review of the pharmacist recommendation dated 04/01/24 revealed the pharmacist noted further that pulse monitoring was continuing not to take place related to Resident #40's physician order for carvedilol. The Director of Nursing verified the facility did not respond to the pharmacist's notification in a timely manner of a lack of obtaining Resident #40's pulse prior to administering carvedilol in an interview on 06/27/24 at 9:30 A.M.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to adequate monitoring was completed as ordered prior to the administration of a medication. This affected one (#40) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included visual hallucinations, repeated falls, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired and required the assistance of one staff person for completing her activities of daily living. Review of a physician order dated 03/16/23 revealed Resident #40 was ordered carvedilol (medication used to treat high blood pressure) with instructions to give 6.25 milligrams (mg) by mouth two times a day for hypertension (high blood pressure) and hold for systolic blood pressure (SBP) below 100 millimeters of mercury (mmhg) and/or a heart rate below 60 beats per minute. Review of Resident #40's medication administration records from September, October, November, and December 2023, and January and February 2024 revealed no documented blood pressures or pulse measurements were taken as ordered prior to giving the medication. Review of a pharmacist recommendation dated 03/04/24 revealed the pharmacist noted nursing was no longer taking and documenting blood pressure and pulse prior to administration as required. The pharmacist further documented for Resident #40's physician to updated the order entry in the facility's medical record system to force nursing to document the blood pressure and pulse with each dose, and also educate nursing staff that any order with a parameter attached to it required the parameter to be checked, and the dose to be held, when the parameter(s) fall outside of the stated range. Interview with the Director of Nursing on 06/27/24 at 9:30 A.M. verified the nursing staff did not obtain Resident #40's blood pressure or pulse prior to administering carvedilol as ordered in September 2023 through February 2024. Review of the policy titled, Administering Medications, dated 04/01/19, revealed medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation and staff interview, the facility failed to ensure all required postings were on displaying in the facility in a manner that was accessible and understandable. This had the potential to affect all 65 residents residing in the facility. The facility census was 65. Findings Include: Observation of the facility on 06/26/24 between 2:45 P.M. and 3:00 P.M. revealed no evidence of posted contact information for the State Survey Agency and other pertinent agencies and advocacy groups, including the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit, were accessible to residents and resident representatives. The Administrator verified that such required information was not posted in an interview on 06/26/24 at 3:10 P.M.

Based on observation and staff interview, the facility failed to ensure daily nursing staffing information was up-to-date and posted in a prominent place readily accessible to residents and visitors. This had the potential to affect all 65 residents residing in the facility. The facility census was 65. Findings Include: Observation of the posted nursing staff information on 06/24/24 at 8:45 A.M. revealed the posted nursing staff information was located on a bulletin board inside a staffing information area near the front desk that was not visible to residents and visitors. Further observation revealed the posted nursing staffing information was dated 06/14/24. Receptionist #955 verified the posted nursing staffing information was not current and not visible to residents or visitors in the facility during an interview on 06/24/24 at approximately 8:45 A.M.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #17 from developing pressure ulcers, and failed to ensure the pressure ulcers were timely identified, properly treated, and interventions were initiated to promote healing. Actual Harm occurred on 01/06/24 when Resident #17 who was cognitively impaired, at risk for pressure ulcer development, and required assistance with bed mobility, developed new, in-house acquired bilateral heel pressure ulcers that were first assessed to be unstageable (a type of bed sore that occurred due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue. It is a full thickness tissue loss where the depth of the wound or bed sore was completely obscured by eschar in the wound bed) without proper prevention, treatment, and interventions implemented. This affected one resident (Resident #17) out of three residents reviewed for pressure ulcers. The facility census was 67. Findings include: Review of Resident #17's medical record revealed an admitted [DATE] and diagnoses included epilepsy, unspecified, intractable, with status epilepticus, edema, and type two diabetes mellitus. Review of Resident #17's care plan dated 10/18/23 included Resident #17 was at risk for potential for alteration in skin integrity related to decreased mobility. Resident #17 would not develop any skin breakdown through the comprehensive review target date of 01/25/24. Interventions included pressure reducing cushion to the chair, pressure reducing mattress to the bed and evaluate Resident #17's specific risk factors. There were no interventions related to turning and repositioning or off loading heels from the mattress. There were no additional care plans or interventions related to Resident #17's bilateral pressure ulcers until 03/04/24 which was two months after pressure ulcers were identified. Review of Resident #17's Braden Scale dated 12/16/23 revealed Resident #17 was at moderate risk for developing a pressure ulcer, injury. Review of Resident #17's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 did not have a pressure ulcer, injury. Review of Resident #17's Weekly Skin Evaluation dated 01/01/24 included Resident #17's skin was intact and dry. Resident #17 had bilateral lower extremity pitting edema and diuretics were continued. Review of Resident #17's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had severe cognitive impairment. Resident #17 required partial to moderate assistance to roll from lying on back to left and right side, and return to lying on back on the bed, to move from lying on the back to sitting on the side of the bed and with no back support. Resident #17 required substantial to maximal assistance for toileting and personal hygiene. Resident #17 had a pressure ulcer, but the stage was not documented. Review of Resident #17's progress notes dated 01/06/24 at 5:31 P.M. revealed on 01/05/24 at 11:00 P.M. Resident #17 had an open area on the back of his right ankle and heel, area soft and mushy. Resident #17 had an area to the left heel which was soft but unopened. Areas cleansed with normal saline and silver alginate was applied. Medihoney was applied to the right ankle and heel. ABD pad applied to both areas and wrapped with Kerlix. Review of Resident #17's physician orders dated 01/05/24 through 01/08/24 did not reveal orders to cleanse the right ankle and heel open areas with normal saline and apply silver alginate or to apply medihoney to the right ankle and heel. There were no orders to apply an ABD (abdominal) pad and wrap with Kerlix for both heels. Review of Resident #17's physician orders dated 01/06/24 revealed orders for heel protectors while in bed, every shift Resident #17 to have heel protectors while in bed. Review of Resident #17's physician orders from 01/06/24 through 04/09/24 did not reveal orders for turning and repositioning. Review of Resident #17's progress notes from 01/06/24 through 04/09/24 did not reveal evidence Resident #17 was turned and repositioned. Review of Resident #17's aide charting from 01/06/24 through 04/09/24 did not reveal a task for turning and repositioning Resident #17. Review of Resident #17's Weekly Pressure Report Only dated 01/08/24 included Resident #17 had pressure ulcers of the right and left heel, and the pressure ulcers were first observed on 01/06/24. Resident #17 had a right heel unstageable pressure injury and measurements were length 7.9 cm, width 8.7 cm and depth was UTD (unable to determine). Resident #17 had an unstageable left heel pressure ulcer and measurements were length 5.6 cm, width 4.9 cm and depth UTD. Review of Resident #17's Wound Care notes dated 01/08/24 included Resident #17 presented with heel wounds. Resident #17 was a long term care resident of the facility and was confused, weak, poorly mobile and quite frail appearing. Wound Care Physician (WCP) #260 wrote he was asked to evaluate Resident #17's heels and the right heel had an unstageable pressure ulcer and measurements were length 7.9 centimeters (cm), width 8.7 cm and depth UTD (unable to determine) cm. The wound base was composed of 90 percent granulation tissue and 10 percent eschar. The entire base of the heel is open tissue with pink granulation tissue, and there were a few small patches of eschar. The wound was draining serous fluid. Prevalon boots at all times to relieve pressure. This was the initial evaluation of Resident #17's right heel and treatment was pack wound with alginate, cover with ABD (abdominal pad), pad and wrap with Kerlix. Change and apply treatment daily and prn (as needed). Please consider Prevalon boots. Further review of the notes included the second wound was an unstageable pressure injury located on the left heel. Half of the wound was thick, dry well adhered eschar and half black non-blanching tissue. The area was dry and not draining. Start skin prep to mature the eschar and measurements were length 5.6 cm, width 4.9 cm and depth UTD cm. The wound base was composed of 50 percent DTPI (deep tissue pressure injury) tissue. This was the initial evaluation of Resident #17's left heel wound and treatment was apply skin prep, cover with ABD pad and wrap with Kerlix daily and prn. Additional orders were Prevalon boots (heel protection boots which lift the heel to help prevent the development of heel pressure injuries). Review of Resident #17's care plan dated 03/04/24 included Resident #17 had actual skin integrity related to an unstageable wound of the left heel and a stage three pressure ulcer of the right heel. Resident #17's skin injury would be healed by the review date of 04/18/24. Interventions included to educate resident, family, caregivers of causative factors and measures to prevent skin injury, and pressure relieving device in bed. There was no evidence of interventions related to Prevalon boots, off loading heels from the mattress or a turning and repositioning schedule. Review of Resident #17's Braden Scale dated 03/16/24 revealed Resident #17 was at moderate risk to develop a pressure ulcer or injury. Review of Resident #17's Wound Care notes dated 04/09/24 included Resident #17's right heel wound was a stage three pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible but do not obscure the depth of tissue loss). and measurements were length 4.2 cm, width 3.4 cm and depth was 0.2 cm with intact skin bridge present. The wound base was 100 percent granulation tissue with moderate serous drainage. Wound status was slightly larger but remained clear. Continue to wear protective boots. Treatment was cleanse wound with normal saline, pat dry, cover with ABD pad and wrap with Kerlix. Skin prep heel, pack deepest part of the wound bed with moistened collagen. Change and apply treatment daily and prn. Continue to wear protective boots. Further review revealed Resident #17's left heel wound was an unstageable pressure ulcer and measurements were length 1.1 cm, width 2.2 cm and UTD cm. Wound base was 100 percent slough with moderate serous drainage. Sharp, excisional debridement was performed using a scalpel and forceps. The tissue was debrided down to the muscle and eschar was removed. Post debridement measurements were length 1.1 cm, width 2.2 cm and depth UTD cm. Area debrided was three square cm. Treatment orders were cleanse left heel wound with normal saline, pat dry, apply Santyl ointment followed by calcium alginate to wound bed. Cover with ABD pad and wrap with Kerlix, Change and apply treatment daily and prn. Recommendations included pressure reduction mattress per facility protocol, offload heels per facility protocol, reposition per facility protocol. The plan of care was discussed with nursing staff and resident. Review of Resident #17's physician orders dated 04/09/24 revealed orders for Santyl ointment 250 Unit/Gram, apply to left heel topically every night shift for wound care. There was no evidence calcium alginate was ordered to be applied to the left heel after Santyl ointment was applied. Review of Resident #17's Treatment Administration Record (TAR) dated 04/09/24 revealed Santyl Ointment 250 Unit/Gram, apply to left heel topically every night shift for wound care. Registered Nurse #252 signed the TAR on 04/09/24 that she applied Santyl Ointment to the left heel, but there was no evidence calcium alginate was applied to Resident #17's left heel after the Santyl ointment was applied. Further review of the TAR dated 04/10/24 at 1:02 A.M. revealed Registered Nurse (RN) #252 documented she applied Santyl Ointment topically to both feet. Observation on 04/09/24 at 4:10 P.M. of Resident #17 revealed he was lying on his back in bed, had slid down in the bed, both feet were pressed firmly against the footboard, and his heels were resting directly on the mattress. Both Resident #17's right and left ankles and heels had dressings noted, and the dressings were not dated. Resident #17 did not have Prevalon boots on and was not lying on a low air loss mattress. Interview on 04/09/24 at 4:10 P.M. of Resident #17 revealed he was pleasantly confused and unable to answer questions. Observation on 04/09/24 at 4:12 P.M. of Resident #17 with Wound Nurse/Licensed Practical Nurse (WN/LPN) #235 revealed Resident #17 was lying on his back in bed, had slid down in the bed, both feet were pressed firmly against the footboard, and his heels were resting directly on the mattress. Both Resident #17's right and left ankles and heels had dressings, and the dressings were not dated. Resident #17 was not wearing Prevalon boots and was not lying on a low air loss mattress. WN/LPN #235 confirmed Resident #17 did not have Prevalon boots on, the dressings were not dated, his feet were pressed up against the footboard and his heels were directly on the mattress. WN/LPN #235 confirmed Resident #17 was not lying on a low air loss mattress, but his current mattress was a pressure reduction mattress with a perimeter mattress. WN/LPN #235 stated Resident #17 was very tall and staff had to keep moving him up in his bed. Observation on 04/10/24 at 8:00 A.M. of Resident #17 with Licensed Practical Nurse (LPN) #204 revealed Resident #17 was lying in bed on his back, had slid down in the bed, his left foot was pressed firmly against the footboard, his right leg was bent and both heels were resting directly on the mattress. Resident #17 was not wearing Prevalon boots. Observation revealed Resident #17's Prevalon boots were lying on the floor next to the wall in his room. LPN #204 confirmed Resident #17 was not wearing Prevalon boots, his heels were not offloaded to reduce pressure on his heels, and LPN #204 left the room to find an aide to help move Resident #17 up in the bed. LPN #204 returned to the room with State tested Nursing Assistant (STNA) #212 and moved Resident #17 up in the bed. LPN #204 stated Resident #17 slid down in the bed frequently, his feet pressed against the footboard, and it could be because he was tall and the bed was not long enough for him. LPN #204 indicated the facility could order a longer bed for Resident #17. Neither LPN #204 or STNA #212 put Resident #17's Prevalon boots on him to offload his heels from the mattress. Interview on 04/10/24 at 8:00 A.M. with STNA #212 revealed she was not assigned to care for Resident #17 today, and right now there was no aide assigned to care for Resident #17 because STNA #232 had not arrived to work and Resident #17 was in STNA #232's assignment. STNA #212 stated all the aides were watching over STNA #232's residents until she arrived. STNA #212 stated she had not repositioned Resident #17 or provided care for him today. STNA #212 stated she was not usually assigned to care for Resident #17 and did not know anything about his bilateral heel wounds. Observation on 04/10/24 at 9:15 A.M. of Resident #17 revealed STNA #223 was feeding Resident #17 and LPN #204 was completing dressing changes of his heels. Observation of LPN #204 revealed she was changing Resident #17's right heel dressing. LPN #202 stated she cleansed Resident #17's right heel with normal saline, patted it dry, and applied skin prep before the surveyor entered the room. LPN #204 held Resident #17's right heel up and with the surveyor observed Resident #17's right heel wound. The wound was about one and half inches by one inch, was reddish-pink in color, small amount of clear drainage and a skin bridge was intact. Further observation revealed Resident #17's right heel had a very dark, blackened area to his right heel about the size of a quarter, and the blackened area was close to the wound LPN #204 was completing a dressing change on. LPN #204 confirmed the dark, black area on Resident #17's right heel. Observation revealed LPN #17 provided a clean barrier under Resident #17's right heel, donned clean gloves, applied collagen, an ABD pad, then wrapped the heel with Kerlix. LPN #204 stated she had already completed Resident #17's left heel dressing, the tissue was soft, a small amount of reddish-brown drainage was noted, and she cleansed the left heel wound with normal saline, applied Santyl ointment, followed by an ABD pad and then wrapped the heel with Kerlix. LPN #204 stated she did not apply alginate to the wound. When asked about Resident #17 not having Prevalon boots on to offload his heels from the bed, LPN #204 stated she was just getting ready to put them on and walked over to the Prevalon boots lying against the wall and put them on Resident #17's heels. Interview on 04/10/24 at 9:15 A.M. with STNA #223 revealed she was only feeding Resident #17 to help out, did not have him in her assignment, and had not provided care or repositioning for him. STNA #223 stated she did not know Resident #17 and was not usually assigned to work on the nursing unit he resided on. Interview on 04/10/24 at 9:48 A.M. with STNA #233 revealed there was no permanent STNA assigned to take care of residents residing on the nursing unit Resident #17 resided on. STNA #233 stated she did not routinely take care of Resident #17 and could not name any aide who would know him and would be able to talk about his bilateral heel sores. STNA #233 stated she never looked at Resident #27's heels when she cared for him, but she did know he had sores on them. Interview on 04/10/24 at 10:52 A.M. with WN/LPN #235 revealed she was made aware Resident #17 was not wearing his Prevalon boots while he was in bed and his heels were not offloaded off the mattress. WN #235 stated she would need to educate the staff about the importance of Resident #17 wearing Prevalon boots. Interview on 04/10/24 at 12:22 P.M. with Certified Wound Nurse Practioner (CWNP) #261 revealed she did not see a quarter sized, very dark and blackened area on Resident #17's right heel close to his existing wound when she saw him on 04/09/24. CWNP #261 stated if she had seen it she would have documented the observation and ordered a treatment if needed. CWNP #261 stated she would have skin prep applied to the area and would evaluate the area on her next visit to the facility. CWNP #261 stated a pressure injury could happen very quickly, and could happen in one day or even in an hour. Interview on 04/10/24 at 12:45 P.M. with WN/LPN #235 revealed Resident #17's right and left heel pressure ulcers were found on 01/06/24, it was a weekend, she was not working, but the nurse who found the pressure ulcers notified her via a text message on her phone. WN/LPN #235 was not aware Resident #17 had a blackened area on his right heel close to his existing pressure ulcer, and she would look at it on 04/11/24 when his dressing change was completed. WN/LPN #235 did not want to take the dressing off on 04/10/24 to observe the area because he just had his dressing changed and she did not want to put him at risk by doing a second dressing change. Interview on 04/10/24 at 1:07 P.M. with STNA #212 revealed she had Resident #17 in her assignment because STNA #232 took a different assignment when she arrived. STNA #212 stated she took care of Resident #17 since around 9:30 A.M. STNA #212 stated she assisted Resident #17 to his chair in his room because his son came to visit and asked her to help Resident #17 get out of bed and into his chair. STNA #212 stated she got another aide to help her assist Resident #17 to his chair. STNA #212 stated Resident #17 was lying on his back in bed and she had not repositioned him from 7:00 A.M. until about 10:30 A.M. when she transferred him to his chair. STNA #212 stated Resident #17 did not typically refuse care or repositioning. Interview on 04/10/24 at 1:13 P.M. with WN/LPN #235 and the Director of Nursing (DON) revealed the physician orders placed on 04/09/24 in Resident #17's electronic record for his left heel were not correct and when WN/LPN #235 placed the orders she forgot to put Santyl ointment followed by calcium alginate, ABD pad and Kerlix. WN/LPN #235 stated because she did not place the orders correctly the TAR was also wrong and on 04/10/24 LPN #204 did not apply calcium alginate after the Santyl was applied and before placing the ABD pad and wrapping with Kerlix. The DON stated the documentation on the TAR of Santyl to Resident #17's both feet was probably a mistake. Interview on 04/10/24 at 2:35 P.M. with the DON revealed she could explain why there were no orders for treatments to Resident #17's right and left heel wounds in his electronic record on 01/05/24. The DON stated the facility was transitioning from one electronic system to another in early January and Resident #17's orders were placed on a paper TAR and did not get transcribed into his electronic record. The DON indicated she would try to find Resident #17's paper TAR which was in the medical records area in the basement of the facility, left the room to find it and arrived a short time later with Resident #17's paper TAR dated 01/05/24 with orders for treatments to the right and left heel wounds. Interview on 04/11/24 at 1:05 P.M. with Minimum Data Set (MDS) Nurse #234 revealed the Annual MDS assessment dated [DATE] had a mistake which she corrected. MDS #234 stated Resident #17 did not have a pressure ulcer on that assessment and the question if Resident #17 had a pressure ulcer should have been marked no. Review of the facility policy titled Pressure Injury Prevention and Management reviewed 08/22/22 included the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer, injury, prevent infection and the development of additional pressure ulcers, injuries. Licensed nurses would conduct a Braden Scale pressure injury risk assessment whenever the resident's condition changed significantly. Evidence-based interventions for prevention would be implemented for all residents who were assessed at risk or who had a pressure injury present. Interventions included to redistribute pressure such as repositioning, protecting and, or offloading heels etcetera, provide appropriate, pressure-redistributing, support surfaces. Interventions on a resident's plan of care would be modified as needed. Considerations for modifications included new onset or recurrent pressure injury development. Review of the policy titled Specialty Mattresses revised 07/2018 included specialty mattresses were not typically used for extremities that could be elevated or would benefit from the use of pressure reduction devices such as pillows, pressure reduction boots. Use of low-air-loss mattresses was reserved for residents with stage three and stage four pressure ulcers. This deficiency represents non-compliance investigated under Complaint Number OH00151992.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #1, #24 and #55 received proper, timely incontinence care. This affected three resident's (Resident's #1, #24 and #55) out of four resident's reviewed for incontinence care. Findings include: 1. Review of Resident #55's medical record revealed an admitted [DATE] and diagnoses included cerebral infarction, pseudobulbar affect, and type two diabetes mellitus with ketoacidosis without coma. Review of Resident #55's Annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #55's Brief Inteview for Mental Status was not assessed. Resident #55 was always incontinent of urine and bowel. Resident #55 was dependent for all ADL's (Activity of Daily Living) including toileting and personal hygiene. Review of Resident #55's care plan revised 05/18/22 included Resident #55 experienced bowel incontinence. Resident #55's toileting needs would be met by staff, with interventions aimed at the prevention of infection and, or skin impairment. Interventions included inspect for skin breakdown and intervene when needed, and provide incontinence care every two hours and as needed, apply house moisture barrier cream as needed. Observation on 04/08/24 at 5:35 A.M. of State tested Nursing Assistant (STNA) #251 preparing to provide incontinence care for Resident #55 revealed STNA #251 prepared a basin of warm soapy water, gathered supplies including two incontinence briefs and proceeded to provide incontinence care for Resident #55. STNA #251 removed Resident #55's incontinence brief, and when the incontinence brief was removed it was revealed Resident #55 was wearing two incontinence briefs. STNA #251 confirmed Resident #55 was wearing two incontinence briefs and said Resident #55 was a heavy wetter. Both incontinence briefs were soaked with urine, and further observation revealed the folded sheet under Resident #55 used as a draw sheet was extremely wet with urine. Observation revealed Resident #55's fitted sheet covering his mattress was dirty and had dried unidentified material stuck to it. STNA #251 confirmed the sheet had dried material on it, scraped some of the dried material with his fingers and brushed it on the floor. STNA #251 continued with Resident #55's incontinence care, picked up one of the two clean incontinence briefs, tore the tabs off and placed the brief inside the second brief. STNA #251 stated he had to use two incontinence briefs for Resident #55 because he was a heavy wetter, and he made a liner by ripping the tabs off one of the incontinence briefs. STNA #251 put the incontinence brief with the makeshift liner on Resident #55, finished with the incontinence care and left Resident #55's room. Interview on 04/08/24 at 10:00 A.M. with the Director of Nursing (DON) revealed it was not acceptable to have two incontinence briefs on residents and she would start educating the staff right away. Review of the facility policy titled Perineal Care undated included it was the practice of the facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. 2. Review of Resident #1's medical record revealed an admitted [DATE] and diagnoses included pruritus, dementia and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #1's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 was always incontinent of urine and bowel. Resident #1 was dependent on staff for toileting hygiene and bathing. Review of Resident #1's care plan revised 08/31/21 included Resident #1 had episodes of bladder and bowel incontinence related to impaired mobility and diagnoses. Resident #1 would be at a reduced risk for complications from incontinence through the next review. Resident #1 would be comfortable, clean, dry and free from skin breakdown through the next review. Interventions included to assist Resident #1 with toileting needs, provide peri care after each incontinence episode, apply house barrier cream after incontinence care. Review of Resident #1's aide charting in the electronic medical record revealed on 04/08/24 at 1:25 A.M. Resident #1 was incontinent of urine and care was provided. There was no further evidence on 04/08/24 from 1:25 A.M. through 7:00 A.M. that Resident #1 was incontinent of urine and care was provided. Further review revealed there was no evidence on 04/08/24 from 12:00 A.M. through 6:59 A.M. that Resident #1 was incontinent of bowel and incontinence care was provided. Observation on 04/08/24 at 6:17 A.M. of Resident #1 revealed Resident #1 was in the bathroom sitting in her wheelchair next to the sink, the water was running, and a very unpleasant strong odor of feces and urine was noted in the room. STNA #201 was standing next to Resident #1 assisting her to wash her hands and clean her nails. STNA #201 stated Resident #1 had feces under her fingernails and she was helping her clean her hands and fingernails. Further observation revealed Resident #1's bed did not have any sheets on it, a very large wet spot covered the bare mattress, and dirty feces covered sheets were on the floor under Resident #1's bed along with a dirty incontinence brief with feces covering the inside and outside of the brief in multiple areas. STNA #201 confirmed the feces covered incontinence brief and sheets were under Resident #1's bed and on the floor, she left them on the floor because when she entered the room Resident #1 was already in the bathroom and she needed to assist her before tending to the bed, incontinence brief and sheets on the floor. Further observation revealed two additional incontinence briefs covered in urine and feces were in the trash can in the room. STNA #201 stated those incontinence briefs were from earlier, and she had not taken them out of the room yet. STNA #201 stated the large wet spot on the mattress was urine and she needed to clean the area before putting sheets back on the bed. STNA #201 stated Resident #1 often took her incontinence briefs off and sometimes they were found in the bed and sometimes on the floor. STNA #201 was vague when she was asked about the last time she provided incontinence care for Resident #1. Review of the facility policy titled Perineal Care undated included it was the practice of the facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. 3. Review of Resident #24's medical record revealed an admitted [DATE] and diagnoses included chronic obstructive pulmonary disease, aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), cerebral infarction, and major depressive disorder. Review of Resident #24's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 was always incontinent of urine and bowel. Resident #24 was dependent on staff for toileting hygiene and bathing and required substantial to maximal assistance for personal hygiene. Review of Resident #24's care plan revised 02/06/24 included Resident #24 had episodes of bladder and bowel incontinence related to impaired mobility, physical limitations and diagnoses. Resident #24 would be at reduced risk for complications from incontinence through the next review. Interventions included to assist Resident #24 with toileting needs, provide disposable incontinence products. Observation on 04/08/24 at 6:30 A.M. of STNA #251 revealed he was preparing for incontinence care of Resident #24. STNA #251 gathered two clean incontinence briefs, towels, prepared a basin of warm soapy water, and proceeded to provide Resident #24's incontinence care. Observation of Resident #24 revealed STNA #251 removed two incontinence briefs, and they were both saturated with urine and a large bowel movement. STNA #251 stated he had to put two incontinence briefs on Resident #24 so her briefs did not leak. STNA #251 stated Resident #24 liked a bigger incontinence brief, and he used a larger incontinence brief, then ripped the tabs off a second incontinence brief to make a liner. Resident #24 stated the incontinence briefs pinched her and that was why she asked for a larger brief. Further observation revealed Resident #24's draw sheet and fitted sheet were soaked with urine, and a large dried urine ring could be seen around the wet urine on the sheets. Resident #24 stated the last time she was changed was before she went to sleep. When asked if she put her call light on to be changed Resident #24 stated she did not think about putting her call light on to be changed and it was uncomfortable to lay in urine. STNA #251 confirmed the sheets were soaked and there was a dried urine ring around the wet urine. STNA #251 stated there were only three aides working last night, he had a split assignment which made it difficult to give the residents he was assigned to the care they needed. STNA #251 finished the incontinence care, dipping clean towels into the soapy water each time he needed a new towel, using the same gloves each time and put two clean incontinence briefs on Resident #24, one of which had the tabs ripped off to make a liner. STNA #251 did not remove his soiled gloves used for incontinence care and after Resident #24's incontinence care was complete, using the same soapy water he used for incontinence care he dipped a clean towel in the water and proceeded to clean Resident #24's face with the towel dipped in the water. STNA #251 confirmed he did not change his gloves and stated but I used a clean towel each time. When explained to him he did not change his gloves, and his gloves were soiled from the incontinence care STNA #251 stated I see what you are getting at and he would keep that in mind when he provided resident incontinnce care. Review of the facility policy titled Perineal Care undated included it was the practice of the facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. This deficiency represents non-compliance investigated under Complaint Number OH00151992.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #45 had an individualized care plan with appropriate interventions in place to manage symptoms of dementia to prevent wandering in other residents rooms. This affected one resident (Resident #45) out of three resident reviewed for dementia care. The facility census was 67. Findings include: Review of Resident #45's medical record revealed an admitted [DATE] and diagnoses included dementia, major depressive disorder, and morbid obesity. Review of Resident #45's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 had severe cognitive impairment. Resident #45 used a manual wheelchair. Resident #45 was independent for bed mobility, the ability to transfer from a bed to a wheelchair, and the ability to come to a standing position from sitting in a wheelchair or the side of the bed. Review of Resident #45's care plan revised 01/24/24 included Resident #45 had impaired cognitive process for daily decision making. Resident #45 was at risk for further decline in cognitive status. Resident #45 would not exhibit further decline in cognitive status and Resident #45's needs would be met daily through the next review on 04/16/24. Interventions included to reorient and redirect as needed. Further review did not reveal a care plan for monitoring Resident #45 to ensure he did not go in resident rooms and upset residents when he tried to take their belongings. Review of Resident #45's progress notes from 10/08/23 through 03/30/24 revealed many notes stating Resident #45 required continuous supervision and redirection because Resident #45 roamed around the facility and entered other resident rooms unannounced and went through their belongings. Resident #45 was sometimes agitated, aggressive and combative with staff when they attempted to redirect him. Review of Resident #10, Resident, #45, Resident #53 medical records, and facility Self Reported Incidents revealed the following incidents related to Resident #45's wandering behavior: a. Review of Resident #10's medical record revealed an admitted [DATE] and diagnoses included peripheral vascular disease, nontraumatic intracranial hemorrhage, and dementia. Review of Resident #10's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 had impaired cognitive function related to dementia. Resident #10 would cope with his cognitive impairment evidenced by having no episodes of anxiety or frustrations through the next review. Interventions included to reassure Resident #10 of safety and redirect as needed. Review of the facility Self Reported Incident Form (SRI) tracking number 244499 dated 02/23/24 included Resident #45 wandered into Resident #10's room and began going through his belongings. Both residents had a diagnosis of dementia. Resident #45 was verbally aggressive and saying he wanted to fight with Resident #10. Housekeeper #262 redirected Resident #45 out of Resident #10's room and before she could intervene Resident #45 reentered Resident #10's room and Resident #10 hit Resident #45 on the head with his cane to get him out of the room. Resident's #10 and #45 were immediately separated. Resident #45 had a small nickel size bump on his head and neither resident had a significant injury. Resident #10 and #45 were referred to psych services for evaluation. Resident's #10 and #45 were monitored and there was no further incident. b. Review of Resident #53's medical record revealed an admitted [DATE] and diagnoses included epilepsy, major depressive disorder, factitious disorder imposed on self and schizoaffective disorder, bipolar type. Review of Resident #53's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was cognitively intact. Resident #53 was independent with ADL's (Activity of Daily Living) and required setup or clean-up assistance with bathing. Review of Resident #53's care plan dated 03/07/24 included Resident #53 had the potential to make false allegations. Resident #53 would be educated on how false allegations can affect other people. Interventions were to help Resident #53 make positive decisions. Resident #53 refused Psych services despite education and encouragement from staff. Staff would encourage Resident #53 to talk with Psych services. Interventions included to keep Resident #53 safe during episode of behavior, and attempt to redirect. There was no care plan or evidence Resident #53 had self-inflicted injuries. Review of Resident #53's progress notes dated 03/26/24 at 5:25 P.M. revealed Resident #53 saw Resident #45 reaching for his belongings located in his drawer and snatched the item out of Resident #45's hand causing him to hit his hand on the dresser. Resident's #45 and #53 were separated. Resident #53 had pain from hitting his hand on the dresser, his physician was notified and an x-ray of his right hand was ordered. Review of Resident #53's progress notes dated 03/26/24 at 11:21 P.M. revealed the portable x-ray company was called for Resident #53's right hand x-ray results and the results were pending. Review of Resident #45's medical record revealed Resident #45 was moved to a different room on 03/27/24 and not on 03/26/24 the date of incident. Review of Resident #45's progress notes dated 03/28/24 at 1:11 P.M. revealed Resident #45 was moved from room [ROOM NUMBER] to 107A. Family aware. There were no notes regarding the reason Resident #45 was moved and no notes about Resident #45 entering Resident #53's room and going through his belongings. Review of Resident #53's progress notes dated 03/28/24 at 7:56 P.M. included Resident #53 returned from the local hospital with a cast on his right hand due to a closed displaced fracture of the neck of the fourth metacarpal bone of his right hand. Resident #53's physician aware. Review of Resident #53's hospital After Visit Summary dated 03/28/24 revealed Resident #53 was seen for a hand injury. Resident #53's diagnosis was hand injury, right, initial encounter, right hand pain, closed displaced fracture of the neck of the fourth metacarpal bone of the left (right) hand. Review of Resident #45's progress notes dated 03/29/24 at 7:02 P.M. included Resident #45 was in another unidentified resident's room which he destroyed, throwing items all over the room, and also throwing items including a candle and flower pot at the resident whose room he destroyed. The resident then struck Resident #45 and Resident #45 was escorted out of the room by staff. Resident #45 grabbed a metal fork and held in a threatening way towards staff. Resident #45 refused to allow a head to toe assessment. Resident #45's physician made aware, family was unable to be contacted. Resident #45 to be sent out for behaviors via 911 and EMS (Emergency Medical Services). Review of Resident #45's progress notes dated 03/30/24 at 2:18 P.M. revealed Resident #45 was admitted to the hospital for dementia with behavioral disturbances. Review of Resident #53's progress notes dated 04/03/24 at 5:38 P.M. written by Resident #53's physician included Resident #53 was seen on rounds following a recent ER (emergency room ) visit which revealed a fracture to the metacarpal on Resident #53's right hand. Resident #53 was involved in an altercation with another resident, resulting in swelling of the hand. An x-ray was ordered and did not reveal any fractures. Two days later Resident #53 left following an appointment and went to the ER. Asked Resident #53 numerous different ways if Resident #53 had any other injury following the altercation and initial x-ray that might have resulted in an injury. Resident #53 denied another injury and stated I've used that x-ray company before, they are no good, they do not know what they are doing, there was a fracture and they missed it. Resident #53's physician showed Resident #53 the portable x-ray pictures taken at the facility which showed no fracture and Resident #53 stated they must not have turned it the right way or something. Resident #53's physician wrote given Resident #53's history he was suspicious there might have been subsequent trauma (possible self-inflicted) that Resident #53 was not forthcoming with. Resident #53 reported having a lawyer. Resident #53 was currently in an ulnar gutter splint. Interview on 04/08/24 at 10:20 A.M. with Licensed Practical Nurse (LPN) #206 revealed she was working on 03/26/24, the day Resident #45 entered Resident #53's room uninvited. LPN #206 stated she heard a noise in Resident #53's room, Resident #53 was screaming and yelling because Resident #45 was trying to steal his belongings. Resident #53 told her he hit the money out of Resident #45's hand and his hand hit the dresser. LPN #206 stated she notified Resident #53's physician, the Director of Nursing (DON), and removed Resident #45 from Resident #53's room and transferred Resident #45 immediately to another room, right after the altercation happened. LPN #206 stated Resident #45 had dementia, was really confused and could be redirected. LPN #206 indicated she never saw the money in Resident #53's drawer. LPN #206 stated Resident #53's physician ordered an x-ray of his right hand, and the x-ray was negative for a fracture. LPN #206 stated Resident #53 did not tell her Resident #45 pushed his wheelchair into him, causing him to fall forward and hit his hand while he was trying to hit the money out of Resident #45's hand. LPN #206 stated she was told Resident #53 had a fracture and had a cast on his arm and hand. Observation on 04/08/24 at 10:54 A.M. of Resident #53 revealed he was lying in bed and had a cast on his right arm and hand. Resident #53 stated Resident #45 came into his room about four to five times uninvited and sometimes he would get violent. Resident #53 stated he told the nurses about it but nothing was done and Resident #45 continued to enter his room uninvited. Resident #53 indicated on 03/26/24 Resident #45 again came into his room uninvited, started going through his dresser, and had Resident #53's money in his hand. Resident #53 stated he tried to grab his money out of Resident #45's had, Resident #45 was getting violent and pushed against him with his wheelchair causing Resident #53 to fall forward and hit his right hand on the dresser. Resident #53 stated his hand swelled up, the facility took an X-ray and told him the X-ray did not show he had a fracture. Resident #53 stated two days after this happened he went to the hospital ER, had his hand evaluated and the hospital x-rays showed he had a fracture of his right hand. Resident #53 stated Resident #45 came into his room uninvited two more times after they had the situation with his money. Resident #53 indicated they finally moved Resident #45 across the facility to another room which was not close to his. Resident #53 stated he was in worst shape now than when he was admitted . Interview on 04/09/24 at 8:18 A.M. with State tested Nursing Assistant (STNA) #212 revealed Resident #53 told her he knew his hand was broken, and he was going to sue the physician who said it was not broken. STNA #212 stated Resident #53 was extremely upset Resident #45 came into his room uninvited and tried to steal his belongings. STNA #212 stated Resident #45 wandered in and out of all the residents rooms and became aggressive if staff or other residents tried to stop him from going through their belongings. STNA #212 indicated Resident #45 used his wheelchair as a weapon when he was agitated and combative, and had pushed his wheelchair into her when he was upset. STNA #212 stated she had seen Resident #45 push his wheelchair into other staff and residents when he was upset. STNA #212 stated Resident #45 was very strong and was in the hospital now. Interview on 04/09/24 at 8:53 A.M. with the Administrator and the Director of Nursing (DON) revealed Resident #53 said a resident with dementia (Resident #45) came into his room and took things out of his drawers and when Resident #53 was attempting to get his belongings back he hit his arm on the nightstand and said he was in a lot of pain. The Administrator stated Resident #53's physician ordered an x-ray and the x-ray was negative for a fracture, and he did not know how Resident #53 fractured his hand. The DON stated Resident #53 told her the facility x-ray was wrong and that was why he went to the hospital ER for an x-ray. The Administrator stated Resident #53 went on an unsupervised LOA (leave of absence) and he did not know what happened, but he thought Resident #53 went to the hospital ER and when he returned to the facility Resident #53 had a cast on his arm and said he had a fracture of his hand. The Administrator and DON stated they did not remember Resident #53 saying Resident #45 pushed his wheelchair against him causing him to fall forward. The Administrator stated last week Resident #53 came to him, said he did not want to cause trouble, but he just wanted compensation for the work he would be missing. Resident #53 said he would call off the state if we compensated him. The Administrator indicated he knew Resident #53 from other nursing homes and Resident #53 always had problems. The Administrator and DON stated Resident #53 told them he fractured his hand at the facility because he hit it on his dresser, but they thought it was possible he self-inflicted the fracture because his goal was to receive money. Interview on 04/10/24 at 10:53 A.M. with the Administrator and Physician #263 revealed Resident #53 told him Resident #45 was in his room uninvited in his wheelchair looking through his belongings and allegedly had Resident #53's money in his hands. Resident #53 reached for his money, ended up on the ground and the injury to his hand happened when Resident #45 was leaving the room he ran over his hand with the wheelchair. Physician #263 stated there were other concerns with Resident #53, but following the episode an x-ray of Resident #53's hand was ordered and did not show a fracture. Two days later Resident #53 went to the ER, and the x-rays at the ER showed he had a fracture. Physician #263 stated he looked at the x-rays taken at the facility and did not see a fracture, and he asked Resident #53 several ways if there was another incident following the incident with Resident #45 when he hit his hand. Resident #53 denied another incident occurred. Physician #263 stated he had a suspicion either something else happened or the injury was self-inflicted and resulted in a fracture. Physician #263 stated he reviewed the hospital notes and there was nothing that led him to believe the injury was self-inflicted except that the location of the fracture is where things tend to break when folks improperly punch something. Physician #263 stated he was not sure the fracture was consistent with Resident #53's hand hitting a dresser and his general demeanor was suspicious. Interview on 04/11/24 at 2:11 P.M. with Resident #53 via a phone call revealed Resident #45 was back in the facility and had already been in a resident room next door to Resident #53 causing problems. Resident #53 stated he heard yelling and screaming and then Resident #45 was removed from the room and redirected to another part of the facility. Resident #53 stated he was going to have to sleep with one eye open until he was discharged from the facility. Review of the facility policy titled Dementia Care undated included it was the policy of the facility to provide the appropriate treatment and services to every resident who displayed signs of, or was diagnosed with dementia, to meet his or her highest practicable physical, mental and psychosocial well-being. Care plan interventions would be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia and dementia-like illnesses. Care and services would be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. If needed, the environment would be modified to accommodate individual resident care needs. This deficiency represents non-compliance investigated under Master Complaint Number OH00152659 and Complaint Number OH00151992.

Based on observation, interview, and record review, the facility failed to ensure physician orders were in place for care or treatment of a peripherally inserted central catheter (PICC) line. This affected one (Resident #11) of one facility-identified residents with a PICC line. The facility census was 65. Findings include: Review of medical record for Resident #11 revealed an admitted [DATE] with diagnoses including congestive heart failure, epilepsy, cerebral infarction, and mixed hyperlipidemia. Review of progress note for Resident #11 dated 02/20/24 revealed the resident was admitted to facility with a PICC line to left arm used to administer medication to treat endocarditis. Review of physician's orders for Resident #11 revealed an order dated 02/21/24 for 100 milliliters (ml) daily of ceftriaxone sodium intravenously for 28 days. Review of the physician's orders revealed there were no orders for care and treatment of the of the PICC line site. Review of the plan of care for Resident #11 initiated 02/20/24 revealed it did not include interventions regarding care and treatment of the resident's PICC line. Observation on 03/04/24 at 10:20 A.M. revealed Resident #11 had an intact, transparent dressing to the PICC line on the left upper arm which was not dated. Interview on 03/04/24 at 10:25 A.M. with Resident #11 confirmed the PICC line dressing was changed at hospital and had not been changed since his admission to the facility. Interview on 03/04/24 at 11:09 A.M. with Licensed Practical Nurse (LPN) #800 confirmed the PICC line dressing to Resident #11's upper arm was not dated, and the nurse was unsure when it had been applied. Interview on 03/04/24 at 11:29 A.M. with LPN #800 confirmed Resident #11 did not have physician orders to change the dressing to the resident's PICC line. LPN #800 confirmed PICC line dressings should be changed every seven days at a minimum. Interview on 03/04/24 at 11:33 A.M. with Director of Nursing (DON) confirmed Resident #11 was admitted with a PICC line and the facility did not have physician's orders regarding care and treatment of the PICC line site. The DON further confirmed they did not know when the dressing to the resident's PICC line had been placed, but she thought it had been present upon Resident #11's admission to the facility on [DATE]. Review of facility policy titled Intravenous Therapy: Preventing Catheter-Related Infections dated October 2010 revealed PICC line dressing should be changed ever seven days or more frequently if needed. This deficiency represents non-compliance investigated under Complaint Number OH00151489.

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure resident safety during a two-staff assisted transfer. This affected one (Resident #30) of three reviewed for safe transfers. The facility census was 65. Findings include: Review of the medical record for Resident #30 revealed admitted [DATE] with diagnoses including convulsions, migraine, fatigue, anxiety disorder, hyperlipidemia, and major depressive disorder. Review of plan of care for Resident #30 dated 05/17/23 revealed the required staff assistance with activities of daily living (ADLs.) Interventions included the resident required weight-bearing assistance including holding, lifting, or supporting the trunk or limbs and required non-weight bearing assistance including steadying, contact guard assistance or guided maneuvering when transferring between surfaces. Review of the therapy progress note for Resident #30 dated 09/13/23 revealed the resident was working with the occupational therapy department at the facility and required moderate assistance to sit and stand during pivot transfers. Review of Minimum Data Set (MDS) quarterly assessment for Resident #30 dated 09/21/23 revealed the resident required extensive two staff assistance for bed mobility and transfers. Review of pain assessment for Resident #30 dated 09/21/23 timed at 2:45 P.M. revealed the resident complained of throbbing pain to the left ankle which the resident rated as five on a scale of one to 10 with 10 being the worst pain. Review of progress note for Resident #30 dated 09/21/23 timed at 2:47 P.M. revealed while the resident was being transferred by staff his left foot shifted causing pain. The nurse called the nurse practitioner (NP) and obtained an order for an x-ray to the left ankle. Review of x-ray report for Resident #30 dated 09/22/23 timed at 1:53 P.M. revealed the x-ray showed a possible fracture to the left ankle of indeterminate age. Review of the change in condition evaluation for Resident #30 dated 09/22/23 timed at 5:42 P.M. revealed the resident facility provided the resident with Tylenol and assisted with leg elevation for pain the left ankle and obtained an order for the resident to be sent to the emergency room for evaluation of a possible fracture. Review of the hospital left foot x-ray for Resident #30 result dated 09/22/23 timed 9:41 P.M. revealed the resident had mild osteopenia and mild soft tissue swelling to the left ankle but there was no acute fracture or dislocation. Review of the progress note for Resident #30 dated 09/23/23 timed at 2:02 A.M. revealed the resident returned from the hospital with a boot and copies of hospital x-rays revealing a sprain to the left ankle but no fracture. Interview on 03/05/24 at 9:26 A.M. with Resident #30 confirmed during a two-person transfer on 09/21/23 his left leg got caught under the bed. Resident #30 reported initially the x-ray taken at the facility indicated he had an ankle fracture, but the hospital x-ray said it was a sprain. Resident #30 confirmed State tested Nursing Assistants (STNAs) #802 and #804 were completing a two-person transfer and one STNA had a bad wrist. Resident #30 confirmed while being transferred his foot got caught under lower frame of bed and he asked the STNAs to stop. Resident #30 confirmed one of the STNAs stopped but the other did not. Interview on 03/05/24 at 10:22 A.M. with STNA #802 confirmed she was not the assigned nurse aide for Resident #30 but was asked on 09/21/23 by STNA #804 to assist in the transfer. STNA #802 confirmed while assisting STNA #804 with a manual transfer, STNA #804's wrist gave out and caused Resident #30 to dip down on left side. STNA #802 confirmed Resident #30's left foot slipped under the bed during transfer. STNA #802 confirmed STNA #804 was wearing a wrist brace at time of incident and Resident #30 verbalized pain when he dipped down on left side. STNA #802 confirmed they re-stabilized Resident #30 to keep him from falling, got him into the bed, and went to get nurse. STNA #802 confirmed when they re-stabilized Resident #30 his foot came out from under bed. Interview on 03/05/24 at 10:56 A.M. with STNA #804 confirmed she was unable to remember the details of the wheelchair to bed transfer for Resident #30 on 09/21/23. STNA #804 confirmed Resident #30's left leg got hit or tangled up during the transfer. STNA #804 confirmed she was Resident #30's assigned nurse aide and had asked for help from STNA #802 for a two-person arm and arm transfer from wheelchair to bed. STNA #804 confirmed Resident #30 told them to stop during the transfer. STNA #804 confirmed she could not recall if she was wearing a wrist brace on 09/21/23. Interview on 03/05/24 at 11:01 A.M. with Certified Occupational Therapist Assistant (COTA) #808 confirmed Resident #30 was a two person transfer at the time of the incident in September 2023. Interview on 03/05/24 at 11:10 A.M. with Licensed Practical Nurse (LPN) #809 confirmed she was notified by an STNA on 09/21/23 that Resident #30 had twisted his ankle and was complaining of pain following a pivot transfer. LPN #809 confirmed she was unable to remember which STNA had notified her, but the resident complained of pain and discomfort to the ankle, and she elevated Resident #30's foot and obtained a physician's order for a left ankle x-ray. Interview on 03/05/24 at 1:06 P.M. with the Director of Nursing (DON) confirmed was notified Resident #30 had complained of ankle pain following a transfer on 09/21/23 but she he was unaware Resident #30's foot had gotten stuck and was unsure if STNA #804 wore a wrist brace. The DON confirmed if a staff member had an injury, they should notify human resources and a two-person arm and arm transfer would be unsafe if a staff member had a physical injury. Interview on 03/05/24 at 1:16 P.M. with Human Resources Director (HRD) #810 confirmed she was unaware of STNA #804 wearing a wrist brace on 09/21/23. Interview on 03/05/24 at 1:53 P.M. with STNA #802 confirmed she and STNA #804 had not been using a gait belt when transferring Resident #30 on 09/21/23. STNA #802 confirmed gait belts were available for use, but she had held onto Resident #30's right arm and the back of his pants during the transfer. Interview on 03/05/24 at 2:46 P.M. with COTA #808 confirmed staff should utilize a gait belt when performing a manual resident transfer. Review of the facility policy titled Safe Lifting and Movement of Residents dated July 2017 revealed in order to protect the safety and well-being of staff and residents and to promote quality care the facility utilized appropriate techniques and devices to lift and move residents. Staff responsible for direct care would be trained in the use of gait belts. This deficiency represents non-compliance investigated under Complaint Number OH00151192.

Based on interview and closed record review, the facility failed to ensure treatments and interventions were in place as ordered to heal pressure areas. Actual Harm occurred to Resident #80 when a treatment to a coccyx wound was not completed as ordered and the wound declined and became larger. This affected one (Resident #80) of four residents reviewed for pressure ulcers. Findings include: Review of the closed record of Resident #80 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was cognitively intact, and required the extensive assistance of one to two staff for all of her activities of daily living. Her skin was intact and she was occasionally incontinent of bowel and bladder. Review of a shower sheet dated 11/28/17 revealed Resident #80's skin was intact with no redness. A shower sheet dated 12/05/17 indicated the resident had redness to the left buttock and her skin was not intact. A nursing note dated 12/06/17 at 8:19 A.M. indicated the resident was found with an impaired skin area to her left lower buttocks. Review of a wound consult note dated 12/06/17 revealed the resident had an unstageable area measuring 5.5 centimeters (cm) by 6.5 cm to her left lower buttock. The area had 30% slough and the depth was unable to be determined. The note indicated the area had previously been a moisture associated skin damaged area that had just opened to the current area. A dressing was ordered to be done daily, to include covering the area with silver alginate and a padded dressing daily. A nursing note dated 12/12/17 at 12:21 P.M. revealed the physician ordered vitamins as supplements, an air mattress and bedrest for several days to allow side to side turning and offloading of the wound area. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed the resident's treatment was completed daily. A note by the wound nurse dated 12/13/17 revealed the area had improved, although another area of excoriation that measured 2.9 cm by 1.8 cm had been observed on the left inner buttock. Review of the wound consult service note dated 12/13/17 indicated the new area was ordered to please cover with an absorbent daily and PRN (as needed). The note indicated may add alginate if drainage noted. Review of the TAR for (MONTH) (YEAR) did not reveal the order for the second wound or the option to add the alginate to the area if drainage was noted. A note from the wound consult service dated 12/20/17 indicated the first area had continued to improve, but the other area had opened more due to the resident having loose stools and refusing to get out of bed. Treatments were continued and a catheter was placed to keep the area dry. The note indicated the dressing as ordered on [DATE] was to be continued, however, the TAR did not contain evidence of the order for the second wound area. A wound consult service note dated 12/27/17 revealed the first area had improved and the dressing (silver alginate) was changed to barrier cream and with an absorbent dressing. The note indicated the second area had opened up more due to moisture, was shallow /denuded and although the area in the center of the wound was improved, other areas were open and beefy red although cleaner than last week. The treatment was to be continued with a note to add the silver alginate if drainage or odor was noted. The TAR for (MONTH) (YEAR) showed the change to the treatment for [REDACTED]. Review of a wound consult service note dated 01/03/18 revealed the first area continued to heal. The second area remained open, moist and poorly blanching with areas of avascular tissue, about the same as last week. The note indicated the resident had a continued declinein medical status , including poor oral intake, increased weakness, more time in her bed and a urinary tract infection. The orders were to be continued. Review of the TAR for (MONTH) (YEAR) did not list an absorbent padding to the second area, or the option to add the silver alginate if needed for drainage or odor. A note from the wound consult service dated 01/10/18 revealed the left lower buttock area had continued to improve, however the second area, now classified as on the coccyx, had declined and was covered with slough and necrotic tissue. It measured 9.1 cm by 7.5 cm and had an odor. A debridement was performed to removed the necrotic area and a new treatment was ordered to pack the wound with Dakin soaked gauze, and change the dressing daily. This dressing change was recorded on the TAR for (MONTH) (YEAR). An interview with the Director of Nursing (DON) on 03/15/18 at 4:10 P.M. verified the TARs for (MONTH) (YEAR) and (MONTH) (YEAR) did not have evidence the wound to the coccyx, discovered on 12/13/17 with treatment orders on that date, had treatments recorded as completed from 12/13/17 through 01/10/18, when the wound had declined and a new treatment order was put in place. A nursing note dated 01/15/18 at 2:24 A.M. revealed a dressing change was completed on that shift to Resident #80's sacral area wound with a foul smell. The note indicated a wound culture was obtained and sent to the lab. Review of the laboratory result from the wound culture dated 01/15/18 revealed the results were called to a nurse at the facility on 01/15/18 at 6:49 P.M., indicating there had been a problem with sample integrity and the nurse was notified to recollect. An interview with Registered Nurse (RN) #400 on 03/15/18 at 4:00 P.M. by phone revealed he was the nurse who documented the note on 01/15/18 regarding the foul smell of the wound. He verified the wound smelled bad and was black. He stated he obtained the wound culture and sent it to the lab early in the morning. He stated he did not call a physician regarding his observations, but said he did pass on to the staff on the next shift that he had sent a wound culture. He stated he did not feel he needed a physician order [REDACTED]. An interview on 03/15/18 at 2:00 P.M., with RN #405 who received the phone call from the lab about the results of the wound culture, revealed she notified the next shift about the need to recollect the wound culture. She stated since the wound dressing was not done on her shift, she did not collect a new wound culture. The DON was interviewed on 03/14/18 at 2:30 P.M. and verified Resident #80's coccyx wound had been noted as having an odor by RN #400 on 01/15/18 with a wound culture sent to the lab. She verified the wound culture was not completed with a recommendation to collect another culture for testing, and another culture was not obtained. This deficiency substantiates Complaint Number OH 750.

Based on observation, interview and record review the facility failed to implement interventions to prevent development and deterioration of a pressure wound. This affected one resident (Resident #71) of three residents reviewed for pressure wounds. Harm occurred when Resident #71's incontinence associated [MEDICAL CONDITION] deteriorated to a State III pressure wound (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.). The facility identified six residents with pressure wounds. Findings Include: A review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden (pressure ulcer risk) assessment was completed on 10/29/15 and scored the resident's risk factors at 10, defined as high risk. A nutritional assessment dated [DATE] indicated the resident was receiving adequate nutrition through her tube feeding. A significant change Minimum Data Set 3.0 ((MDS) dated [DATE] identified Resident #71 as having functional limitations on both sides of upper and lower extremities and total dependence for bed mobility and transfers. The MDS assessment was coded that Resident #71 had no turning/repositioning program in place. An interview with Licensed Practical Nurse (LPN) #225 on 04/11/16 at 1:48 P.M. revealed Resident #71 had a Stage III pressure wound that developed while she resided at the facility. Observation of the wound and dressing change on 04/13/16 at 9:00 A.M. revealed the resident had an open area on the sacrum that measured 1.2 centimeter (cm) x 2 cm x 1 cm. The wound was deep red in color. A red/yellow, moist granulating area was present positioned at 5:00 on the surrounding tissue. An interview with LPN #225 during the dressing change revealed the area had been chemically debrided and since 03/02/16 was to be packed with calcium alginate (calcium and sodium fibers made from seaweed spun into rope or flat dressing form) and covered with a dressing. She stated the wound had become deeper since the previous weekly measurement and the skin around the wound had reopened since then. Review of the physician orders, medication and treatment records for December, 2015 revealed documented preventive measures included a pressure reducing mattress, pressure reducing cushion in the chair and [MEDICATION NAME] ointment to the buttocks, perineal area and groin every shift and a rolled washcloth was to be placed in Resident # 71's right hand to prevent contracture and laceration due to fingernails. Review of the December, 2015 treatment administration record revealed nine shifts during the month where these interventions were not documented as administered. A nurses note dated 12/18/16 revealed the nursing assistant informed the nurses of an open area on the resident's sacrum. A weekly wound documentation dated 12/23/16 identified the area on the coccyx as incontinence associated [MEDICAL CONDITION]. The size was 1.0 cm x 2.0 cm x 0.1 cm. A physician's order was written on 12/19/16 to cleanse the wound, pat dry and apply calcium alginate and cover with a dry clean dressing and change three times per week and as needed. No other interventions were put in place at that time. A weekly wound documentation dated 01/06/16 stated the wound was not healing and measured 3 cm x 2 cm x 0.1 cm. A weekly wound documentation dated 1/20/16 showed the wound continued to decline and was classified as an in- house pressure area Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.). The wound measured 2.2 cm x 2.2 cm x 0.1 cm. A weekly wound documentation dated 02/17/16 identified the wound as 2.0 cm x 2.3 cm and having slough (dead skin tissue that may have a yellow or white appearance) causing it to be classified as unstageable. The treatment was changed to include Santyl ointment ([MEDICATION NAME] agent) and calcium alginate with a dressing, scheduled to be changed every night on night shift and as needed. Weekly wound documentation dated 03/02/16 revealed the wound measured 1.5 cm x 1.5 cm x 0.1 cm and the wound had progressed to a Stage III. Weekly wound documentation dated 04/13/16 revealed the wound had declined with undermining between 1.0 cm to 2.2 cm and open area with slough had developed. The wound care doctor was contacted and reduced the frequency of dressing changes. An interview on 04/14/16 at 11:42 A.M. with the Director of Nursing (DON) revealed the wound had been classified by the wound care physician as a pressure wound due to the location of the wound and that it had not healed as incontinence associated [MEDICAL CONDITION] would have been expected to by that time. She identified the following interventions had been put in place for Resident #71: the pressure reducing mattress was replaced by an air mattress on 02/19/16, vitamin supplements were introduced on 02/20/16 and a protein supplement was ordered on [DATE] (all implemented after the wound was classifed as unstageable). The DON stated she checked the orders to verify interventions that had been initiated for Resident #71. Neither a turning and positioning schedule nor a limited get up schedule with naps were identified in the interventions. She stated a tilt in space chair with a built in cushion was ordered on [DATE] which was two weeks after the wound had progressed to Stage III. The physician's orders did not include any turning and repositioning program from 12/06/15 to 04/14/16. Review of the Care Kardex for Resident #71 revealed it did not include a turning and repositioning program for the resident to reduce pressure and prevent skin breakdown. Review of task documentation by the state tested nursing assistants (STNAs) revealed no reference to a turning or repositioning schedule to reduce pressure on the sacral wound. An order dated 09/18/15 indicated the resident could be seen by the wound care specialist. The facility provided no physician's progress notes that addressed or acknowledged the resident's wound. A progress note from the attending physician dated 02/17/16 only indicated the resident had no [MEDICAL CONDITION] or rashes. An observation on 04/14/16 at 11:08 A.M. revealed the resident was on her back in bed and did not have ordered elbow protectors or a handroll in place to her right hand. An interview with LPN #225 at that time verified the observation. An observation of the wheelchair used for the resident revealed a hard ridge could be felt toward the back of the seat. An immediate interview with LPN #225 who, after feeling the seat of the chair, stated there was not a whole lot of cushion on the seat. An interview with LPN #226 on 04/14/16 at 11:48 A.M. confirmed Resident #71 was unable to move on her own in bed. An interview with LPN #226 on 04/14/16 at 12:10 P.M. revealed the wound doctor did not leave progress notes when he visited. The wound nurse documented the measurements in the weekly wound documentation. An observation on 04/14/16 at 12:52 P.M. revealed the resident was on her back in bed, had elbow protectors on and was without a handroll to the right hand. An interview with LPN # 226 verified Resident #71 was on her back in bed without a handroll in place. An interview with STNA # 223 on 04/14/16 at 12:52 P.M. revealed the facility standard turning program was turning and repositioning every two hours. An interview with LPN #226 on 04/14/16 12:53 P.M. revealed the facility standard turning program was turning and repositioning every two hours. On 04/14/16 at 1:08 P.M. the DON provided a numbered circle that identified back, left and right when asked for the facility standard turning and positioning protocol. She stated I just give them a clock. The numbered circle indicated the resident should be on the left side from 10:00 to 12:00. An observation of the resident on 04/14/16 at 1:30 P.M. revealed the resident was on her back in bed. An interview with STNA #223 on 04/14/16 at 1:32 P.M. verified the resident was on her back. An occupational Therapy screen on 04/14/16 generated recommendations of implementing a soft foam cushion to maintain skin integrity and a two hour get up schedule. An interview with the DON on 04/14/16 at 2:00 P.M. revealed therapy had evaluated the resident's chair on 04/14/16 and was going to replace the chair cushion. An observation on 04/14/16 at 6:47 P.M. revealed the resident was lying flat in bed and flat on her back with no pillows for positioning. An interview with LPN # 229 at 6:48 P.M. verified the resident was on her back with the head of the bed flat. An additional interview with LPN #225 and Registered Nurse (RN) #228 on 04/15/16 at 9:25 A.M. revealed the facility felt they did not need any documentation of the wound doctor's visits since the wound nurse documented the measurements in the chart weekly. RN # 228 stated the nurse consulted him by phone if needed and described the wound and that any documentation he had was kept at this office. An interview with RN #228 and LPN #225 on 04/15/16 at 11:15 A.M. verified there were blanks spaces in the documentation of [MEDICATION NAME] administration, use of the pressure relieving mattress and cushion on the treatment administration record for December, 2015 for Resident #71 where signatures were missing. They said usually there would be a code that identified why the space was left blank but they did not see any codes and could not say why the spaces were blank. An interview with RN # 228 on 04/15/16 at 11:38 A.M. verified the resident was observed on her back on 04/14/16. RN #228 said she had found positioning the resident challenging for the staff. She stated Resident #71 did not actively move.

Based on observation, record review, and staff interview, the facility failed to ensure interventions were in place to prevent a fall. This resulted in actual harm for one resident (Resident #29) who fell , sustained multiple bruising, head trauma and required treatment in the emergency room . The deficient practice affected two (Resident #29 and Resident #50) residents reviewed for falls. The facility census was 74. Findings included: 1. Resident #29 was re-admitted to the facility on [DATE]. Review of the medical record revealed a medical history including dementia, depression and anxiety. On 01/21/14 at 11:02 AM, licensed practical nurse (LPN) #14 was interviewed. She reported Resident #29 sustained a fall with injury in the past 30 days. On 01/21/14 at 11:09 A.M., Resident #29 was observed in a broda chair in the dining room. She presented with two black eyes and a bruised, raised abrasion to the center of the her forehead. Review of the nurses notes dated 01/16/14 revealed the resident was found on the floor at 6:00 A.M., lying in the center of the floor on her right side. Vitals were assessed. Bruising was noted to the right hip and right elbow both purple in color; redness to the right shoulder; bruise to right eye, and hematoma to the forehead. Resident was unable to express pain. The physician ordered the resident be sent out to the hospital 911. Review of the falls risk care plan dated 05/23/13 and current through 05/17/14 revealed the resident was ordered a low bed with the left side of the bed against the wall per her preference; mat to floor at the right side of the bed; an alarm to broad chair and / bed; and antitipers to the front and back of the wheelchair. The falls risk assessment dated [DATE] assessed Resident #29 required total care, was disoriented, and had three or more falls in the past three months. Review of last three fall incident reports revealed the following: Resident #29 had a fall on 10/26/13. She was found on the floor mat next to her bed without injury. Current interventions were appropriate and in place. No new interventions were implemented. Resident #29 had a fall on 11/19/13. She was found on the floor in the dining room / television area. Chair alarm was sounding and she was assessed to be uninjured. Current interventions were appropriate and in place. No new interventions were implemented. Resident #29 had a fall on 01/16/14. She was found on the floor in her room, lying in the center of the floor, lying on her right side. Review of the investigation follow-up dated 01/16/14 revealed Resident #29 had been dressed at 5:30 A.M. and placed in the wrong bed, did not have any alarms on, and did not have any mats to the floor. She sustained bruising to her hip, elbow, eyes, and a raised forehead bruise and abrasion. The director of nursing (DON) was interviewed on 01/23/14 at 1:00 P.M. She verified that the facility staff failed to have ordered interventions in place for Resident #29 and she suffered multiple body bruises and head trauma at the time of the fall. 2. Review of the medical record revealed Resident #50 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's fall risk assessments 07/10/13 through 01/15/14 indicated she was at high risk for falls. She had current fall interventions including low bed with mat to floor on left side and against the wall on right side, pressure sensitive alarms to bed and wheelchair, bathroom door alarm, motion sensor alarm inside room door, nonskid carpet in bathroom and nonskid pad to wheelchair seat. Review of interdisciplinary progress notes revealed Resident #50 had falls on 10/08/13, 10/15/13, 11/29/13, 12/14/13, 12/18/13, 12/31/13 and 01/06/14. On 01/22/14 at 2:45 P.M., Resident #50 was observed in her room, lying in a low bed. The low bed was positioned against the wall on right side and had a mat on the floor to the left side. Pressure sensitive alarming devices were on the bed and wheelchair, and an alarm visible to exterior bathroom door. Upon entering the resident's room there was no audible sound. Review of the facility's fall investigations and interview with the director of nursing (DON) on 01/23/14 at 10:10 A.M. revealed on 10/08/13 the investigation did not indicate whether the bed and bathroom door alarms sounded. The DON agreed and indicated the alarms were not sounding. Following the 10/14/13 and 11/29/13 falls, the state tested nursing assistants (STNA's) were inserviced to ensure Resident #50's motion sensor door alarm was set to alarm rather than chime. The DON indicated when the door alarm was set to chime, it chimed once but when set to alarm, it sounded for a longer period of time. Review of the 12/31/13 investigation revealed Resident #50 was left unattended in a wheelchair in her room at 5:00 A.M. The STNA was counseled. Review of the 01/06/14 investigation indicated Resident #50 was found on the floor mat next to her bed. She was last seen in bed. The DON agreed the investigation did not indicate whether the bed alarm was sounding. She indicated the resident frequently detached the wire from the alarming device. On 01/23/14 at 10:50 A.M., a tour of Resident #50's room was completed accompanied by Licensed Practical Nurse (LPN) #24 (the restorative nurse). Upon entering the room, the motion sensor alarm chimed once. The wire to the resident's bed alarm was found detached from the alarming device. There was no audible sound. The LPN reattached the wire. The alarm immediately sounded. She silenced the alarm, detached the wire from the alarming device, and again the alarm sounded. LPN #24 agreed if Resident #50 detached the wire from the alarming device, it should have sounded. She confirmed the door alarm should have buzzed rather than chimed when we entered the resident's room.

Based on observation, interview and record review, the facility failed to provide appropriate supervision and assistance during a transfer. This affected one resident (#1) who fell and sustained multiple leg fractures, out of three residents reviewed for falls. Findings include: Resident #1 was [AGE] years old and had been admitted to the facility in 2006. She had [DIAGNOSES REDACTED]. The resident was being provided Hospice end of life care services. The resident was totally dependant on staff for her activities of daily living. The care plan indicated Resident #1 was at risk for falls. The care plan noted she was non ambulatory and required a mechanical lift (Hoyer) transfer to and from her Broda-style chair. The care plan noted the resident had generalized weakness and kept her arms and legs tightened against her body. The resident was resistive to care at times and had severe cognitive impairment. Resident #1's care plan interventions included a plan regarding the resident's agitation and resistance to care. The plan was to leave her in a safe environment and re-approach at a later time when the resident was calm. A nurses note dated 03/13/12 at 1:20 P.M. indicated the Hospice nurse had reported Resident #1 had fallen during the Hoyer lift transfer. The Hospice nurse reported she and State tested Nurse Aide (STNA) #2 had transferred the resident from her Broda chair to bed, the resident became combative and had kicked at the nurse. The Hoyer pad strap came off. The resident fell between the chair and the wall hitting her head. Resident #1 was hospitalized and treated for [REDACTED]. On 03/28/12 at 11:00 A.M. the Hospice nurse (RN #1) and director of nursing (DON) were interviewed. RN #1 indicated on 03/13/12 she had seen Resident #1 about one hour before the fall. The resident was agitated and told the Hospice nurse to "kiss her ass". The nurse indicated when she went to check on the resident later, she found STNA #2 in the room with the resident preparing to transfer her using the Hoyer lift. The hospice nurse offered to be the "spotter" for the aide and assist in the transfer. She said the STNA had lifted the resident only a few inches when the resident kicked the nurse in the torso causing her to step back. She said the Hoyer pad's left shoulder corner then became disconnected from the Hoyer and the resident slid out of the pad and down the wall. The DON indicated prior to the fall the resident had been agitated in the dining room. The resident had been trying to hit the STNA with a spoon during the meal. The Hospice nurse indicated she had not been aware of the spoon incident and noted the resident looked calm when she found STNA #2 preparing to transfer the resident. A review of the facility investigation report of Resident #1's fall revealed the Hoyer device and pad were checked by the maintenance department and found to be in good working order. An interview with the DON on 03/27/12 at 11:30 A.M. revealed she had the actual Hoyer pad involved in the fall. The pad was observed to be in good repair with intact end loops. The DON indicated she had tried to duplicate the incident and had more than one staff get into the Hoyer and try to get the loops to "disconnect" from the Hoyer. She indicated she was not able to get the Hoyer pad to disconnect. She indicated because of this she doubted STNA #2 had attached the Hoyer pad properly. She indicated STNA #2 was terminated the day after the fall. This deficiency substantiates Complaint Number OH 896.