Every finding on record at Heritage Healthcare of Lyndhurst

Based on medical record review and interview, the facility failed to accurately track bowel movements and implement related physician orders for bowel regimen. This affected one resident (Resident #2) of one resident reviewed for bowel regimen. The facility census was 97.Findings include:Review of the medical record for Resident #2 revealed an admission date of 09/14/25 and discharge to the hospital on hospital 07/29/26. Diagnoses included unspecified dementia, altered mental status, chronic diastolic heart failure, dysphagia, neuromuscular dysfunction of bladder, and obstructive and reflux uropathy. Review of the plan of care initiated on 01/22/26 revealed Resident #2 had episodes of bowel incontinence. Intervention included to monitor for no bowel movement (BM) in three days.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had intact cognition. Review of Resident #2's physician orders revealed orders dated 06/22/26 to 07/30/26 for docusate sodium oral capsule 100 milligrams (mg) twice daily for constipation and polyethylene glycol 3350 oral packet 17 grams by mouth twice daily for constipation, and orders dated 11/26/25 to 07/30/26 for milk of magnesia (MOM) suspension 1200 mg/15 milliliters (ml) give 30 ml every 24 hours as needed for constipation if no BM in three days, bisacodyl suppository 10 mg rectally every 24 hours as needed for constipation daily if no results from MOM, and fleet enema 7-19 grams/118 ml one unit rectally every 24 hours as needed for constipation if no results from laxative suppository. Review of Resident #2's Treatment Administration Record (TAR) for July 2026 revealed Resident #2 had no bowel movements from 07/01/26 to 07/04/26 (four days), from 07/07/26 to 07/17/26 (11 days), and from 07/20/26 to 07/24/26 (five days). Review of Resident #2's Medication Administration Record (MAR) for July 2026 revealedthe as needed medications, MOM, bisacodyl suppository, and fleet enema, ordered for constipation were not administered. Review of the nurse practitioner (NP) note dated 07/29/26 at 10:15 A.M. revealed nursing reported Resident #2 was more lethargic and began to vomit yellow emesis. The resident did not open eyes, follow commands, and blood pressure was below normal reading 80 systolic and 40 diastolic. Resident #2's abdomen was soft, not tender, and not distended with positive bowel sounds but the resident's urine had slight hematuria (blood in urine). Resident #2 was transferred to the hospital via emergency services.Review of Resident #2's hospital After Visit Summary for hospitalization from 07/29/26 to 08/03/26 revealed the resident was admitted after an unresponsive episode secondary to urinary tract infection and pneumonia. Care was managed by gastroenterology and infectious disease. Gastroenterology was consulted for nausea and vomiting secondary to fecal impaction (a large, hard mass of dried stool stuck in the rectum or lower colon and cannot be pushed out naturally) and urinary tract infection.Interview on 08/13/26 at 1:46 P.M. with Director of Nursing (DON) stated the electronic medical record dashboard was to alert if a resident had not had a bowel movement for three days. Interview on 08/13/26 at 2:43 P.M. with Licensed Practical Nurse (LPN) #331 revealed the nursing assistants documented bowel movements and then let nurses know if there was no bowel movement. Resident #2 received routine laxatives daily and the nurses were alerted on the computer when residents had no bowel movement in three days. LPN #331 denied knowledge of Resident #2 having BM issues. Interview on 08/17/26 at 8:51 A.M. with DON verified there was no documentation of Resident #2 having bowel movements from 07/01/26 to 07/04/26 (four days), from 07/07/26 to 07/17/26 (11 days), and from 07/20/26 to 07/24/26 (five days), and confirmed the physician ordered interventions, MOM, bisacodyl suppository and fleet enema, were not administered when documented BMs exceeded three days.

Based on observation, review of the food temperature log, review of food committee meeting minutes, review of the Food Drug Administration (FDA) Food Code 2022, policy review, and interview, the facility failed to serve food at a safe, appetizing and palatable temperature. This affected all residents who received meals from the kitchen (except Resident #60 and Resident #90 who were ordered nothing by mouth (NPO). The census was 94. Findings include: Observation on 07/27/26 at 4:50 P.M. revealed Italian cold cut subs and pasta salad were in separate metal pans and sitting on ice within the steam table. The subs were stacked on top of each other, three subs deep. At 5:00 P.M., [NAME] #100 took the temperature of the following foods: pasta salad was 43.3 degrees Fahrenheit (F), Italian cold cut sub was 60.8 degrees F (which was a sub taken from the bottom of the pan, closest to the ice) and cheesecake was 60.4 degrees F (which was in individual four-ounce cups sitting on each individual meal tray on the tray line). [NAME] #100 did not take the food temperature of the pureed sub or the mechanical soft sub at that time which were also in a metal pans sitting on ice on the steam table. Interview, during the observation, with [NAME] #100 revealed he prepared the subs and the pasta salad that day around 2:00 P.M. then placed the subs and pasta salad into the refrigerator. [NAME] #100 also revealed he removed the subs and pasta salad from the refrigerator and placed the pan of subs and the pan of pasta salad on ice within the steam table at 4:20 P.M. that day. In addition, [NAME] #100 stated he prepared the cheesecake at 3:30 P.M. that day then placed it in the refrigerator, then the dietary aide dished the cheesecake into individual bowls. Observation on 07/27/26 at 5:05 P.M. revealed [NAME] #100 began serving the dinner meal from the steam table. Interview on 07/27/26 at 5:08 P.M. with Dietary Aide (DA) #101 revealed DA #101 dished out some of the cheesecake into individual cups approximately 45 minutes ago then placed the individual cheesecake cups on to the individual meal trays [not refrigerated]. Observation on 07/27/26 at 5:15 P.M revealed Dietary Manager (DM) #102 arrived to the kitchen. At 5:16 P.M. DM #102 took temperatures of the following foods (after stirring the food around in the pan) which were in separate metal pans on ice within the steamtable: mechanical soft meat was 45.5 degrees F and pureed meat was 50 degrees F. Interview, during the observation, with [NAME] #100 (with DM #102 present) revealed [NAME] #100 removed the mechanical soft meat from the refrigerator at the same time he removed the Italian cold cut sub and pasta salad [at 4:20 P.M.] and removed the pureed meat from the refrigerator at 4:30 P.M. then placed the mechanical soft meat and pureed meat on steam table. [NAME] #100 also verified he did not take the temperature of the mechanical meat and pureed meat prior to starting tray line service. Interview on 07/27/26 at 5:20 P.M. with DM #102 verified cold food should be held at 41 degrees F or below and verified the Italian cold cut sub, cheesecake, mechanical soft meat and pureed meat temperatures were not at the proper temperature. DM #102 also verified [NAME] #100 should have taken the mechanical soft meat and pureed meat prior to the beginning of tray line service. Observation on 07/27/26 at 5:26 P.M. revealed [NAME] #100 served the test tray and placed it on the meal cart for the Critical Recovery Unit (CRU). At 5:28 P.M., the meal cart arrived on the CRU unit. At 5:33 P.M., Certified Nurse Aide (CNA) #103 began passing meal trays to residents. At 5:40 P.M., Licensed Practical Nurse (LPN) #104 assisted CNA #103 with passing meal trays to residents. At 5:42 P.M. the Director of Nursing assisted with passing meal trays to residents. At 5:45 P.M., DM #102 took the temperature of the food on the test tray: Italian cold cut sub was 64.2 degrees F, pasta salad was 70 degrees F, and cheesecake was 65.1 degrees F. The surveyor tasted the Italian cold cut meat and cheese, the pasta salad and the cheesecake which all tasted at room temperature. Another interview, during the observation, with DM #102 verified cold food should be held at or below 41 degrees F. Observation on 07/28/26 at 8:42 A.M. revealed Resident #67 was feeding himself breakfast within his room. Interview, during the observation, with Resident #67 revealed the food was not always served at the appropriate temperature such as hot food was served cold and cold food was served warm. Observation on 07/28/26 at 8:45 A.M. revealed Resident #20 was sitting in her electric wheelchair in her room, feeding herself breakfast. Interview, during the observation, with Resident #20 revealed the food was so-so and sometimes hot food was served cold and cold food was served warm. Interview on 07/28/26 at 9:40 A.M. with LPN #108 revealed Resident #51 complained that the hot food was served cold. Review of the food temperature log from the Spring Menu 2026, Day Two revealed the following food and temperatures: Italian cold cut sub 60.8 degrees F, ground cold cut was 45.5 degrees F, pureed meat 50.0 degrees F, pasta salad was 43.3 degrees F and cheesecake 60.4 degrees F. Review of the facility's undated Cold Food policy revealed cold food policies and procedures require keeping perishable items at 41 degrees F or below. Review of the FDA Food Code 2022 from Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding revealed bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth. Review of the food committee meeting minutes from April 2026 revealed, are you receiving your meals timely and at a good temperature most of the time? The answer was: depending on the aides. Review of the food committee meeting minutes from June 2026 revealed, , are you receiving your meals timely and at a good temperature most of the time? The answer was: depends on the aides. Review of the food committee meeting minutes from July 2026 revealed, are you receiving your meals timely and at a good temperature most of the time? The answer was: yes.depending on aides' food sometimes comes slower. This deficiency represents non-compliance investigated under Complaint Number 3068890.

Based on observation, interview, medical record review, review of hospice notes, and facility policy review, the facility failed to ensure care and services were provided to facilitate resident preference, comfort and hydration. Actual Harm occurred on 03/24/25 at 10:04 A.M. when Resident #58, a resident who was receiving end-of-life hospice care who staff believed was actively dying, was left alone behind a closed door, thirsty, in severe pain, and unable to call for assistance. Resident #58 was dependent on all aspects of care and unable to call for help, was denied hydration measures, and had minimal pain control for 2 days. This affected one resident (#58) of three residents reviewed for quality of care and treatment. The facility census was 81. Findings include Review of Resident #58's medical record revealed an admitted [DATE]. Medical diagnoses included amyotrophic lateral sclerosis (ALS) (a progressive disease that specifically affects motor neurons responsible for controlling muscle movement, leading to muscle weakness and paralysis), chronic pain syndrome, weakness, lack of coordination, and a need for assistance with personal care. Review of Resident #58's care plan dated 02/22/24 revealed the resident was at risk for altered nutrition/hydration status related to ALS. Interventions included administering medications as ordered, providing total assistance with meals and snacks, encouraging consumption of fluids provided, and monitoring for signs and symptoms of dehydration. An additional care plan focus dated 12/04/24 revealed the resident required hospice care due to end of life processes, with a terminal diagnosis of ALS. Listed interventions included administering medications for comfort prior to activity or care and to keep the resident comfortable to the extent possible. An additional care plan focus dated 02/21/25 revealed Resident #58 was receiving opioid pain medication for pain control. Interventions included administering medication as ordered, assessing pain type, location and characteristics before and after administration of as-needed pain medication, and encourage fluid intake. An additional intervention included to monitor symptoms of a potential overdose including constricted pupils, loss of consciousness, shallow breathing, respiratory depression, limp body, or pale, cold, or clammy skin. Review of the Hospice Skilled Nursing Communication note dated 01/16/25 revealed Resident #58 needed a blow call light (a call light that can be activated by blowing air into a small tube) due to a decreased range of motion to the resident's left hand. Review of Resident #58's Minimum Data Set (MDS) annual assessment dated [DATE] revealed the resident was cognitively intact. Resident #58 had impairment on both sides of the upper and lower extremities and was dependent on staff for all activities of daily living, including eating. Resident #58's daily preferences, including having snacks available between meals, were listed as very important to her. Resident #58 was noted to have anxiety and depression and received scheduled and as-needed (PRN) pain medication. Resident #58 was noted to receive hospice services and to have a disease that may result in a life expectancy of less than six months. Review of Resident #58's physician's orders revealed an order dated 02/27/25 which stated the resident was admitted to hospice services with a diagnosis of ALS. Review of Resident #58's physician's orders revealed on 03/22/25, all of Resident #58's routine scheduled medications, including Robaxin (a muscle relaxer used to treat painful muscle spasms) 750 milligram (mg) tablet twice daily, Morphine Sulfate Extended Release (ER) (an opioid analgesic used to treat severe pain) 30 mg every eight hours routinely, and Gabapentin (an anticonvulsant and pain adjunct commonly used to treat nerve pain) 900 mg four times daily routinely, were discontinued. Resident #58 had as-needed Morphine Sulfate 20 mg/milliliter (ml) 1 ml ordered as needed for pain related to ALS. There was no documented evidence of a physician order for Resident #58 to have nothing by mouth (NPO) or any orders related to limiting hydration. Review of the Hospice Skilled Nursing Communication note dated 03/22/25, completed by Hospice Registered Nurse (RN) #801, revealed to discontinue all medications, except comfort medications, as Resident #58 was actively transitioning (dying). Review of Resident #58's Medication Administration Record (MAR) for March 2025 reflected all routine medications, including scheduled Robaxin, Morphine Sulfate, and Gabapentin, had been discontinued on 03/22/25. The MAR noted only one as-needed dose of Morphine Sulfate 1 ml had been administered (on 03/23/25 at 6:30 P.M.) since the routine medications had been discontinued. The MAR recorded the effectiveness of the pain medication dose as a U, noting it was unknown if the medication had been effective to treat Resident #58's pain. Review of Resident #58's nursing progress notes revealed a note dated 03/23/25 at 8:01 P.M., authored by RN #323, which revealed Resident #58 remained more alert throughout the shift, discussed with staff and family members. The note stated Resident #58 was able to express her needs. Resident #58 had refused all meals but tolerated sips of fluid well. Observation on 03/24/25 at 10:04 A.M. revealed the door to Resident #58's room was closed. A sign was posted next to Resident #58's door which stated, please don't close my door unless asked. Upon knocking and opening the door, Resident #58 was observed lying in bed, with both of her arms positioned to her side, and her head lifted off the bed. Her eyes were wide as she looked towards the doorway. Resident #58 repeatedly mouthed the words help me, help me. Resident #58 was observed with tears in her eyes, was able to mouth words clearly, but had no sound projection. Resident #58 stated she was so thirsty and requested a drink. Resident #58's lips were very dry, and her lips stuck together as she mouthed her words. Three Styrofoam cups of water and a half-full bottle of soda was on the resident's bedside table. Resident #58 shared she was unable to move her arms or legs due to ALS. Resident #58 additionally stated that she was unable to use her call light to summon staff assistance, as she also could not move her hands. Further review revealed Resident #58 had a push-button call light next to her left hand. When asked, Resident #57 was unable to move her hand to activate the call light button. Resident #58 continued to mouth help me, help me, and the surveyor exited the room to summon staff assistance. Observation on 03/24/25 at 10:06 A.M. revealed Certified Nursing Assistant (CNA) #265 walked up the hall. CNA #265 was informed Resident #58 requested help and was thirsty. CNA #265 stated she is actively dying; she can't have anything to drink as she was ordered nothing by mouth (NPO). CNA #265 entered Resident #58's room and confirmed there were three cups of water and a half-full bottle of soda on the bedside table and confirmed the sign next to the door. CNA turned to leave Resident #58's room, who mouthed the words don't close, please don't close, referring to the door. CNA #265 confirmed the resident was unable to use her pushed button call light and walked away. The surveyor exited Resident #58's room to find the resident's assigned nurse. A few minutes later, CNA #265 again walked up the hall and stated Resident #58's nurse was on a break, but the Director of Nursing (DON) had stated she could give Resident #58 a drink. CNA #265 shared that her shift started at 7:00 A.M. and she had not yet been into Resident #58's room to provide care nor had she offered the resident anything as she was told Resident #58 was NPO. CNA #265 entered Resident #58's room, where Resident #58 stated she had not had anything to drink since the previous day. Resident #58 stated she had asked staff multiple times, but had been told no, she was not allowed to have anything to drink. Resident #58 additionally stated she had pain everywhere and rated her pain at a 10 on a scale of 1-10, with 10 being the worst pain she could imagine. Interview on 03/24/25 at 10:10 A.M. with RN #262 revealed she was Resident #58's primary nurse. RN #262 was informed Resident #58's pain level was a 10 and her pain was all over. RN #262 stated she had other tasks, including administering another resident's tube feeding, before she could provide any pain medication to Resident #58. Observation on 03/24/25 at 10:13 A.M. revealed RN #262 returned to the surveyor and stated she would address Resident #58's pain. RN #262 revealed Resident #58 was actively dying and was NPO status over the weekend because of her medical diagnosis. RN #262 stated hospice made the Resident #58 NPO status over the weekend as she had been lethargic and it was a bad weekend for the resident. RN #262 confirmed Resident #58 was alert and oriented and revealed she could have pain medications when needed. RN #262 approached the medication card to prepare the resident's dose of pain medication. Observation on 03/24/25 at 10:37 A.M. revealed Hospice RN #801 walked up the hall. Hospice RN #801 confirmed she was Resident #58's hospice nurse and stated the resident was actively transitioning. Hospice RN #801 confirmed she had visited Resident #58 on 03/22/25, at which time Resident #58 was comatose. Hospice RN #801 discontinued all of Resident #58's routine medications, including all routine pain medications, due to the resident's change in condition. Hospice RN #801 revealed there was never a written order for Resident #58 to be NPO. When asked if she had instructed the staff caring for Resident #58 to treat the resident as NPO, Hospice Nurse #801 repeated there was never a hospice-initiated order for Resident #58 to be NPO. Upon entering Resident #58's room, the door to the resident's room was again observed to be closed. Resident #58 remained in bed alone behind the closed door and unable to use her call light or make any purposeful movement. Further review of Resident #58's medical record revealed no evidence or documentation Resident #58's physician had been notified of Resident #58's decline on 03/22/25 or the staff withholding fluids. Interview on 04/01/25 at 2:43 P.M. with Resident #58 revealed she still had a push button call light she was unable to use. Resident #58 stated she had been receiving some fluids over the last few days and was thankful. Resident #58 stated hospice was still working on getting her a blow call light. During the interview, Resident #58's voice was noted to have sound projection and her voice sounded stronger than during prior interviews on 03/24/25. Interview on 04/02/25 at 11:49 A.M. with the Administrator confirmed she was aware Resident #58 needed a blow call light. The Administrator confirmed staff discussed it, but she did not remember the outcome. Interview on 04/02/25 at 12:35 P.M. with the DON confirmed there was no documentation that Resident #58's physician had been notified of Resident #58's change in condition or the withholding of fluids. The DON revealed the staff were only notifying the contracted hospice provider and stated the resident's physician should be notified with any change in condition, even when the resident was receiving hospice services. Review of the policy Hydration - Clinical Protocol revised September 2017 revealed the staff, with the physician's input, will identify and report to the physician individuals with signs and symptoms (for example, delirium, lethargy, increased thirst) or lab test results that may reflect fluid and electrolyte imbalance. The physician and staff will identify significant risks for subsequent fluid and electrolyte imbalance, to include, for example, individuals who are not eating or drinking well. The physician will manage significant fluid and electrolyte imbalance, and associated risks, appropriately and in a timely manner. The staff will provide supportive measures such as supplemental fluids where indicated. Review of the policy Pain - Clinical Protocol revised March 2018 revealed with input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. The nursing staff assess each individual for pain upon admission to the facility, at quarterly review, whenever there is a significant change in condition, and when there is a new onset of pain or worsening of existing pain. The physician will order pharmacologic interventions to address the individual's pain. Review of the policy Change in Resident's Condition or Status revised February 2021 revealed the facility promptly notifies the resident's physician when there has been changes in the resident's medical/mental condition and/or status, or there is a need to alter the resident's medical treatment significantly. This deficiency represents non-compliance investigated under Complaint Numbers OH00163018 and OH00162481

Based on observations, interviews, and review of the facility policy and procedures the facility failed to ensure proper storage of food items and failed to maintain a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect 76 of 81 residents in the facility as five residents (Resident #17, #35, #44, #52, and #62) received nothing by mouth. The facility census was 81. Findings include: 1. Observation during the initial tour of the kitchen on 03/24/25 from 9:50 A.M. to 10:30 A.M. revealed observation of the walk-in freezer #2 with several boxes of frozen food stored on the floor of the freezer. Dairy walk-in cooler #3 had an opened box of hard boiled eggs in clear plastic bags with one of the clear plastic bags opened and undated, and a clear container with cooked fish with the lid opened. The prep table with the Robocoup had several dried, beige, food splatters and what looked like shredded cheese pieces on table next to the Robocoup. A moderate amount of various food crumbs were observed on bottom shelf of the prep table on the large white plastic tray that had a container labeled salt, a large clear container also had a moderate amount of various food crumbs in it. In the container was a large bottle of imitation vanilla, lemon juice, cooking wine, and corn starch. The oven across of this area was heavily stained and appeared dated. [NAME] #402 stated at this time it was not used due to not working and waiting on a part and stated stains will not come out. Observation of the steamer and the tilt skillet also had various greased on food crumbs. Observation of the fryer, grill, and the cart the grill sat on had a moderate amount of grease on food crumbs. The juice machine observed sitting on a cart that had a large amount of standing water with a moderate amount of various dried juice splashes on the juice machine, the wall on the side and wall behind down to the floor also had various dried splatter. Observation of the dry storage area revealed several boxes of food supply on the floor, some opened, two large containers of onion powder on the floor between the boxes. A clear scoop was stored inside a large white container of sugar. The floor under each rack had various debris including package of cracker, toothpicks, white powder, etc. Interview on 03/24/25 between 9:50 A.M. and 10:30 A.M. with Dietary Manager (DM) #211 confirmed the above findings. DM #211 stated they had a delivery this past Friday and had been trying to get it put away among transitioning to a new company. 2. Observation on 03/25/25 from 4:27 P.M. to 4:37 P.M. during the tour of the nursing unit refrigerators with Diet Technician (DT) #401 revealed on the Reflections memory care unit refrigerator revealed it was heavily soiled with various, dried, sticky spills some red and some cream in color, and strands of hair on the shelf of the inside door. A disposable container of food was observed not labeled or dated. Observation of the first floor CRU nursing unit fridge revealed it was full of various lunch bags, a pizza box, and a paper plate with pizza slices covered by a napkin no label or date. The refrigerator was heavily soiled, there was a large spillage/substance on the bottom of fridge with a folk sitting in it and a large grocery bag with items in it. The freezer portion revealed three empty plastic cups with two of them stacked together, various dried food splatter, an empty plastic bag stuck to bottom in a sticky substance. There was no nursing unit refrigerator on the second floor. Interview on 03/25/25 between 4:27 P.M. to 4:37 P.M. with DT #211 verified the above findings. DT #211 stated both refrigerators contained both staff and resident foods. DT #211 stated the problem was between nursing and housekeeping neither knew who responsibility it was to clean the refrigerators. Review of the diet type report revealed five residents (Resident #17, #35, #44, #52, and #62) who received nothing by mouth. Reviewed policy Sanitation, revised November 2022 revealed the food service area is maintained in a clean and sanitary manner.

Based on review of facility documentation and interview with the Administrator, the facility failed to provide a complete and detailed Facility Assessment. This had the potential to affect all 81 residents residing in the facility. Findings include: Review of the Enhanced Facility Assessment, reviewed and updated on 10/01/24 by the Administrator revealed the facility assessment did not identify all the personnel involved in the writing and approval process of the plan, the average census was not accurate, the average number of residents admitted and discharged in a day were not accurate, it did not include common diagnoses the facility admits, what kind of services or care offered, or details regarding staffing levels on each shift. Interview on 03/31/25 at 1:32 P.M. with the Administrator revealed she understood and agreed with the above discrepancies.

Based on observation, interview and record review, the facility failed to implement an effective infection control program to include proper use of personal protective equipment for enhanced barrier precautions, hand hygiene, handling of incontinence care supplies, and respiratory equipment storage. This affected Resident #9, #10, #21, #42, #49, and #58 with the potential to affect all 81 residents in the facility. Findings Include: 1. Record review for Resident #21 revealed an admitted [DATE]. Diagnosis included functional quadriplegia, hemiplegia and hemiparesis, and encounter for attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 had impairment on one side of the upper and lower extremities, was dependent for activities of daily living including bed mobility. Resident #21 had a feeding tube. Review of the care plan for Resident #21 dated 10/08/24 revealed a care plan for enhanced barrier precautions (EBP) infection prevention related to peg tube: use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device for residents with the following(s): trachs, central lines, tube feeding, catheters and/or wounds. Interventions included apply EBP. Record review of the physician orders for Resident #21 dated 11/16/24 revealed EBP: Use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device for residents with the following(s): trachs, central lines, tube feeding, catheters and/or wounds. Observation on 03/24/25 at 2:28 P.M. revealed Resident #21 had an EBP sign near her entrance door. PPE was located near the sign. Observation of Certified Nursing Assistant (CNA) #267 turn and reposition Resident #21 from her back to her side while in bed revealed CNA #267 did not don any personal protective equipment (PPE) prior to providing hands on care for Resident #21. CNA #267 verified Resident #21 had a feeding tube intact. After completing care, CNA #267 confirmed she did not wear any PPE while providing hands on care for Resident #21 and revealed Resident #21 was not on EBP. Interview on 03/24/25 at 3:00 P.M. with Director of Nursing (DON) confirmed Resident #21 was on EBP. 2. Record review for Resident #10 revealed an admitted [DATE]. Diagnosis included dysphagia, gastrostomy status, and vascular dementia. Review of the quarterly MDS dated [DATE] revealed Resident #10 was severely cognitively impaired. Resident #10 was dependent for toileting hygiene and personal hygiene. Resident #10 was always incontinent of bowel and bladder. Resident #10 had a feeding tube. Review of the care plan for Resident #10 dated 09/23/24 revealed EBP Infection Prevention related to peg tube and Contact Isolation for CRE in urine. EBP: Use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device for residents with the following(s): trach, central lines, tube feeding, catheters and/or wounds. Review of the physician orders for Resident #10 revealed an order dated 03/04/24 for contact isolation for CRE in urine every shift precaution for infinity. Observation on 03/25/25 at 4:26 P.M. of CNA #274 provide incontinence care for Resident #10 revealed CNA #274 donned PPE and entered Resident #10's room. Resident #10 was lying in bed. CNA #274 placed her gloved hand inside the front of Resident #10's brief and revealed she was wet and needed changed. CNA #274 then left Resident #10's room with the isolation gown and gloves on, went to the first linen cart, lifted the cover, looked at the surveyor and removed her gloves, looked inside the cart then replaced the cover. CNA #274 walked down the hall to the second linen cart, removed wash cloths then returned to Resident #10's room with the isolation gown still on and the soiled gloves in her hand. CNA #274 confirmed she left Resident #10's room with soiled gloves and a gown on and touched two clean linen carts with her soiled hands. 3. Record review for Resident #40 revealed an admitted [DATE]. Diagnosis included amyotrophic lateral sclerosis, protein calorie malnutrition, and muscle weakness. Review of the Admission MDS dated [DATE] revealed Resident #40 was cognitively intact. Resident #40 had impairment on both sides of the upper and lower extremities and was dependent for all activities of daily living, Resident #40 was always incontinent of bowel and bladder and Resident #40 had a feeding tube. Review of the care plan for Resident #40 dated 01/21/25 revealed a care plan for EBP: use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device for residents with the following(s): trachs, central lines, tube feeding, catheters and/or wounds. Interventions included apply EBP. Review of the physician orders for Resident #40 revealed an order dated 03/24/25 for EBP: Use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device for residents with the following(s): trachs, central lines, tube feeding, catheters and/or wounds. Observation on 03/25/25 at 10:07 A.M. revealed after CNA #451 disposed of soiled linen in the soiled utility room (removed from Resident #10's room), CNA #451 left the soiled utility room, removed her gloves (did not wash her hands) and revealed she was going to change Resident #40. CNA #451 entered Resident #40's room, did not don PPE or wash her hands, spoke with Resident #40 then revealed she needed to get clean linen. CNA #451 left the room, did not wash her hands, went to the linen cart and obtained clean washcloths and towels. CNA #451 returned to Resident #40's room, did not wash her hands or don PPE. CNA #451 confirmed Resident #40 had a feeding tube that was infusing. CNA #451 then went to the bathroom that was shared by Resident #40 and #61. Observation revealed two uncovered wash basins sitting directly on the floor side by side next to the toilet. Observation revealed there was no name or room number on either basin. CNA #451 put on gloves and picked up the wash basin sitting on the floor closest to the toilet. CNA #451 partially filled the basin with water (did not rinse or wash the basin) and sat the basin on Resident #40's bed side table. CNA #451 did not don a gown. CNA #451 then removed Resident #40's brief. Resident #40 had a large bowel movement. A small trash can was sitting next to Resident #40's bed with no trash bag in it. CNA #451 removed Resident #40's soiled brief and placed it in a disposable bag. CNA #451 then provided incontinence care for Resident #40 using the basin of water and multiple wash cloths. CNA #451 disposed of the multiple wash clothes that were soiled with stool in the trash can that had no bag in it. CNA #451 then went to Resident #40's closet, opened the closet door with the same soiled gloves on and obtained a brief and placed the brief on Resident #40. CNA #451 revealed Resident #40's oxygen tubing displaced during care. CNA #451 placed the nasal cannula back in Resident #40's nares and placed the tubing behind her ears. CNA #451 then moved the hair from Resident #40's forehead and face with the same gloves on used to provide incontinent care. CNA #451 confirmed Resident #40's sheet and pad under her were soiled with urine. CNA #451 then went back to Resident #40's closet (with the same gloves on) rummaged in the closet and revealed she did not have what she needed in the closet. CNA #451 then went to the roommate (Resident #61) closet, rummaged in the closet with the same gloves on and revealed she also did not have what she needed. CNA #451 then took off her gloves and grabbed the bag with the soiled brief. CNA #451 did not wash her hands, she exited the room with soiled brief and took it to the soiled linen room. CNA #451 then removed a sheet, gown, and pad from the clean linen cart that was stocked with linen and gowns and handed the supplies to CNA #249. CNA #451 then obtained a disposable trash bag. Both CNA'S returned to Resident #40's room. CNA #451 put on gloves (no gown) and bagged the soiled washcloths and towels that were in the trash can. CNA #451 did not clean the can and still never washed her hands or used hand sanitizer. CNA #249 handed CNA #451 an isolation gown to don. CNA #451 donned the gown but did not tie any of the ties and did not place the gown over her shoulders. CNA #451 and #249 then changed Resident #40's soiled sheets and bed pad and dressed Resident #40. During care CNA #451 isolation gown had fallen down to her mid chest and the sleeves of the gown was down to the elbows. CNA #249 removed her gown and gloves and left the room. CNA #249 did not wash her hands or use hand sanitizer prior to leaving the room. CNA #451 then emptied the basin of water used to wash Resident #40 in the bathroom sink, rinsed the inside of the basin once with plain water and placed the wet basin on top of the other basin on the floor in the bathroom, uncovered. CNA #451 revealed each resident (Resident #40 and #61) had their own wash basin and confirmed neither basin was marked or had any way to identify which basin belonged to which resident. CNA #451 then removed the isolation gown and gloves, did not wash her hands, then exited the room and took the bag with the soiled washcloths to the linen room. CNA #451 then exited the linen room without washing her hands or using hand sanitizer. CNA #451 confirmed she never washed her hands or used hand sanitizer after providing incontinence care for Resident #10 or before, during or after providing incontinence care for Resident #40 and confirmed she never used an isolation gown during incontinence care for Resident #40. After CNA #451 confirmed she never washed her hands or used hand sanitizer at all while providing care, CNA #451 walked away during the interview to answer Resident #10's call light without washing her hands or using hand sanitizer. Interview on 03/25/25 at 10:35 A.M. with CNA #249 confirmed she never washed her hands or used hand sanitizer after providing care or prior to leaving Resident #40's room. Interview on 03/25/25 at 1:46 P.M. with the Director of Nursing (DON) revealed when a resident was on EBP/Contact isolation, staff were to don gloves and a gown when providing any hands on care. Staff were required to wash their hands prior to leaving the resident room and were not to wear gloves in the halls. Wash basins were to be cleaned with soap and water after each use, bagged and labeled with the resident identifying information. Wash basins were not shared between residents nor stored on the floor. Review of the facility policy titled, Enhanced Barrier Precautions revised August 2022 revealed EBP are used as an infection prevention and control intervention to reduce the spread of multi drug resistant organisms (MRDO's) to residents. Gloves and gown are applied prior to performing the high contact resident care activity. Examples of high-contact resident care activities requiring the use of gowns and gloves for EPB's include dressing, bathing, showering, transferring, hygiene, changing linens, changing briefs or assisting with toileting, device care or use, or wound care. EBP's are indicated for residents with wounds and or indwelling medical devices regardless of MRDO colonization. EBP's remain in place for the duration of the residents stay or until the resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Review of the facility policy titled, Handwashing/Hand Hygiene revised October 2023 revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated immediately before touching a resident; before performing an aseptic task; after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching a residents environment; before moving from work on a soiled body site to a clean body site; and immediately after glove removal. 37096 4. Review of the medical record for Resident #9 revealed an admittance date of 03/13/23 with diagnoses including spinal injury at T7 through T10, paraplegia, spinal stenosis, hypertension, depression, and heart failure. Review of Resident #9's physician orders for March 2025 revealed morning medications that included Allopurinol 100 milligram (mg), 0.6 mg Colchicine 0.6 mg. Furosemide 40 mg, multivitamin, potassium 20 milliequivalents (meq), vitamin B12, Vyvanse 40 mg, Flomax 0.4. and Gabapentin 800 mg. Observation on 03/26/25 at 7:57 A.M. of medication administration with Registered Nurse (RN) #310 revealed the nurse prepared Resident #9's morning medications and administered the medications. There was no hand sanitizer on the medication cart. RN #310 did not sanitize or wash hands prior to preparing medication Resident #9 medications or after administering the medications. Interview on 03/26/25 at 8:40 A.M. with RN #310 verified she did not sanitize or wash her hand prior to administering medication to Resident #9. 5. Review of the medical record for Resident #58 revealed an admittance date of 02/20/24. Diagnoses included amyotrophic lateral sclerosis, fibromyalgia, chronic pain, and depression and anxiety, Review of Resident #'58's physician orders for March 2025 revealed morning medications that included Omeprazole 40 mg, and Colace 100 mg. Observation on 03/26/57 at 8:30 A.M. of mediation administration with RN #310 revealed the nurse prepared Resident #58's morning medication and administering the medications. There was no hand sanitizer on the medication cart. RN #310 did not sanitize or wash hands prior to preparing medications or after leaving the room. Interview on 03/26/25 at 8:40 A.M. with RN #310 verified she did not sanitize or wash her hand prior to administering medication to Resident #58. Review of the policy titled Administering Medications, revised April 2019 revealed the staff follows established facility infection control procedures. Such as handwashing or using hand sanitizer antiseptic technique, gloves, and isolation precautions for administration of medication. 6. Review of the medical record for Resident #49 revealed an admittance date of 02/14/25. Diagnoses included heart failure, obesity, obstructive sleep apnea, renal dialysis, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. Review of the Minimum Data set 3.0 dated 02/21/25 revealed the resident had intact cognition and was receiving oxygen therapy. Review of the physician orders for March 2015 revealed an order for bilevel positive airway pressure (BIPAP) with two liters of oxygen at bedtime for sleep apnea. Observation on 03/24/25 at 11:55 A.M. revealed Resident #49's mask to the BIPAP was laying on the floor. Interview with Resident #49 at this time stated that the aid came in to turn of her call light and knocked the mask off the nightstand. Interview on 03/24/25 at 12:00 P.M. with Registered Nurse #334 verified the mask was not stored in a sanitary manner and stated she would replace the mask for the BIPAP.

Based on observation, interview, record review, and review of the facility policy, the facility failed to provide hygiene and grooming as scheduled and as needed for three residents (#13, #28, and #60) of three residents reviewed for hygiene. The facility census was 81. Findings include: 1.Record review for Resident #13 revealed an admitted [DATE]. Diagnosis included cerebral infarction, muscle wasting and atrophy, and muscle weakness. Review of the Modification of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 had impairment on both sides of the lower extremities, dependent for toileting hygiene, bathing, and substantial/maximal assistants for personal hygiene. Review of the care plan for Resident #13 dated 07/24/24 revealed Resident #13 had an activity of daily living (ADL) self-care performance deficit. Resident #13 requires assistance with ADLs. Interventions included to assist with activities of daily living (i.e.: dressing, grooming, personal hygiene, toileting, bed mobility, transfers, bathing, locomotion, oral care, etc.) and adjust level of assistance and support as needed every shift. Bathing: Check nail length and trim and clean on bath day and as necessary. Record review of the Shower Schedule revealed Resident #13's showers/baths were scheduled on Mondays and Thursdays 7:00 A.M. to 3:00 P.M. Observation on 03/24/25 at 9:55 A.M. revealed Resident #13 was lying in bed. Resident #13's fingernails were long, uneven and embedded with a thick dark substance. Resident #13 revealed she was not getting her showers routinely as scheduled. Observation on 03/25/25 at 3:16 P.M. with Certified Nursing Assistant (CNA) #278 confirmed Resident #13's fingernails were long, uneven and embedded with a thick dark substance. CNA #278 walked away (without offering to assist with nail care) after observing and confirming Resident #13's fingernails. Observation on 03/26/25 at 8:33 A.M. revealed Resident #13 was lying in bed. Resident #13's fingernails were long, uneven and embedded with a thick dark substance. Resident #13 revealed the staff did not offer or assist with cleaning or trimming her nails and went on to say she would like it if they did. Observation on 03/26/25 at 8:38 A.M. with CNA #267 revealed nail care was done on shower days and as needed. CNA #267 confirmed Resident #13's nails continued to be long, uneven and embedded with a thick dark substance. CNA #267 walked away (without offering to assist with nail care) after observing and confirming Resident #13's fingernails. Observation on 03/26/25 at 8:58 A.M. revealed Resident #13 was sitting up in bed feeding herself breakfast. Resident #13's nails continued to be long, uneven and embedded with a thick dark substance. Review of the shower/tub bath/bed bath sheets from 01/01/25 through 03/26/25 revealed there was no bath sheet to confirm Resident #13 received or was offered a shower or bed bath on 01/02/25, 01/16/25, 01/20/25, 01/23/25, 01/27/25, 01/30/25, 02/13/25, 02/20/25, 02/24/25, 02/27/25/03/03/25, 03/06/25, 03/10/25, 03/13/25, 03/17/25, or 03/24/25. Interview on 03/26/25 at 2:41 P.M. with the Administrator confirmed there were no other shower sheets completed for Resident #13. Administrator confirmed when the shower or bath was completed, the shower sheet was also completed to confirm the shower was done. 2. Record review for Resident #60 revealed an admitted [DATE]. Diagnosis included rhabdomyolysis, osteoarthritis, and muscle weakness. Review of the Medicare 5-day MDS assessment dated [DATE] revealed Resident #60 was cognitively intact. Resident #60 had impairment to one side of the upper extremity, was dependent for toileting and required partial/moderate assistants with shower/bathing. Review of the care plan dated 01/14/25 for Resident #60 revealed Resident #60 required staff assistance with activities of daily living related to weakness, impaired mobility, fall, rhabdomyolysis, obesity, and multiple comorbidities. Interventions included to assist with activities of daily living (i.e.: dressing, grooming, personal hygiene, toileting, bed mobility, transfers, bathing, locomotion, oral care, etc.) and adjust level of assistance and support to assist with one to two staff as needed every shift. Review of Shower Schedule for Resident #60 revealed showers were to be completed on Mondays and Thursdays from 11:00 P.M. to 7:00 A.M. Interview on 03/24/25 at 3:53 P.M. with Resident #60 revealed she was not getting baths like she was supposed to. The staff told her she was supposed to get her showers/baths on the night shift, 11:00 P.M. to 7:00 A.M. Resident #60 revealed she felt that was crazy. Usually staff would not even offer her a bath/shower but when they did come in the middle of the night and wake her up, she would tell them it's late so then they would say she refused. Resident #60 revealed she wasn't refusing her showers, she just did not want to have to get them in the middle of the night when she was sleeping. Review of the shower sheets for Resident #60 from 01/31/25 through 03/26/25 revealed on 01/31/25 and 03/04/25 Resident #60 refused her bath. There was no bath sheet to confirm Resident #60 received or was offered a shower or bed bath on 02/07/25, 02/17/25, 02/20/25, 02/24/25, 03/06/25, 03/10/25, 03/17/25, 03/20/25, and 03/24/25. Interview on 03/26/25 at 2:41 P.M. with the Administrator confirmed there were no other shower sheets completed for Resident #60. Administrator confirmed when the shower or bath was completed, the shower sheet was also completed to confirm the shower was done. Review of the shower sheets/record with Administrator and Unit Manager RN #257 on 03/26/25 at 5:16 P.M. confirmed the shower sheets were not completed to confirm showers were completed as scheduled for Resident #13 and #60. Unit Manager RN #257 revealed if the shower sheets were not completed, that meant the shower/bath was not offered or completed. The shower records would also indicate if the bath/shower was refused. Unit Manager RN #257 revealed she shared her concerns in the past with the previous Director of Nursing (DON) that the showers were not completed as scheduled. Administrator confirmed she was also aware of concerns with Residents showers/baths not completed and the previous DON was working on it. Interview on 03/27/25 at 1:25 P.M. with LPN #304 confirmed there were times residents showers were not being offered or completed and revealed it was because at times there was just not enough time. Interview on 03/27/25 at 3:18 P.M. with CNA #306 stated, Its not that there is not enough time to complete tasks, it's some staff just don't manage their time to do it (showers) so some showers don't get done. Interview on 03/27/25 at 3:24 P.M. with CNA #256 revealed the facility used a lot of agency staff and they just don't do showers. CNA #256 stated, we all know the showers are supposed to get done but agency, they just do what they want., they'll say we did not know we were supposed to do showers even though facility staff would tell them about the facility shower book and schedule. 3. Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included morbid (severe) obesity due to excess calories, lymphedema, major depressive disorder, generalized anxiety disorder, muscle weakness, and acquired absence of right leg below knee. Review of the Minimum Data Set (MDS) quarterly dated 01/28/25 revealed Resident #28 had intact cognition, was dependent on staff for transfers and toileting hygiene, was frequently incontinent of bladder, and always incontinent of bowel. Interview on 03/24/25 at 12:05 P.M. with Resident #28 revealed a few Fridays ago, he did not get put to bed due to short staffing on the night shift. Resident #28 stated by 5:00 A.M. (on 03/15/25) he still had not been put to bed and had a bowel movement. Resident #28 stated he turned on his call light multiple times, and was told by one aide that she needed to get the other aide because he required a hoyer (mechanical) lift for transfers. Resident #28 stated the aide came back and said that the other aide was on break and the resident would have to wait for assistance. Resident #28 stated when he had the bowel movement he was told by the aide again she had to find the second aide. Resident #28 stated no one came back and he didn't see anybody until the first shift arrived the following morning. Resident #28 stated Certified Nurse Aide (CNA) #256 was one of the four aides that had to clean him up and get him in bed. Resident #28 stated the night shift aide was from agency staffing. Resident #28 stated the incident was very demeaning. Review of Resident #28's progress notes was silent of documentation related to Resident #28 being left up in wheelchair and not being provided with incontinence care all night. Interview on 03/27/25 at 10:13 A.M. with CNA #256 verified Resident #28 was up all night and soiled when first shift arrived to work. CNA #256 stated two aides and two nurses were scheduled on the unit, but one of the aides could not be found for hours. CNA #256 stated she believed the incident occurred the morning of 03/08/25. CNA #256 stated she had arrived early to work at approximately 6:50 A.M. and Resident #28's call light was on. CNA #256 stated there were a few call lights on when she arrived. CNA #256 started when she got to Resident #28's room she saw him up in his power wheelchair and asked him if he had an appointment. CNA #256 stated he informed her that he had been up all night and had been trying to get into bed since 1:00 A.M. CNA #256 stated he informed her that he was told by the night staff that they would come back. CNA #256 stated Resident #28 was upset and appeared tired. CNA #256 stated Resident #28 usually went to be late. CNA #256 stated the resident requested his call light not be turned off until care was performed, as night staff kept turning off his call light. CNA #256 stated Resident #28 told her that around 1:00 A.M. he had a bowel movement and wanted to get into bed so they could change him. CNA #256 confirmed the resident did have a bowel movement, and recalled it looked like he had been sitting in it for a while at the time care was provided. CNA #256 stated she also observed the resident's urinal was full, and two cups were also full of urine. CNA #256 stated she knew those were his favorite cups. CNA #256 stated she had reported the incident to Registered Nurse (RN) #258 and believed the nurse reported it to someone. CNA #256 stated she was made aware the aide from agency was put on list to not return to the facility. Interviews on 03/27/25 at 11:33 A.M. and 1:11 P.M. with RN #258 via phone verified the incident regarding Resident #28 occurred and stated she was the dayshift nurse for Resident #28 that weekend. RN #258 stated she could not recall the date of the weekend or the day it occurred. RN #258 stated when she came in she went to his room and care was provided immediately. RN #258 stated she assessed him and gave him his morning medications and told him to get some rest. RN #258 stated she reported it to the manager on duty but could not remember who that was. RN #258 stated she was distraught about the incident and Resident #28 was upset but ready to go to bed. RN #258 stated all the aides helped, got him fresh sheets, and he was in bed by 7:15 A.M. RN #258 stated she did not get report from the night nurse until Resident #28 received care. RN #258 stated the night nurse was still there and she was aware of what happened, and she told the night nurse that was unacceptable. RN #258 stated the night nurse did not say what happened on nights and the resident never said to her he felt he was neglected or abused. RN #258 stated she checked on him throughout her shift. RN #258 stated she did not make a note or document in Resident #28's medical record the events of Resident #28's concern. Review of the facility policy titled, Supporting Activities of Daily Living (ADLs) revised March 2018 revealed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00163010 and OH00161974.

Based on observation, interview, and record review, the facility failed to ensure residents received meals compatible with their likes and dislikes. This affected one resident (Resident #22) and had the potential to affect 76 of 81 residents receiving food from the kitchen as five residents (Resident #17, #35, #44, #52, and #62) received nothing by mouth (NPO). The facility census was 81. Findings include: Record review for Resident #22 revealed an admitted [DATE]. Diagnosis included chronic kidney disease, gout, and type two diabetes mellitus. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively intact. Resident #22's preferences were very important to him. Review of the care plan dated 03/06/25 revealed Resident (#22) is at risk for altered nutritional status related to: Diuretic use, abnormal labs, obesity, therapeutic diet needs, edema and weight changes. Interventions included to provide meals / snacks / fluids based on resident food preferences and physician orders. Review of the physician orders dated 06/04/24 revealed Resident #22's diet order was a two gram low sodium diet, regular texture, regular consistency low sodium diet; double protein/meat portions for nutrition. Review of the facility list of resident diets revealed Resident #17, #35, #44, #52, and #62 received nothing by mouth. Observation on 03/27/25 at 1:19 P.M. of the lunch meal revealed Resident #22 was served corn for his portion of vegetables. Resident #22 did not eat any of his corn. Resident #22 stated, They gave me corn, I told them over and over I don't like corn. Interview on 03/27/25 at 2:26 P.M. with Dietary Tech (DT) #401 confirmed Resident #22 received corn for his vegetable serving at lunch. DT #401 revealed food likes and dislikes were not updated in the new system they recently started. The ordered type and texture was available, but no likes or dislikes were available for any residents. Interview on 03/27/25 at 3:06 P.M. with Dietary Manager (DM) #211 revealed on 03/19/25 the previous contract company removed their software that included the residents food likes and dislikes. The system they had would automatically replace a residents dislikes with an alternate item of equal nutritional value that the resident liked. Since the company took the software on 03/19/25, the facility no longer had the information to include any of the residents food likes and dislikes. DM #211 revealed she had no way to retrieve the information other than to ask the residents again. DM #211 revealed she planned to start that next week.

Based on record review, interview, and review of the facility policy, the facility failed to offer the flu and or pneumonia vaccine for all residents. This affected four residents (Resident #9, #10, #13, and #21) of five residents reviewed for immunizations. The facility census was 81. Findings include: 1. Record review for Resident #21 revealed an admitted [DATE]. Diagnosis included functional quadriplegia, hemiplegia and hemiparesis, and encounter for attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact. Review of the immunization record for Resident #21 revealed the flu nor the pneumonia vaccine was neither offered nor refused for 2024 or 2025. Record review revealed no contraindication to the flu or pneumococcal vaccine. Interview and record review on 03/31/25 at 1:05 P.M. with Director of Nursing (DON) confirmed the flu nor the pneumococcal vaccine was neither offered nor refused for 2024 or 2025 for Resident #21. Interview on 04/01/25 at 11:15 A.M. with Resident #21 confirmed she was not offered the flu or the pneumococcal vaccine for 2024 or 2025. 2. Record review for Resident #9 revealed a readmitted [DATE]. Diagnosis included paraplegia, incomplete, anxiety disorder, and weakness. Review of the quarterly MDS dated [DATE] for Resident #9 revealed Resident #9 was cognitively intact. Review of the immunization record for Resident #9 revealed the pneumococcal vaccine was not offered nor refused for 2024 or 2025. The record did not indicate the last time the pneumococcal vaccine was received. Interview and record review on 03/31/25 at 1:06 P.M. with DON confirmed the pneumococcal vaccine was not offered nor refused for 2024 or 2025 for Resident #9. Interview on 04/01/25 at 11:20 A.M. with Resident #9 confirmed he was not offered the pneumococcal vaccine for 2024 or 2025. 3. Record review for Resident #13 revealed an admitted [DATE]. Diagnosis included cerebral infarction, muscle wasting and atrophy, and muscle weakness. Review of the Modification of the quarterly MDS dated [DATE] revealed Resident #13 was cognitively intact. Review of the immunization record for Resident #13 revealed the pneumococcal vaccine was not offered nor refused for 2024 or 2025. The record did not indicate the last time the pneumococcal vaccine was received. Interview and record review on 03/31/25 at 1:07 P.M. with DON confirmed the pneumococcal vaccine was not offered nor refused for 2024 or 2025 for Resident #13. Interview on 03/31/25 at 3:05 P.M. with Resident #13 revealed she was not offered the pneumococcal vaccine for 2024 or 2025. 4. Record review for Resident #10 revealed an admitted [DATE]. Diagnosis included dysphagia, gastrostomy status, and vascular dementia. Review of the quarterly MDS dated [DATE] revealed Resident #10 was severely cognitively impaired. Review of the immunization record for Resident #10 revealed the flu nor the pneumonia vaccine was neither offered nor refused for 2024 or 2025. The record did not indicate the last time the pneumococcal vaccine was received. Record review revealed no contraindication to the flu or pneumococcal vaccine. Interview and record review on 03/31/25 at 2:18 P.M. with DON confirmed the flu nor the pneumococcal vaccine was neither offered nor refused for 2024 or 2025 for Resident #10. Review of the facility policy titled, Pneumococcal Vaccine revised October 2019 revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Review of the facility policy titled, Influenza Vaccine revised March 2022 revealed all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccination against influenza.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's request to go to bed and receive timely care was respected and the resident was timely assisted in a dignified manner. This affected one resident (#28) of three residents reviewed for dignity. The facility census was 81. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included morbid (severe) obesity due to excess calories, lymphedema, major depressive disorder, generalized anxiety disorder, muscle weakness, and acquired absence of right leg below knee. Review of the Minimum Data Set (MDS) quarterly dated 01/28/25 revealed Resident #28 had intact cognition, was dependent on staff for transfers and toileting hygiene, was frequently incontinent of bladder, and always incontinent of bowel. Interview on 03/24/25 at 12:05 P.M. with Resident #28 revealed a few Fridays ago, he did not get put to bed due to short staffing on the night shift. Resident #28 stated by 5:00 A.M. (on 03/15/25) he still had not been put to bed and had a bowel movement. Resident #28 stated he turned on his call light multiple times, and was told by one aide that she needed to get the other aide because he required a hoyer (mechanical) lift for transfers. Resident #28 stated the aide came back and said that the other aide was on break and the resident would have to wait for assistance. Resident #28 stated when he had the bowel movement he was told by the aide again she had to find the second aide. Resident #28 stated no one came back and he didn't see anybody until the first shift arrived the following morning. Resident #28 stated Certified Nurse Aide (CNA) #256 was one of the four aides that had to clean him up and get him in bed. Resident #28 stated the night shift aide was from agency staffing. Resident #28 stated the incident was very demeaning. Review of Resident #28's progress notes was silent of documentation related to Resident #28 being left up in wheelchair and not being provided with incontinence care all night. Interview on 03/27/25 at 10:13 A.M. with CNA #256 verified Resident #28 was up all night and soiled when first shift arrived to work. CNA #256 stated two aides and two nurses were scheduled on the unit, but one of the aides could not be found for hours. CNA #256 stated she believed the incident occurred the morning of 03/08/25. CNA #256 stated she had arrived early to work at approximately 6:50 A.M. and Resident #28's call light was on. CNA #256 stated there were a few call lights on when she arrived. CNA #256 started when she got to Resident #28's room she saw him up in his power wheelchair and asked him if he had an appointment. CNA #256 stated he informed her that he had been up all night and had been trying to get into bed since 1:00 A.M. CNA #256 stated he informed her that he was told by the night staff that they would come back. CNA #256 stated Resident #28 was upset and appeared tired. CNA #256 stated Resident #28 usually went to be late. CNA #256 stated the resident requested his call light not be turned off until care was performed, as night staff kept turning off his call light. CNA #256 stated Resident #28 told her that around 1:00 A.M. he had a bowel movement and wanted to get into bed so they could change him. CNA #256 confirmed the resident did have a bowel movement, and recalled it looked like he had been sitting in it for a while at the time care was provided. CNA #256 stated she also observed the resident's urinal was full, and two cups were also full of urine. CNA #256 stated she knew those were his favorite cups. CNA #256 stated she had reported the incident to Registered Nurse (RN) #258 and believed the nurse reported it to someone. CNA #256 stated she was made aware the aide from agency was put on list to not return to the facility. Interviews on 03/27/25 at 11:33 A.M. and 1:11 P.M. with RN #258 via phone verified the incident regarding Resident #28 occurred and stated she was the dayshift nurse for Resident #28 that weekend. RN #258 stated she could not recall the date of the weekend or the day it occurred. RN #258 stated when she came in she went to his room and care was provided immediately. RN #258 stated she assessed him and gave him his morning medications and told him to get some rest. RN #258 stated she reported it to the manager on duty but could not remember who that was. RN #258 stated she was distraught about the incident and Resident #28 was upset but ready to go to bed. RN #258 stated all the aides helped, got him fresh sheets, and he was in bed by 7:15 A.M. RN #258 stated she did not get report from the night nurse until Resident #28 received care. RN #258 stated the night nurse was still there and she was aware of what happened, and she told the night nurse that was unacceptable. RN #258 stated the night nurse did not say what happened on nights and the resident never said to her he felt he was neglected or abused. RN #258 stated she checked on him throughout her shift. RN #258 stated she did not make a note or document in Resident #28's medical record the events of Resident #28's concern. Interviews on 03/27/25 at 12:02 P.M. and 2:41 P.M. with Human Resources Director (HRD) #240 revealed she was the manager on duty on duty the weekend of 03/15/25 to 03/16/25 and recalled being told by staff Resident #28 did not get to bed at the time he liked. HRD #240 stated the incident did not occur on the weekend of 03/08/25. HRD #240 stated the morning of 03/16/25 at 6:57 A.M. she was told by the unit manager that was on call that the agency aide did nothing all night and needed to be placed on the do not return list. HRD #240 stated when she arrived at the facility between 9:30 A.M. and 10:30 A.M., she observed nursing staff at the nurses' station upset and they made her aware of what had occurred. HRD #240 stated when she went to talk with Resident #28 he was sitting up in bed and he stated he was fine. HRD #240 stated she then started collecting statements from the staff regarding the incident. HRD #240 stated she had informed the Administrator and Nurse Manager (NM) #261 what she was told about Resident #28 being left in his chair and not being changed all night. HRD #240 provided written statements from some staff but stated she did not have a written statement from Resident #28 or RN #258. Interview on 03/27/25 at 12:54 P.M. with NM #261 revealed she was on call both days 03/15 and 03/16. NM #261 stated she was aware that Resident #261 did not get his shower that evening on 03/15/25. NM #261 stated she got a call from the weekend manager and called into the building on 03/16/25 to ensure they gave Resident #28 a shower. NM #261 stated she was not aware of him being left in his chair all night. NM #261 stated he stays up late by his choice, but he does go to bed. NM #261 stated she was not aware of any resident not being put into bed or concerns related to timely incontinence care not being provided for any residents Review of the handwritten statements provided revealed statement by HRD #240 dated 03/16/25 revealed she was the weekend manager on the weekend, 03/15/25 and 03/16/25. When she arrived on 03/16/25, she began her rounds of the building and when she stopped at the nursing station, RN #258 and CNAs #265, #258, #267, and an agency CNA #600, were all letting her know that Resident #28 was out of his bed and left up in his chair all night. CNA #253, the night aide from 03/15/25, was called and stated she put Resident #28 to bed both nights. She told her that she wasn't sure why she was being told this by staff and that and she looked more into this issue. She asked Resident #28 how he was doing, and he stated he was fine. She apologized to him for this happening and assured that they will not let this happen again. NM #261 made her aware that the agency aide needed to be on the do not return list for poor performance. She attempted to reach out the agency aide to obtain a statement but was unsuccessful in reaching her. Review of the handwritten statement dated 03/16/24 by agency CNA #600 revealed she was working day shift and upon arrival it was brought to their attention that their resident had been up in his chair all night and needed care. The manager on duty, HRD #240 was notified by staff, and the incident was quickly handled. The resident was properly taken care of and free from any additional problems. Review of the handwritten stated dated 03/16/25 by CNA #256 revealed when they arrived for day shift, Resident #28's call light was on, and she went to check on him because it was early. She found him in his chair, and he explained to her what happened and that he wanted to lay down. She then grabbed the nurse, and she reported it to the manager on duty. The statement stated this incident occurred on the morning of 03/16/25. Review of the handwritten statement by HRD #240 dated 03/16/25 revealed HRD #240 interviewed LPN #254 regarding Resident #28. LPN #254 stated that the aide was working on putting Resident #28 to bed. When she went to go check on him, Resident #28 said he was fine and continued to sleep in his chair and did not request to go into his bed. Review of the handwritten stated dated 03/17/25 by CNA #253 revealed on 03/15/25 and 03/16/25, when she was assigned to care for Resident #28, she put him in the bed on both nights. Interview on 03/27/25 at 2:59 P.M. with the Administrator stated the weekend manager for the weekend of 03/15/25 -03/16/25, HRD #240 had concerns about Resident #28 not being placed in bed. She told HRD #240 to get statements, investigate it, and follow-up with Resident #28 to make sure he was ok. The Administrator stated he was fine at that time after the incident had occurred. The Administrator stated HRD #240 gave her the statements and she talked to the staff making sure that they were putting residents to bed timely. The Administrator stated she talked to the one aide that worked that night but was not sure of her name. The Administrator stated she also contacted the night nurse, LPN #254, she basically seconded the resident was sleeping in his chair and said he was fine. The Administrator stated she did not give a time of when she checked on him, and then stated she was not able to give a time. The Administrator stated she did not follow up with Resident #28 and then stated he never brought the concern directly to her. The Administrator stated the aide told her via phone that she put him to be as he requested. The Administrator stated Resident #28 at that time was not alleging neglect, although he was upset, but she saw it as a customer service issue. The Administrator stated she had done a recent customer service but was not sure if it was in regard to this particular incident. The Administrator stated the agency aide was put on the do not return list but was not his aide at that time. Interview on 04/01/25 at 1:28 P.M. with CNA #253 via phone revealed on the weekend of 03/15/25 on the night shift there was an agency aide that worked that night, and she had the hall where Resident #28 resided. CNA #253 stated the agency aide left leaving her and the nurse on the floor and she needed help from nurse to do rounds. CNA #253 stated they didn't realize she had left until around 3:00 A.M. - 4:00 A.M. CNA #253 stated the nurse found the agency aide sitting in the lobby told her to get back on the floor, but she didn't. CNA #253 stated the agency aide sat out there until 7:00 AM. and then wanted the nurse to sign her out. CNA #253 stated the agency aide was reported and she had not seen her back. CNA #253 stated she did not recall or was not sure if Resident #28 was in bed that night of 0315/25 but stated every time she was assigned to him she always got in in bed. Interview on 04/01/25 at 2:22 P.M. with LPN #254 via phone stated she was new and had worked for the facility for one week at the time of the incident with Resident #28 on the weekend of 03/15/25-03/16/25. LPN #254 stated the agency aide said to her that got Resident #28 to bed and she left around 3:00 A.M. 04:00 A.M. LPN #254 stated she never went back there until she gave Resident #28 his morning medication, his tramadol and Synthroid, she believed maybe around 5:00 A.M.-6:00 A.M. LPN #254 stated Resident#28 was sleeping in his chair and she woke him up to give him his medications. LPN #254 stated she assumed he was one of those residents that slept in his chair, and he never said anything to her. LPN #254 stated the agency aide left after she told her she had put him to bed, but they had not realized she had left. LPN #254 stated the agency aide had left the building leaving one aide on the floor and she and the other nurse had to help that one aide with check and changes. LPN #254 stated to be honest she was not sure if Resident #28 had rung his call light that night. LPN #254 stated she did not know it was an issue until the morning shift came in freaking out. Review of the policy Resident Self Determination and Participation dated August 2022 revealed the facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident is allowed to choose activities and schedule health care, including daily routines such as sleeping and waking, and personal care needs, that are consistent with his or her interest, values, assessment and plans of care.

Based on observations, record review and interview, the facility failed to ensure residents had access to their personal property in a timely manner. This affected one resident (#40) of one resident reviewed for personal property. The facility census was 81. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included amyotrophic lateral sclerosis (ALS), chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), pulmonary hypertension due to lung diseases and hypoxia, moderate protein-calorie malnutrition, major depressive disorder, and anxiety disorder. Review of the care conference review dated 01/24/25 revealed Social Worker (SW) #234, Nurse Manager (NM) #261, rehab representative, and Resident #40 attended. Under the summarization of discussion of care plan revealed: care meeting schedule with the resident on 01/24/25. Resident #40 has no family or friends to attend the meeting. Social services went over services and code status. The unit manager went over medications and level of care. Therapy went over progress and goals. Resident #40 has no support system in place. Resident #40 stated that she needs her personal items from the prior nursing facility. Resident #40 has no concerns at this time. Social services will continue to support as needed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had intact cognition, had no behaviors, and was dependent on staff for all activities of daily living (ADL). Interview on 03/24/25 at 11:39 A.M. with Resident #40, stated she wanted to get dressed and up in her wheelchair. Observation of Resident #40 revealed she was lying in her bed in a hospital gown. There was no observed wheelchair. She stated all her clothes, and her wheelchair was still at her previous facility. Further observation of Resident #40's closet and room revealed no personal items or clothing. Interview on 03/27/25 8:23 A.M. with NM #261 revealed she was familiar with Resident #40 from a previous facility and stated she has clothes, several totes and an electric wheelchair. NM #261 stated Resident #40 did not have any family or friends that could bring her personal items to the facility, so she had volunteered to pick up her items. NM #261 stated she has a jeep but had to make time to go pick up the resident's property. NM #261 stated SW #234 had reached out to the facility that has her items, and they stated they will not bring them but would hold her items. NM #261 verified since Resident #40 has been at the facility she has not had any of her personal items due to her not having time to get them. NM #261 stated Resident #40 has not expressed to her that she wanted to get up out of bed. Interview on 03/27/25 at 9:41 A.M. with SW #234 stated it was not typically part of her responsibility to ensure residents had their personal items when they were admitted to the facility. SW #234 stated however, she did track down Resident #40's personal property at a facility prior to the last facility. SW #234 stated on two occasions Resident #40 mentioned to her about wanting her personal items earlier into her admission. SW #234 stated they were attempting to make arrangements to pick up her personal items, but there had been issues with the switching of management companies prior to getting new owners last week. Interviews on 04/01/25 at 9:59 A.M. and 12:44 P.M. with the Administrator stated there was no specific timeframe, but within days or a week, for them to pick up a resident's personal property from their previous facility if the resident did not have family to bring it. The Administrator stated Resident #40 had been to several facilities and they had to locate where her items were and believed on 03/27/25 they picked up her items. The Administrator stated it was a long time, but they did pick up the items. The Administrator verified it was documented in the care conference dated 01/24/25 that the resident said she wanted her personal items.

Based on record review, observation, interview and facility policy review, the facility failed to ensure the call lights were within reach for Resident #5 and #21. This affected two residents (#5 and #21) of three residents reviewed for call light use. The facility census was 81. Findings include: 1. Record review for Resident #21 revealed an admitted [DATE]. Diagnoses included functional quadriplegia, hemiplegia and hemiparesis, and encounter for attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 had impairment on one side of the upper and lower extremities, was dependent on staff for activities of daily living (ADL), including bed mobility. Resident #21 had a feeding tube. Observation on 03/24/25 at 2:28 P.M. revealed Resident #21 was lying in bed. Resident #21 requested the surveyor assist her with turning and repositioning stating she was uncomfortable. Observation revealed Resident #21's call light was on the floor. Resident #21 verified she was unable to reach her call light, but she really needed turned. Observation and interview on 03/24/25 at 2:31 P.M. with Certified Nursing Assistant (CNA) #267 confirmed Resident #21's call light was out of reach and lying on the floor. 37096 2. Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included cerebrovascular disease, dementia, psychotic disturbance, mood disturbance and anxiety, and dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment and was dependent on staff for personal hygiene and transfers. Observation on 03/24/25 at 11:05 A.M revealed Resident #5 was lying in bed and his left arm was constricted. The call light was wrapped around the right-side bed rail. Interview at this time with Resident #5 stated he was unable to reach his call light. Interview on 03/24/25 at 11:10 A.M. with Housekeeper #242 verified the call light was not within reach for Resident #5. Review of the facility policy titled Call system, Resident dated September 2022 stated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting, bathing facilities and from the floor. This deficiency represents non-compliance investigated under Complaint Number OH00163018.

Based on observation, interview, record review, and review of the facility policy, the facility failed to respect and promote resident self-determination. This affected two resident (#9 and #60) of three residents reviewed for the ability for residents to choose important facets of their lives. The facility census was 81. Findings include: 1.Record review for Resident #9 revealed a readmitted [DATE]. Diagnosis included paraplegia, incomplete, anxiety disorder, and weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #9 revealed Resident #9 was cognitively intact. Resident #9 had impairment on both sides of the lower extremities and used a wheelchair for mobility. Resident #9 required partial/moderate assistants for bed mobility and dependent for transfers to and from the wheelchair. Vision was adequate with corrective lenses. Review of the care plan for Resident #9 dated [DATE] revealed Resident #21 was at risk for impaired psychiatric/mood status related to diagnosis of depression and attention deficit hyperactivity disorder. Interventions included to provide a calm safe environment when patient is emotional or frustrated and allow time to voice feelings. Refer to social worker as needed if resident communicates the need to speak with someone. Review of the Resident Council minutes dated [DATE] signed by Administrator revealed under the area of Social Services, Residents would like the ancillary services to be posted in rooms. Interview on [DATE] at 2:13 P.M. with Resident #9 revealed he had asked the social worker at least 17 times to let him know when the ancillary services were coming into the facility. Resident #9 reported the social worker had refused and stated the information was posted. Resident #9 stated. he could not always get up there, and needed a second pair of glasses and he never knew when the anciallary services would be coming into the building. Resident #9 revealed he leaves the facility at times for different appointments that he schedules and would like to know in advance when the eye doctor, podiatrist, and dentist were coming so he can plan his schedule and plan to meet with them if needed. Resident #9 revealed he needed a second pair of glasses and wanted to make sure he did not miss the eye doctor's next visit. Interview on [DATE] at 10:51 A.M. with Licensed Social Worker (LSW) #234 confirmed she scheduled all the ancillary service (Podiatrist, Optometry, Dental) visits. LSW #234 confirmed these services are provided at the facility as scheduled by her and each resident had the right to receive the ancillary services. LSW #234 confirmed Resident #9 spoke with her and requested she post the ancillary visit dates. LSW #234 stated, I said they are posted everywhere, he said you need to put them in everyone's room, and I said I am not doing that. LSW #234 confirmed she had the ancillary services dates posted everywhere for residents to see when they are scheduled to visits. Observation [DATE] at 10:52 A.M. with LSW #234 during a walk through of the entire facility where residents resided, revealed the only posted ancillary services expected dates to visit were posted in the secured memory care unit and those were expired dates. LSW #234 revealed she had ancillary schedule for [DATE] completed for when they were coming but she must not of posted the new schedule yet. Interview on [DATE] at 10:59 AM with Administrator revealed any resident who requested a copy posted in their room of the ancillary service visit dates should have it posted in their room per their request. 2. Record review for Resident #60 revealed an admitted [DATE]. Diagnosis included rhabdomyolysis, osteoarthritis, and muscle weakness. Review of the Medicare 5-day MDS assessment dated [DATE] revealed Resident #60 was cognitively intact. Resident #60 had impairment to one side of the upper extremity, was dependent for toileting and required partial/moderate assistants with shower/bathing. Review of the care plan dated [DATE] for Resident #60 revealed the resident is, dependent on staff for activities, cognitive stimulation, and social interaction related to physical limitations. Interventions included to honor resident's choices and preferences whenever possible. Review of Shower Schedule revealed showers/baths were completed on all three shifts (7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7 :00 A.M.). The showers were scheduled per shift by room number. Record review revealed Resident #60's showers were to be completed on Mondays and Thursdays from 11:00 P.M. to 7:00 A.M. Record review of Resident #60's medical record revealed Resident #60's preferences/care plan were not completed to include the time of day she preferred her bath/showers. Interview on [DATE] at 3:53 P.M. with Resident #60 revealed the staff told her she was supposed to get her showers/baths on the night shift, 11:00 P.M. to 7:00 A.M.; Resident #60 revealed she felt that was crazy and revealed she was never asked when she wanted them, she was just told that was when she was scheduled to have them. Resident #60 revealed when the staff did come in, in the middle of the night and wake her up, she would tell them it's late so then they would say she refused. Resident #60 revealed she wasn't refusing her showers, she just did not want to have to get them in the middle of the night when she was sleeping. Review of the shower schedule and Resident choices with Administrator and Unit Manager RN #257 on [DATE] at 5:16 P.M. confirmed Resident #60 was scheduled to receive her showers on the 11:00 P.M. to 7:00 A.M. shift two days a week. Administrator and Unit Manager RN #257 confirmed the forms were not completed for Resident #60 on admission to determine her preferences for dates and times to receive showers/baths. Review of the facility policy titled, Resident Self Determination and Participation revised [DATE] revealed our facility respects and promotes the right of each resident to exorcize his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interest, values, assessments and plan of care, including daily routine such as sleeping and waking, exercise and bathing schedules. Residents are encouraged to interact with members of the community and participate in community activities inside and outside the community. Examples of accommodations that support community participation include scheduling treatments or therapy so they do nit interfere with activities or events and assisting the resident with planning.

Based on record review and interview, the facility failed to ensure a completed code status form was completed for Resident #40. This affected one resident (#40) of one resident reviewed for advanced directives. The facility census was 81. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included amyotrophic lateral sclerosis (ALS), chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), pulmonary hypertension due to lung diseases and hypoxia, moderate protein-calorie malnutrition, major depressive disorder, and anxiety disorder. Review of the physician orders for March 2025 revealed Do Not Resuscitate Comfort Care Arrest (DNRCC-A) with a start date of 01/23/25. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had intact cognition, had no behaviors, and was dependent on staff for all activities of daily living (ADL). Interview on 03/25/25 at 2:19 P.M. with the Administrator verified the order for DNRCC-A was written, but the form was never completed. The Administrator stated she had the nurse practitioner come in today to do the form it and was uploaded into Resident #40's electronic medical record with today's date.

Based on record review, interview and facility policy review, the facility failed to ensure notification of significant weight loss to the resident's physician and/or the resident representative. This affected one resident (#45) of seven residents reviewed for nutrition and one resident (#35) of one resident reviewed for tube feeding. The facility census was 81. Findings include: 1. Review of the medical record for Resident #35 revealed an admitted [DATE]. Diagnoses included dementia, adult failure to thrive, dysphagia, Alzheimer's disease with early onset, gastrostomy status, and moderate protein-calorie malnutrition. Review of the weight history for Resident #35 revealed: 02/03/25 weight was 134 pounds 02/20/25 weight was 137 pounds 02/27/25 weight was 130 pounds 03/12/25 weight was 130.5 pounds Review of the progress note dated 03/06/25 at 10:07 A.M. revealed a nutrition noted stating Resident #35's weights were reviewed. Resident #35 showed a weight loss on the last weight after a previous weight gain. Resident #35 was on weekly weights to monitor, awaiting weekly weight to confirm weight loss. Resident #35 receives nothing by mouth (NPO) and receives all of nutrition via percutaneous endoscopic gastrostomy (PEG) tube (feeding tube). No new recommendations. Will follow up after weekly weight obtained. There was no documentation of notification to the physician/nurse practitioner or resident family/representative. Interviews on 03/27/25 at 1:59 P.M. and at 2:13 P.M. with Diet Technician (DT) #401 stated she would notify the residents' family of significant weight loss, and the nurse unit managers would notify the doctors. DT #401 stated she would document in the resident medical record that she had notified the resident's family. DT #401 stated she was not 100% positive that she notified Resident #35's family of the weight loss. DT #401 verified she did not document that she notified Resident #35's family. Interview on 03/27/25 at 3:53 P.M. with Nurse Practitioner (NP) #352 via phone stated she was not aware of Resident #35's weight loss, but if she was notified, she would have seen the resident and noted it. NP #352 stated Resident #35 had been stable medically based on her assessments. 2. Review of the medical record for Resident #45 revealed an admitted d of 10/11/24. Diagnoses included intraoperative cerebrovascular infarction, traumatic subdural hemorrhage with loss of consciousness, multiple fractures, gastrostomy, dysphagia, and moderate protein-calorie malnutrition. Review of the weight history for Resident #45 revealed: 10/11/24 weight was 141 pounds 10/24/24 weight was 138.2 pounds 03/11/25 weight was 125 pounds 03/21/25 weight was 125 pounds Review of the progress notes dated 03/13/25 at 1:33 P.M. revealed a nutrition note stating, spoke with the resident's mother about weight loss today. Resident #45 was unable to be weighed for a period of time per physician orders. Resident #45 will now be weighed weekly to monitor for ongoing trend. Will reevaluate tube feeding as needed. Resident #45 is also now receiving a regular mechanical soft diet with honey thick fluids and needs set up and limited assist at times. Resident #45 was discussed in the interdisciplinary meeting today. Will continue to monitor and follow up as needed. Review of the physician note dated 03/13/25 revealed no nursing concerns, no fevers or chills. There was no documentation of notification to the physician/nurse practitioner or resident family/representative. Interview on 03/27/25 at 5:11 P.M. with the Administrator after reviewing the progress notes and physician/nurse practitioner notes for Residents #35 and #45 verified there was no documentation of notification to the physician/nurse practitioner for Resident #45 and to the physician/nurse practitioner and resident representative for Resident #35 of their significant weight loss. Review of the facility policy Change in a Resident's Condition or Status, revised February 2021, revealed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interview, the facility failed to provide residents with the correct last covered day (LCD). This affected five (Resident #60, Resident #63, Resident #73, Resident #79, and Resident #80) of eleven residents reviewed for liability notices. The census was 81. Findings include: 1. Review of Resident #60's medical record revealed she was admitted to the facility on [DATE]. She was still a resident and had not been discharged . A NOMNC letter revealed skilled services ended on 02/15/25, the LCD. The medical record provided no evidence of Resident #60's next payor source starting on 02/16/25. 2. Review of Resident #63's medical record revealed she was admitted to the facility on [DATE]. She was still a resident and had not been discharged . A NOMNC letter revealed skilled services ended on 11/23/24, the LCD. The medical record provided no evidence of Resident #63's next payor source starting on 11/24/24. 3. Review of Resident #73's medical record revealed he was admitted to the facility on [DATE]. He was still a resident and had not been discharged . A NOMNC letter revealed skilled services ended on 03/21/25, the LCD. The medical record provided no evidence of Resident #73's next payor source starting on 03/22/25. 4. Review of Resident #79's medical record revealed he was admitted to the facility on [DATE] and was discharged on [DATE]. A NOMNC letter revealed skilled services ended on 02/04/25, the LCD. The medical record provided no evidence of Resident #79's reason for leaving the facility on the LCD. 5. Review of Resident #80's medical record revealed he was admitted to the facility on [DATE] and was discharged on [DATE]. A NOMNC letter revealed skilled services ended on 01/11/25. The medical record provided no evidence of Resident #80's reason for leaving the facility prior to the LCD. Interview on 03/25/25 at 3:00 P.M. with Licensed Social Worker (LSW) #234 confirmed the discrepancies noted about the last covered days (LCD) and there were no progress notes to explain a change in LCD or payor concerns

Based on record reviews, observations and interviews, the facility failed to ensure a clean and sanitary environment for Resident #5 and a comfortable mattress in good repair for Resident #61. This affected two residents (#5 and #61) reviewed for a clean, sanitary, and homelike environment. The facility census was 81. Findings include: 1. Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included quadriplegia, anxiety disorder, contracture right and left hand, reduced mobility, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition and required substantial/maximin assistance from staff for bed mobility and was dependent on staff for chair/bed to bed/chair transfers. Interview on 03/24/25 at 11:43 A.M. with Resident #61 stated her bed was uncomfortable, and it sunk in the middle. The resident stated she informed some the aides but did not know their names. Interviews on 03/27/25 at 10:13 A.M. and 04/01/25 at 10:23 A.M. with Certified Nurse Aides (CNAs) #256 and #277 stated the concern with Resident #61's mattress had been going on for about a month. CNA #256 stated Resident #261 complained that she could feel the rails. CNA #256 stated she informed Director of Maintenance (DOM) #266 directly about a month ago. CNA #277 stated she informed the nurse but could not recall the nurse she informed because it had been a while ago. Observation on 03/27/25 at 12:49 P.M. of Resident #61 sitting in a chair in her room next to her bed. At this time, Interview with Resident #61 revealed she was not comfortable in her chair, but they tried to make it comfortable by adding pillows. Resident #61 then pointed to her bed and stated, see. Observation of Resident #61's bed revealed it was made but there was a large dip in the middle of the mattress. Resident #61 stated it had been that way for about a month, and she could not remember who the aides were, but they were aware of the dip. Observation on 03/27/25 at 12:53 P.M. with Nurse Manager (NM) #261 of Resident #61's bed. At this time, Interview with NM #261 verified the large dip in mattress and stated she would get her a new mattress. NM #261 stated the mattress was a regular mattress not an air mattress. Observation on 03/27/25 at 1:00 P.M. of DOM #266 walking down the hall with a mattress in a plastic covering. Interview at this time with DOM #266 stated he was not sure if he was made aware of her needing a new mattress, and he would have to check the maintenance logs. Reviewed on maintenance logs dated 01/27/25 through 03/28/25 revealed no documented concerns related to Resident #61's mattress. Follow-up interview on 04/01/25 at 8:19 A.M. with DOM #266 verified there were no concerns on the maintenance logs related to Resident #61's mattress. DOM #266 stated 03/27/25 was the first time he was made aware of Resident #61 needing a new mattress. 37096 2. Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included cerebrovascular disease, dementia, psychotic disturbance, mood disturbance and anxiety, and dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment and was dependent on staff for personal hygiene and transfers. Observation on 03/24/25 at 11:05 A.M, revealed Resident #5 was lying in bed. The resident had a floor mat to the right side of the bed. The mat was covered with a dried white substance. The carpeted next to the mat had large areas with a dried white substance. Interview 03/24/25 at 11:10 A.M. with Housekeeper #242 verified the dirty floor mat and spillage on the carpet. Housekeeper #242 stated she did not get to clean Resident #5 room today. This deficiency represents non-compliance investigated under Complaint Number OH00163018.

Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure quarterly care plan meetings were offered/completed for Resident #13. This affected one resident (#13) of one resident reviewed for quarterly care plan timing. The facility census was 81. Findings include: Record review for Resident #13 revealed an admitted [DATE]. Diagnoses included cerebral infarction, neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, resistant to multiple antimicrobial drugs, constipation, and muscle weakness. Review of the modification of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 had impairment on both sides of her lower extremities, required partial/moderate assistance with eating and was dependent on staff for toilet hygiene, bathing, bed mobility, and transfers, and required substantial/maximal assistance for personal hygiene. Resident #13 had an indwelling catheter and was always incontinent of bowel. Interview on 03/24/25 at 9:53 A.M. with Resident #13 revealed she was not offered a care plan meeting quarterly. Record review of Resident #13's medical record from 04/01/24 through 03/27/25 revealed no documentation of a care plan meeting completed or refusals of a care plan meeting. Interview on 03/25/25 at 4:06 P.M. with Licensed Social Worker (LSW) #234 revealed the latest in the day she could do a care plan meeting was 2:30 P.M.; LSW #234 revealed Resident #13's daughter wanted to do it later in the day. LSW #234 confirmed Resident #13 did not have a scheduled care plan meeting set at this time and confirmed she had not had a care plan meeting over the past seven months due to Resident #13 wanting to have it when her daughter could attend and that was past 2:30 P.M. LSW #234 revealed she was unsure about any care plan meetings Resident #13 had prior to that. LSW #234 revealed she did not document any attempts made to schedule a care plan meeting with Resident #13 or the responsible party. Interview on 03/27/25 at 12:01 P.M. with Resident #13's Responsible Party revealed Resident #13 was at the facility for five years and only had two care plan meetings in five years. Resident #13's Responsible Party revealed they did schedule one months ago, and then Resident #13 became ill. Resident #13 and the Responsible Party requested she attend the care plan meeting without Resident #13 because she was not feeling well, but the facility refused. The facility staff said the resident had to be there, and the facility canceled the meeting and never rescheduled it. Resident #13's daughter revealed, at times, she requested and was denied the meeting on the phone because it was hard for her to get to the facility. Interview on 03/27/25 at 12:25 P.M. with the Administrator revealed the Social Worker was to schedule quarterly care plan meetings with each resident. Expectations included doing care conferences on the phone, in the evenings if preferred, and the residents did not have to be present if they did not want to per the resident's choice. The Administrator verified Resident #13 had no documented evidence that a care plan meeting was offered over the past 12 months. Review of the facility policy titled, Resident Participation-Assessment/Care Plans, revised February 2021, revealed the resident and his or her legal guardian are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. Facility staff support and encourage resident/representative participation in the care planning process by holding care plan meetings at times of day when the resident, representative and family members can attend. The Social Service Director/Designee is responsible for notifying the resident/representative.

Based on observation, interview, record review, and review of facility policy, the facility failed to obtain ordered laboratory testing to identify a urinary tract infection and failed to provide proper care and treatment for an indwelling urinary catheter to prevent urinary tract infections (UTI). This affected one resident (Resident #13) of one resident reviewed for a foley catheter. In addition, the facility failed to timely initiate treatment for a UTI for Resident #42. This affected one resident (#42) of four residents reviewed for medications. The facility census was 81. Findings include: Record review for Resident #13 revealed an admitted [DATE]. Diagnosis included cerebral infarction, neuromuscular dysfunction of the bladder (a problem in which the resident lacks bladder control), obstructive and reflux uropathy (backup of urine into the unilateral or bilateral kidneys, depending on the location of the obstruction, this can lead to potential kidney damage), muscle wasting and atrophy, and muscle weakness. Review of the care plan dated 07/24/24 revealed Resident #13 had an indwelling urinary catheter size 22 French related to obstructive uropathy, neurogenic bladder and urinary retention. Interventions included changing the foley catheter per the physician orders, maintaining infection control, and maintaining the urinary drainage bag below the bladder level. Review of the Modification of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 had impairment on both sides of the lower extremities, was dependent on staff for toileting hygiene, and required substantial/maximal assistants for personal hygiene. Resident #13 had an indwelling catheter and was always incontinent of bowel. Review of the previous UA C&S results for Resident #13 from 07/03/24 through 04/01/25 revealed the resident had a history of recurrent UTIs and was diagnosed with and subsequently treated for UTIs on 07/14/24, 08/05/24, and 02/01/25. Review of the Certified Nurse Practitioner (CNP) note dated 03/13/25 at 8:04 A.M. revealed Resident #13's daughter stated the resident was confused and for the last two days, the resident had not been herself. The resident was noted to be back to her baseline at the time of the note. The note referenced the plan for the resident's care was for nursing staff to continue current care, monitor the resident closely, and obtain a urinalysis (UA) with a culture and sensitivity (C&S) and labs. Review of the CNP progress note dated 03/18/25 at 8:18 P.M. for Resident #13 reported urinary pain and the listed plan included discussing with nursing staff for administration of pyridium (a medication used to decrease urinary pain) and obtaining a UA C&S. Review of the progress note dated 03/20/25 at 6:57 A.M. authored by Licensed Practical Nurse (LPN) #254 for Resident #13 revealed the nurse and another unnamed nurse had attempted to change Resident #13's indwelling catheter but could not locate the proper sized catheter. A subsequent note timed 8:09 A.M. authored by Registered Nurse (RN) #301 revealed the resident's nurse practitioner had been contacted concerning the resident's urinary catheter and ordered the resident to be sent to the local emergency department. Review of the progress note dated 03/23/25 at 8:11 P.M. authored by RN #323 for Resident #13 revealed the resident returned from a local hospital on 03/23/25 at approximately 5:30 P.M. The resident had been hospitalized and treated for diagnoses of cystitis (bladder infection). Review of the hospital After Visit Summary from 03/20/25 through 03/23/25 for Resident #13 revealed the resident had been hospitalized for possible cystitis and UTI, and upon arrival had a malpositioned indwelling urinary catheter. The resident's urinary catheter was changed, and during the hospitalization she received intravenous antibiotics to treat her UTI. Review of the CNP progress note dated 03/24/25 at 1:19 P.M. authored by CNP #802 revealed Resident #13 returned from the local hospital on 03/23/25 where she had been treated for a UTI. The plan discussed with nursing staff stated to continue current care and to monitor the resident closely. Observation on 03/25/25 at 3:03 P.M. revealed Resident #13 was lying in bed. Resident #13's urinary catheter drainage bag was lying on the bed next to Resident #13's right leg. No staff were present in the room. The drainage bag was not positioned below the resident's bladder level. Observation and interview on 03/25/25 at 3:05 P.M. with RN #301 confirmed Resident #13 was lying in bed. Resident #13's urinary drainage bag remained positioned next to the resident's right leg, unchanged from the prior observation. RN #301 confirmed the urine was unable to flow freely by gravity due to the inappropriate placement of the urinary drainage bag. RN #301 revealed she had not been in Resident #13's room, so she dd not know why the bag was placed and left on the bed. Telephone interview on 03/26/25 at 11:09 A.M. with CNP #802 revealed the nursing staff never obtained the urine for the UA and C&S ordered on 03/13/25 or 03/18/25 for Resident #13, so she had the resident sent to the local emergency room for evaluation. The staff never explained to her why they did not obtain Resident #13's urinalysis per the orders. Resident #13 required the catheter due to a diagnosis of neurogenic bladder. CNP #802 revealed a urinary catheter drained the urine by gravity. CNP #802 stated urinary drainage bags must be kept below the bladder level for the urine to drain. If the urine cannot drain, urine could backflow and could grow bacteria and develop into a UTI. Observation in 03/27/25 at 11:43 A.M. revealed Resident #13 was seated in her tilt-back wheelchair in her room. The wheelchair was tilted back in a reclined position, and the urinary drainage bag was hanging on the armrest of the chair. The catheter bag was positioned above Resident #13's abdomen and above the bladder level. No staff were present in Resident #13's room. Observation and interview on 03/27/25 at 11:43 A.M. with LPN #304 verified Resident #13 seated in her tilt-back wheelchair in her room. The wheelchair was tilted back in a reclined position, and the urinary drainage bag was hanging on the armrest of the chair. The catheter bag was positioned above Resident #13's abdomen and above the bladder level. LPN #304 stated, I don't know how many times I have to tell them, thank you for telling me. LPN #304 confirmed she had found the catheter bag above Resident #13's bladder several times in the past. Review of the policy Supporting Activities of Daily Living (ADLs) dated March 2018 revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. 37096 2. Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included sepsis, osteomyelitis, heart failure, dementia, and peripheral vascular disease. Review of the laboratory service report dated 03/06/25 at 10:11 A.M. revealed the urine culture resulted Escherichia coli and extended spectrum beta lactamase (ESBL) producing organism. The report revealed the organism was resistant to ciprofloxacin and sensitive to Macrobid. Review of the admitting medications reconciliation dated 03/06/25 revealed ciprofloxacin 250 milligram (mg) twice daily was crossed off not to be administered. Review of Resident #42's physician orders dated 03/06/25 at 6:13 P.M. revealed an order dated 03/08/25 for Macrobid 100 milligrams, an antibiotic, two times a day to treat urinary tract infection. Review of the nursing progress note dated 03/08/25 stated Macrobid oral capsule 100 mg by mouth two a day for Urinary tract infection (URI) was not available. Review of the starter kit replacement form dated 03/08/25 stated Macrobid 100 mg was pulled from the started kit to be administered. Moreover, there was no time stating the medication was pulled. Review of the Medication Administration Record (MAR) March 2025 revealed 03/08/25 Macrobid 100 mg was documented as not administered and to see nurses note. Macrobid 100 mg was administered 03/09/25 through 03/18/25. Review of the comprehensive Minimum Data Set 3.0 dated 03/12/25 revealed the resident had moderate cognitive impairment and was dependent on staff for toileting, transfers and ambulation. The assessment indicated the resident received an antibiotic and an antiplatelet. Interview on 03/31/25 at 10:09 at 12:05 P.M. with the Director of Nursing (DON) verified there was a delay in initiating treatment for Resident #42's UTI. The DON confirmed there was a lapse between when the urine culture resulted on 03/06/25 to when Resident #42 received her first dose of antibiotic therapy on 03/08/25.

Based on record review and interview, the facility failed to apply Resident #179's Automatic Positive Airway Pressure (auto-PAP) machine as ordered. This affected one resident (#179) of four residents reviewed for respiratory care. The facility census was 81. Finding include: Review of Resident #179's medical record revealed an admitted [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease (COPD), obesity, and emphysema. Resident #179 was discharged on [DATE]. Review of the physicians order for February 2025 revealed an order for an auto-PAP (a respiratory machine worn while sleeping which provides positive airway pressure and automatically adjusts in response to measured airway resistance) to be applied every night and as needed for naps. Review of the Treatment Record (TAR) for February 2025 revealed the treatment was signed off on for evening on 02/19/25 and 02/20/25. Review of the nursing assessment dated [DATE] revealed Resident #179 was alert and orientated to person, place and time. The resident was recorded as independent with activities of daily living. Review of the progress note dated 02/11/25 at 11:00 P.M. revealed the Resident #179 had diminished lungs sounds and difficulty breathing. The Nurse Practitioner (NP) ordered to send Resident #179 to the emergency room (ER). A subsequent note dated 02/21/25 at 10:00 A.M. revealed Resident #179 was unresponsive and sent to the ER for further evaluation. Review of the hospital summary dated 02/13/25 revealed the resident had a history of severe COPD, chronic hypercapnic respiratory failure, history of pulmonary embolism, tracheobronchial malacia (a condition where to airway become soft and can collapse during breathing), and had numerous recent hospitalization s for respiratory failure. Review of a Self-Reported Incident (SRI) dated 02/21/25 revealed the facility self-reported an allegation of neglect. The facility Nurse Practitioner (NP) had reported that staff failed to follow treatment order for Resident #179's auto-PAP application. The witness statement for Licensed Practical Nurse (LPN) #351, recorded by the Administrator, stated LPN #351 was interviewed by telephone and was questioned regarding Resident #179's auto-PAP. LPN #351 stated she did not apply the auto-PAP at bedtime on 02/20/25. LPN #351 was unable to give any specific reason why the auto-PAP for Resident #179 was not applied per order other than she had forgotten to apply the resident's auto-PAP. The facility investigated the incident and concluded no neglect had occurred. Interview on 04/01/25 at 10:28 A.M. with Registered Nurse (RN) #321 revealed she was assigned to Resident #179 the morning of 02/21/25. The resident was up and eating breakfast when she administered her morning medications. Approximately 40 minutes later, RN #321 stated she received a call from Resident #179's daughter who stated she had video-called Resident #179 and stated the resident did not look good. RN #321 assessed Resident #179, who had difficulty breathing. RN #321 applied the resident's auto-PAP and called emergency medical services (EMS) to transfer the resident to the local emergency room (ER) for further treatment. RN #321 did not receive any report from the night nurse that the resident had not had her auto-PAP applied as ordered the night before. Interview on 04/01/25 at 11:24 A.M. with Nurse Practitioner (NP) #352 stated it was reported to her that Resident #179 did not receive her auto-PAP treatment on the night of 02/20/25, and she reported it to the Administrator. Resident #179 was very sick and had horrible lungs. The resident had an extensive medical history, multiple respiratory conditions, and was intubated multiple times prior to admitting to the facility. NP #352 stated not receiving auto-PAP on 02/20/25 had no correlation with the resident being sent to the hospital on 02/21/25. Interview on 04/01/25 at 12:01 P.M. with the Administrator revealed the nurse verified the auto-PAP treatment was not applied overnight on 02/20/25. LPN #351 was an agency nurse was placed on 'do not return' status following the incident. This deficiency represents non-compliance investigated under Complaint Number OH00163179.

Based on record review, review of a facility fall investigation, review of staff disciplinary forms, review of a facility procedure and interview, the facility failed to provide adequate assistance to Resident #35 during incontinence care to prevent a fall with injury. This affected one resident (#35) of three residents reviewed for incontinence care. The facility census was 68. Actual harm occurred on 08/05/24 when Resident #35, who was severely cognitively impaired, required two staff assistance for bed mobility and was incontinent, sustained a fall out of bed when staff were providing incontinence care. At the time of the incident, the staff failed to maintain the resident's safety in bed. The resident exhibited pain to the left side of the head with swelling and bruising to the left cheek and eye and pain with range of motion to the left elbow. Resident #35 was transferred to the hospital and returned with a diagnosis of a head injury and multiple contusions. Findings include: Review of the medical record for Resident #35 revealed an admitted [DATE] with diagnoses including diabetes mellitus type two, vascular dementia, epilepsy, gastrostomy status, and schizoaffective disorder. Review of the fall risk evaluation dated 03/04/24 revealed Resident #35 was at high risk for falls having had a history of falls, impaired cognition, dependence with continence, being confined to a chair and not able to attempt standing without physical help. Review of the care plan updated 07/01/24 revealed Resident #35 was incontinent and required total staff assistance with toileting and bed mobility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had severe cognitive impairment and required extensive assistance from two staff for toileting and bed mobility. The assessment revealed the resident was always incontinent of bowel and blader. Review of the nursing progress note dated 08/05/24 at 6:45 A.M. revealed Resident #35 was being changed and slid to the floor embraced by staff. Review of the nursing progress note dated 08/05/24 at 10:00 A.M. revealed Resident #35's left upper cheek had increased swelling and the resident complained of pain in the left arm and left lateral rib cage area. The nurse practitioner ordered the resident to be transferred to the hospital. Review of the nursing progress note dated 08/05/24 at 1:26 P.M. revealed Resident #35 had a fall and during morning medication administration complained of pain to the left arm and within two hours had a swollen left cheek with bruising. The resident subsequently was transferred to the hospital. Review of the nursing progress note dated 08/05/24 at 3:21 P.M. Resident #35 returned to the facility at 3:30 P.M. by ambulance. The resident was diagnosed with a facial contusion. Review of the hospital discharge information dated 08/05/24 revealed Resident #35 was diagnosed with a fall. Multiple imaging was completed to the brain, cervical spine, facial bone, left elbow, femur, hip, ribs and shoulder which resulted in an additional diagnosis of head injury with multiple contusions. Review of the facility fall investigation dated 08/05/24 revealed Resident #35 was being changed by Certified Nurse Aide (CNA) #207 and CNA #279 when the resident slid out of bed onto the floor while the staff tried to break the fall which resulted in swelling and pain to the left face and upper cheek area. A written witness statement from CNA #207 reported helping change Resident #35 when she slid out of bed, and CNA #279 helped stop the fall to the floor. A written witness statement from CNA #279 reported assisting the resident when she slid off the bed and trying to stop the fall as much as possible bracing the resident. Review of the nursing progress note dated 08/06/24 at 1:10 P.M. identified as a late entry revealed the interdisciplinary team reviewed Resident #35's fall, and it was noted the resident rolled out of bed while being assisted with toileting needs. A nursing assistant (unnamed) broke the fall. Resident #35 had swelling to the left side of the face and was sent to the hospital for evaluation. Grab bars to both sides of the bed were implemented (as a result of the incident). Review of the nurse practitioner progress note dated 08/06/24 revealed Resident #35 was examined due to being sent to the hospital on 08/05/24 following a fall from the bed with facial injury. Per the hospital, multiple imaging was completed, and the resident returned with no new orders and a diagnosis of facial contusion. Resident #35 had bruising and swelling to the left eye and cheek and cried out with range of motion to the left elbow. Review of disciplinary action forms dated 08/06/24 revealed CNA #207 and CNA #279 received a written warning for aggressive care due to Resident #35 being over-rolled to point where the resident was rolled off the bed. The performance improvement identified was to properly roll residents on their side during incontinence care. Review of the nursing progress notes from 08/06/24 through 08/16/24 revealed Resident #35's left cheek and eye orbit remained swollen and bruised with intermittent complaints of pain to the left side including the shoulder, elbow, and arm. Interview on 10/10/24 at 1:22 P.M. with Director of Nursing (DON) verified the above findings and indicated after the details of the incident were discussed with CNA #207 and CNA #279. The DON revealed it was understood that Resident #35 was over-rolled and fell on to the floor. The DON revealed the nursing assistants (CNAs) were at fault and caused the resident's fall to occur. Following the incident both CNAs received a reprimand followed by an in-service on incontinence care and repositioning. On 10/16/24 at 4:05 A.M. a telephone interview with CNA #207 revealed she remembered when Resident #35 fell , but the STNA denied being present during the incident and denied writing a witness statement or receiving disciplinary action as a result of the incident. During a follow-up interview on 10/16/24 at 9:18 A.M. with CNA #207, the STNA continued to state she had not been present nor was she providing care for Resident #35 at the time of the fall on 08/05/24. CNA #207 revealed CNA #230 had reported to her being involved with the incident along with CNA #201. On 10/16/24 at 9:39 A.M. a telephone interview with Licensed Practical Nurse (LPN) #264 revealed the LPN recalled the incident with Resident #35 on 08/05/24 stating the two nursing assistants present were CNA #201 and #230. The LPN revealed the CNA staff reported a fall occurred while they were changing the resident when they rolled her over, she moved about in bed causing her to slide out of the bed. On 10/16/24 at 9:45 A.M. a telephone interview with CNA #230 revealed she recalled Resident #35's fall on 08/05/24. At the time of the interview CNA #230 revealed she was providing care to Resident #35 at the time of the fall. CNA #230 stated CNA #201 was assisting with providing Resident #35 incontinence care. While rolling the resident over, CNA #230 stated she stepped away (from the resident) to grab a washcloth when Resident #35 started moving her legs and rolled over more. CNA #230 revealed they could not pull the resident back, and the resident fell out of the bed toward CNA #201 who did try to stop the fall but could not. Interview on 10/16/24 at 9:50 A.M. with the DON and Administrator verified the cause of Resident #35's fall remained consistent despite a discrepancy with which staff were actually present at the time of the incident. Review of the undated facility procedure, Turning Patients Over in Bed, revealed before turning a resident, position residents closest to the side of the bed to ensure they will not end up too far on the edge of the other side of the bed which increases the chance of falling off the bed. This deficiency represents non-compliance investigated under Complaint Number OH00157983.

Based on closed record review, review of a facility fall investigation, hospital record review, facility policy and procedure review and interviews, the facility failed to provide Resident #06 with necessary and an appropriate level of assistance with bed mobility during incontinence care resulting in the resident falling out of bed. In addition, the facility failed to thoroughly investigate the fall to determine the root cause to identify potential hazards to reduce and/or eliminate falls with major injury. Actual Harm occurred on 08/28/23 when State tested Nursing Assistant (STNA) #400 was providing incontinence care to Resident #06 without the appropriate level of assistance, the resident rolled out of bed and fell to the floor. Following the incident, the resident was transported to the hospital and diagnosed with a right distal femur fracture which required surgical intervention. This affected one resident (#06) of three residents reviewed for falls. The facility census was 61. Findings include: Review of the closed medical record revealed Resident #06 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, legal blindness, and hyperlipidemia. Resident #06 was discharged to the hospital on 08/28/23 and did not return to the facility. Review of the plan of care dated 12/17/22, revealed Resident #06 had potential risk for falls related to end stage renal disease with dialysis three times weekly, diabetes, hypotension, and gastro-esophageal reflux disease. Interventions included bed against wall, educating resident to use call light when attempting to sit on edge of bed, and low bed with mat as ordered. Review of the plan of care dated 01/02/23, revealed Resident #06 had an activities of daily living self-care performance deficit related to chronic kidney disease, impaired mobility, impaired vision, and variable fatigue level. Interventions included the resident was dependent with two staff-person assist with mechanical (Hoyer) lift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #06 was cognitively intact with no exhibited behaviors. The assessment revealed the resident required extensive assistance from two staff for bed mobility and transfers. Review of the physician's orders for August 2023 revealed the resident had an order for a Hoyer lift for transfers. Review of Resident #06's nursing progress note dated 08/28/23 and timed 6:49 A.M. revealed the resident rolled off bed to floor during check and change (incontinence care) at approximately 5:30 A.M. The resident reported pain rated a four out of ten to his right leg. There was no abrasion, edema, or open area observed on his right leg. The resident reported he hit his head on the bed rail and a lump on the rear right side of head was noticed. The resident denied head pain and vital signs were within normal limits. Review of Resident #06's nursing progress note dated 08/28/23 and timed 11:24 A.M. revealed the resident returned from dialysis, neurological checks were completed throughout dialysis, and the resident remained alert and oriented. A nurse practitioner through the resident's insurance program was assessing the resident at this time. Review of the Nurse Practitioner (NP) note, dated 08/28/23, revealed the resident was seen for follow-up after a fall from bed while receiving care the morning of 08/28/23. The resident reported he hit his right thigh on the floor and the posterior right side of his head on the bed rail. The resident now had a small scalp hematoma and right thigh hematoma. The resident's primary NP was contacted. The resident was on an anticoagulant medication and needed to have a computerized tomography (CT) scan completed. Both NPs agreed to send the resident to the emergency department for a CT scan. Review of Resident #06's nursing progress note dated 08/28/23 and timed 1:33 P.M. revealed the resident was sent to the hospital for a CT scan. The physician, family, and Assistant Director of Nursing (ADON) were notified. Review of the hospital documentation revealed the resident was admitted to the hospital on 08/28/23 with a right distal femur fracture. While in the hospital, the resident underwent intramedullary nailing (surgery to repair and stabilize a broken bone). Post-operation, the resident was stable and was discharged . Review of a witness statement from STNA #400, dated 08/28/23 revealed on 08/28/23 at approximately 5:30 A.M. STNA #400 went in to finish up Resident #06. STNA #400 went to roll Resident #06 and Resident #06 let go of the bed rail and rolled off the bed. Resident #06's legs hit the ground first, so he was in a sitting position when STNA #400 went around the bed. Resident #06 started to lay back, so STNA #400 lifted the bed and she and the nurse assisted with getting the resident back into the bed. Review of a witness statement from Licensed Practical Nurse (LPN) #390 dated 08/28/23 revealed the LPN observed the resident lying flat on his back on the floor next to his bed. The aide stated the resident rolled off his bed during incontinence care. The resident complained of pain rated a four out of 10 to his right leg. There was no redness, open area, or edema observed in the right leg. A lump on the right side of the resident's head was noticed. The resident denied any pain and vital signs were normal. Review of facility fall documentation, dated 08/31/23 revealed the resident stated he rolled off the bed while the aide was checking and changing him. The resident was educated on not rolling to the edge of the bed when repositioning himself. The fall documentation did not contain any information on completion of a root cause analysis. Interview on 09/22/23 at 12:47 P.M. with Resident #06's family member, revealed Resident #06 was at another nursing facility because he did not feel comfortable going back to the facility. Resident #06's family member reported Resident #06 fell out of bed during care, which resulted in a hip fracture which required surgery. Resident #06's family member reported he did not want to speculate on the specifics of what occurred, as he had received a couple of different stories from the facility, as well as Resident #06's recollection of the incident. Interview on 09/22/23 at 1:59 P.M. with LPN #390 verified she was the nurse working when Resident #06 fell from his bed during care on 08/28/23. LPN #390 reported on the morning of 08/28/23, STNA #400 yelled down the hallway for help. LPN #390 stated STNA #400 informed her that while she was changing Resident #06, she rolled him to his right side, and he rolled out of the bed. LPN #390 stated Resident #06 confirmed that was what happened at that time. LPN #390 reported STNA #400 was the only staff member in the room at the time the resident fell . LPN #390 verified the fall resulted in a hip fracture. Interview on 09/22/23 at 3:22 P.M. with STNA #400 verified she had provided care for Resident #06 the date he had a fall with injury. STNA #400 reported she was the only staff member in the room and was providing care to Resident #06. STNA #400 stated the resident rolled toward the window and she placed a brief underneath him. When Resident #06 rolled the other way, he fell off the bed and onto the floor. STNA #400 reported Resident #06 was legally blind and could not see where he was going when rolling. STNA #400 reported she could not grab the resident fast enough to keep him from falling. Interview on 09/22/23 at approximately 3:40 P.M. with the Assistant Director of Nursing (ADON) revealed there was no documented root cause analysis in an attempt to identify the cause of the fall. The ADON reported when a resident sustained a fall, a risk management form was completed, immediate interventions were put into place, and the clinical team discussed each fall to determine whether anything else would need to be implemented. The ADON also reported she was unaware Resident #06 required two staff members for bed mobility (per the Minimum Data Set (MDS) 3.0 assessment completed on 07/28/23). Interview on 09/22/23 at 5:02 P.M. with Regional MDS Coordinator #505, verified she completed the activities of daily living portion of the MDS assessment. Regional MDS Coordinator #505 reported she completed this while off-site, and relied on STNA charting, progress notes, skilled charting, and the resident's medical record to determine the need for staff assistance. Regional MDS Coordinator #505 verified Resident #06 required extensive assistance of two staff for bed mobility. Review of the facility policy titled Fall Risk Assessment F689, revised November 2017, revealed the facility would seek to identify and document risk factors for falls. The policy stated the interdisciplinary team would review the resident and resident's record including but not limited to environmental factors that may have contributed to falling such as lighting, layout and facility staffing, and would complete an evaluation in attempt to identify the root cause of a fall. This deficiency represents non-compliance investigated under Complaint Number OH00146327.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure timely assessments were completed, and adequate interventions were implemented to prevent the development of Resident #16's pressure ulcer. Actual Harm occurred on 01/11/23 when Resident #16, who was paraplegic and required extensive assistance of two staff for activities of daily living (ADL) including bed mobility, and transfers was found to have a deep tissue pressure injury (localized areas of tissue necrosis that developed when soft tissue was compressed between bony prominence and external surface for long period of time) to her left lateral foot over the midfoot that was purple- gray in color and the center of the pressure ulcer contained black dry eschar (dead tissue). This affected one resident (Resident #16) of three residents reviewed for wound management. Findings included: Review of the medical record for Resident #16 revealed an admitted [DATE] and diagnoses included paraplegia, person injured in motor- vehicle accident, morbid obesity, and bipolar disorder. Review of care plan dated 10/25/22 revealed Resident #16 had the potential for alteration in skin integrity as she required protective and preventative skin care maintenance related to decreased mobility. Interventions dated 10/25/22 included inspect for any reddened areas during daily care, pressure reducing mattress to bed, weekly skin assessments and notify wound nurse, physician, and family of any new areas. There was nothing in the care plan regarding floating heels and/or not having the heels/ feet not in contact with external surface for prolonged period of time. Review of weekly skin observations (per care plan) dated from 12/01/22 to 01/11/23 revealed Resident #16 had a skin observation completed on 12/02/22, 12/10/22, 12/18/22 but then did not have one completed until 01/08/23. She had one completed on 01/15/23 but then not again until 1/30/23. There was no evidence she refused her assessments. Review of Resident #16's Skin Observation dated 12/10/22 and completed by Licensed Practical Nurse (LPN) #610 revealed the resident's skin was intact. Review of Resident #16's Braden Score Evaluation dated 12/12/22 and completed by Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #608 revealed Resident #16 was at low risk for developing pressure ulcers. She was occasionally moist, chairfast, very limited with her mobility, and had a potential problem with friction and shear. Review of Resident #16's Skin Observation dated 12/18/22 and completed by LPN #610 revealed skin was intact. Review of Resident #16's Skin Observation dated 01/08/23 and completed by LPN #611 revealed Resident #16 had a black spot to her left great toe. There were no measurements. There was no documentation regarding areas to her left heel and/or her left lateral midfoot. Review of nursing note dated 01/09/23 at 10:31 A.M. and completed by LPN #601 revealed she spoke with Resident #16 regarding care as the resident complained of bruising to her left heel and slight dark discoloration around big toe area. The note revealed she normally rested her foot on the leg rest of wheelchair with or without shoes for a long period of time. The note revealed the resident was paralyzed from the waist down and could not feel pain to her left heel. The left heel was purple in color and measured a length of six centimeter (cm) and width of 3.5 cm. She had no other open areas. The note revealed to pad and protect the area and she was educated on not resting her heel on the metal part of the leg rest. The nurse practitioner was notified and ordered an ultrasound to her bilateral extremities and an order for bilateral cushion boots. There was no documentation regarding a pressure area to her left lateral midfoot. Review of nursing notes dated 01/10/23 revealed there was no documentation regarding Resident #16 having a pressure ulcer to her left lateral midfoot. Review of progress note dated 01/11/23 and completed by Wound Physician #607 revealed Resident #16 had a deep tissue pressure ulcer that was acquired late December 2022 to her left medial heel that measured a length of four centimeters (cm), width of four cm and depth was unable to be determined. The wound was described to be ovoid-shaped, red- purple discoloration with thickened intact epidermis and the peri wound was dry and thick. The note revealed she also had a wound acquired late December 2022 that also was from pressure from her shoes and/ or wheelchair leg rests that measured a length of 11.5 cm, width of four cm and the depth was unable to be determined. The wound was described as irregular ovoid shaped purple- gray discolored epidermis with the center of the pressure ulcer containing black dry eschar over the midfoot. Review of Skin Grid Pressure dated 01/11/23 and completed by ADON/ RN #608 revealed Resident #16 had a facility acquired pressure ulcer to her left heel that measured a length of four cm, width of four cm and without any depth. The area was described as suspected deep tissue injury with a date of origin as 01/10/23. Review of Skin Grid Pressure dated 01/11/23 and completed by ADON/ RN #608 revealed Resident #16 had a facility acquired pressure ulcer to her left lateral foot with a date of origin as 01/10/23 and suspected as a deep tissue pressure injury. The area measured a length of 11.5 cm, width of four cm and had no depth. There was no other description of the wound. Record review revealed the plan of care interventions were implemented on 02/02/23 for bilateral lower heels/ feet cushion boots and to pad and protect heels. These interventions were not initiated until after the pressure ulcers had developed Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/23 revealed Resident #16 had intact cognition. She required extensive assist of two staff with bed mobility and transfers. She was unable to ambulate. She was at risk for developing pressure ulcers and had one Stage IV (pressure ulcer with full thickness skin loss with extensive damage to the muscle, bone or supporting structures) pressure ulcer that was not present on admission. Review of progress note dated 06/21/23 and completed by Wound Physician #607 revealed Resident #16's ulcer to her left lateral midfoot bow was a Stage IV pressure ulcer that measured a length of 1.7, width of one and depth of 0.1 cm. The area was irregular ovoid- shaped full thickness wound with a base of 100 percent healthy granulated tissue. The left heel wound had resolved on 02/22/23. Review of Skin Grid Pressure dated 06/28/23 and completed by RN #609 revealed Resident #16 continued to have a pressure ulcer to her left lateral foot that was now staged as a Stage IV. The assessment revealed the wound measured a length of 1.5 cm, width of 0.9 and depth of 0.1 cm. There was no other description of the wound as under description, drainage, color, and odor was blank. Review of July 2023 physician orders revealed Resident #16 had an order to cleanse her left lateral foot with normal saline, dry heel and apply moistened normal saline collagen powder, top with silver calcium alginate and cover with dry dressing every Monday, Wednesday, Friday and as needed. She also had an order to apply foam pad every Monday, Wednesday, and Friday and as needed to her left heel. Interview on 07/03/23 at 7:57 A.M. with Resident #16 revealed she had two pressure ulcers on her left foot: one on her heel and one in the middle of her foot. She revealed she was a paraplegia and unable to see the bottom of her feet and feels the staff should have seen the wounds before the wounds got as bad as they did. She revealed the Wound Physician #607 had told her the pressure ulcer in the middle of her foot was quite large and was not doing well. She revealed she feels the nurses do not do her dressing changes as ordered as she goes days without the dressing being changed. Observation on 07/03/23 at 10:40 A.M. of wound care for Resident #16 completed by ADON/ RN#608 and LPN/ unit manager #614 assisting by holding Resident #16's foot revealed ADON/ RN #608 removed an undated dressing to her left lateral midfoot that contained no drainage. She described the wound to contain dark tissue in the center of the wound with maceration surrounding. She revealed the wound was classified as a Stage IV pressure ulcer and was facility acquired. She cleansed the wound and treatment was applied as ordered. Interview on 07/05/23 at 8:54 A.M., 12:41 P.M. and 1:20 P.M. with the Director of Nursing (DON) revealed Wound Physician #607 had stated in his progress note that Resident #16's pressure ulcers had developed late December 2022, but she revealed this was inaccurate as the origin of both pressure wounds was dated on the Skin grid Pressure as 01/10/23. She revealed the first measurements and assessment per the medical record of the pressure ulcer to her left lateral mid foot was though on 01/11/23 as that was when the actual date when it was found and she verified the wound measured a length of 11.5 cm, width of four cm and the depth was unable to be determined. She also verified the wound was found as an irregular ovoid shaped purple- gray discolored epidermis with the center of the pressure ulcer containing black dry eschar over the midfoot. She also verified the care plan for Resident #16 was to have weekly skin observations but on review of the skin observations sheets this had not been completed as she had one completed on 12/18/22 but then did not have one completed until 01/08/23 and she had one completed on 01/15/23 but then not again until 1/30/23. She also verified the care plan identified preventive measures to prevent pressure ulcers to her bilateral heels such as cushion boots to bilateral lower extremities and pad and protect heels were dated 02/02/23 after she had developed the pressure ulcers. She verified Resident #16 did not have any interventions prior to the development of her pressure ulcer to her left heel and left lateral mid foot such as to float her heels and/ or avoid contact of her heels with external surfaces, and heel protectors despite Resident #16 being a paraplegic and had impaired mobility. Review of facility guideline labeled, Prevention of Pressure Injuries Guidelines dated as last revised August 2022 revealed the purpose of the guideline was to provide information regarding the identification of pressure injury risk factors and prevention intervention for specific risk factors. The guideline revealed risk factors that increase susceptibility to developing a pressure injury included impaired/ decreased mobility. The guidelines included specific risk factors also included friction and shear and one intervention was to monitor shoes for proper fit and another risk factor of chair bound was to evaluate postural alignment, and change position every two hours. The guideline also included for immobility risk factors to float heels when in bed. This deficiency represents non-compliance investigated under Complaint Number OH00143801.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide appropriate supervision of one cognitively impaired resident (Resident #53), who was at high risk for elopement and required supervision with activities of daily living, resulting in the resident leaving the facility without staff knowledge on 08/16/22. This resulted in Immediate Jeopardy when Resident #53 was last observed on 08/16/22 at 7:00 P.M. sitting on the bed in his room by Registered Nurse (RN) #515 and State tested Nursing Assistant (STNA) #414 and was not identified as missing until Resident #53's wife called the facility at 8:05 P.M. and informed RN #515 that Resident #53 had left the facility and was at a local drugstore located on the corner of two busy roads approximately a quarter of a mile away from the facility. Resident #53 passed through two secured doors inside the facility to reach the outside and walked along a busy road and passed by a busy shopping area on his way to the drugstore. The local police escorted Resident #53 back to the facility. Resident #53 had no known injuries. This affected one resident (Resident #53) out of three residents reviewed for elopement. On 08/25/22 at 4:09 P.M. Senior Administrator #606, Licensed Nursing Home Administrator (LNHA) #607 and the Director of Nursing were notified Immediate Jeopardy began on 08/16/22 at 7:00 P.M. when Resident #53 who was at risk for elopement was last observed by facility staff and was not identified as missing until Resident #53's wife called the facility at 8:05 P.M. Resident #53 passed through two secured doors inside the facility to reach the outside and walked along a busy road and passed by a busy shopping area on his way to the drugstore. The Immediate Jeopardy was removed on 08/19/22 when the facility implemented the following corrective action: A head count was completed by the nurse (Registered Nurse (RN) #515), on 8/16/2022, at 8:10 P.M. and reported to the Director of Nursing (DON), and the Administrator (Senior Administrator (SA) #606). Confirmation of the head count was completed. On 8/16/2022 at 8:16 P.M. Resident #53 returned to the facility with no negative effects. Resident #53's attending physician was notified by RN #515, on 8/16/2022 at 9:00 P.M. The Medical Director was notified of the elopement by the Administrator (SA #606) on 8/17/22 at 9:00 A.M. By 8/16/2022, all residents were assessed for elopement by the DON. As a result of the assessments, no other residents were identified as high risk for elopement. An elopement binder at each nurse's station had all residents identified as an elopement risk for staff review. On 8/16/2022 at 8:30 P.M., all staff in the building, including agency staff, were educated by the nursing supervisor in person to review the elopement binders at the start of each shift. This education was provided to the following staff members on shift which included one housekeeping aide, three nurses and 13 STNAs. On 08/17/2022 the remainder of the staff members were educated by the DON or LNHA (Licensed Nursing Home Administrator) either in person or over the phone which included the following staff members, 40 STNAs, seven dietary personnel, eight housekeeping personnel, one medtech, 13 administration, 12 nurses and eight agency nurses. The DON or designee would audit three residents weekly for three months. Audits would be reviewed by Quality Assurance and Performance Improvement (QAPI) monthly with recommendations for changes to be made as necessary. On 8/16/2022 at 8:30 P.M., all staff in the building, including agency staff, were educated by the nursing supervisor in person on the facility elopement procedures and ensuring that no residents were following while leaving unit, and the door closed completely before walking away. This education was provided to the following staff members on shift which included one housekeeping aide, three nurses and 13 STNAs. On 08/17/2022 the remainder of the staff members were educated by the DON or LNHA either in person or over the phone which included the following staff members, 40 STNAs, seven dietary personnel, eight housekeeping personnel, one medtech, 13 administration, 12 nurses and eight agency nurses. On 8/16/2022, a wander guard (alarmed monitoring device) was placed on Resident #53 upon return to the facility at 8:16 P.M. Exit door alarms were tested by the Nursing supervisor and were found to be working properly on 8/16/2022 at 8:30 P.M. Exit doors would be tested daily by Maintenance Director #503 or designee beginning 8/16/2022. Results would be reviewed in QAPI monthly. The Administrator or designee would conduct random audits starting 8/22/2022, of three staff, three times per week for four weeks to test staff knowledge of elopement procedures and how to prevent an elopement. Results will be reviewed in QAPI monthly. Newly admitted residents would continue to have an elopement assessments completed upon admission. The DON or designee would review the elopement assessment for accuracy and would continue indefinitely. On 08/17/22 family member and responsible parties were educated via an electronic communication system that when leaving the facility to ensure that no residents leave with them or behind them. On 8/17/2022 Administrator #606 attempted to contact all legible visitors on the log to interview them regarding when they left facility. No visitors contacted gave any valuable information regarding how elopement occurred. On 8/17/2022, sign placed at secured unit to remind visitors when leaving to ensure no residents follow and that door is secure before walking away. On 8/17/2022, a whole house audit was completed by Maintenance Director #503 to ensure all facility windows were secured. No negative outcome. On 8/17/2022, Resident #53's care plan was reviewed by the Clinical Reimbursement Specialist to ensure all appropriate interventions were in place due to his risk for elopement. All like residents care plans were reviewed and revised if necessary on 08/17/2022. The facility had Corporate Maintenance Staff ensure proper function of all facility doors on 8/19/2022. The Contracted Alarm Company was in the facility on 8/18/2022 to ensure proper function of all facility door alarms. Company was previously, contracted to check them at least four times per year On 8/26/2022, facility would start elopement drills on each nursing shift on a weekly basis. Although the Immediate Jeopardy was removed on 08/19/22, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of Resident #53's medical record revealed an admitted [DATE] and diagnoses included [CONDITION(S)], major depressive disorder and anxiety disorder. Review of Resident #53's physician orders dated, 05/17/22, revealed Resident #53 may go leave of absence with supervision. Review of Resident #53's Wandering and Elopement assessment dated [DATE] revealed Resident #53 was cognitively impaired with poor decision-making skills, had dementia, anxiety disorder, depression and ambulated independently. Resident #53 wandered aimlessly and there were significant changes in Resident #53's status. The assessment revealed Resident #53 liked to wander and roam throughout and was at a high risk for elopement. The assessment further revealed appropriate interventions were initiated and included Resident #53 was on a secured unit, his photo was in the elopement risk book, and staff were aware of Resident #53's elopement risk. Review of Resident #53's care plan dated, 05/18/22, revealed Resident #53 was at high risk for elopement. Resident #53 had a diagnosis of dementia and had impaired cognition. Resident #53 would remain safe within the facility unless accompanied by staff or other authorized persons through next review. Interventions included if Resident #53 was missing from the facility, follow elopement protocol, notify physician and family immediately and document. If Resident #53 was wandering in a potentially unsafe area or situation, redirect to safer area. Review of Resident #53's progress notes on 05/18/22 at 4:00 A.M. included Resident #53 had impaired decision making, disorganized thinking and trouble concentrating. The note revealed Resident #53 stood at the exit door and held bar at times. Resident #53 was distracted with snacks and fluids. Resident #53 was redirected when trying to wander into other resident rooms and had difficulty remembering where his room was. Review of Resident #53's Admission Minimum Data Set (MDS) 3.0 assessment dated , 05/24/22 revealed Resident #53 had severe cognitive impairment, required supervision with Activities of Daily Living, and walking was not steady, but resident could stabilize without staff assistance. Review of Resident #53's progress notes on 06/27/22 at 3:09 P.M. revealed Resident #53 was exit seeking. Review of Resident #53's progress notes on 08/10/22 at 3:55 A.M. revealed Resident #53 had difficulty remembering where his room was and needed redirection at times. Observation on 08/16/22 at 8:41 A.M. revealed a double door leading into the secured memory care unit from another hall inside the facility had a red button located on the wall. The red button needed to be pressed to gain entry to the secured unit. Once the button was pressed the door was able to be opened. One side of the double doors opened, and the secured unit could be entered. After entering the secured unit observation revealed one door prevented the other door from closing and locking to secure the unit. The door alarm sounded and after approximately 30 seconds State tested Nursing Assistant (STNA) #538 walked up the hall, pressed the red button on the wall outside the secured unit and forcefully pulled the door closed so it latched. The door alarm stopped sounding. STNA #538 stated the door had to be forcefully pulled shut to properly close and lock the doors and the door had been like that awhile. Review of Resident #53's Call Summary Report from the local police department revealed on 08/16/22 at 7:51 P.M. a call was placed from the local drugstore to the police requesting an officer be dispatched due to older male seemed confused. The [AGE] year-old male was wearing a green hat, black jacket, and black pants and stated he was walking back from the VA (Veteran Affairs). The officer spoke to the older male's wife and was identified as Resident #53 and had dementia. Resident #53 was transported back to the facility at 8:24 P.M. by the police officer and returned to his unit. Review of Resident #53's Behavior Note assessment dated [DATE] at 9:14 P.M. revealed Resident #53 was observed outside the facility. Resident #53 was brought back into the facility. Resident had no signs or symptoms of injury observed. No complaints of pain. Vital signs were temperature 97.8 Fahrenheit, pulse 80, respirations 18, blood pressure 120/72 with pulse oximeter (oxygen saturation) of 98% on room air. The Director of Nursing and Administrator were notified. The physician and family made aware of the current incident and plan of care at this time. Facility staff checked on patient frequently throughout the night patient resting in bed no signs and symptoms of distress noted. Review of the Self-Reported Incident Form (SRI), tracking number 2, dated 08/16/22 included at 8:05 P.M. the nurse received a call stating Resident #53 was at the local drugstore with the police. Resident #53 was escorted back to the facility with no visible injuries noted. The SRI further included no staff let Resident #53 off the floor, all doors were functioning properly. Staff statements do not indicated neglect occurred. Review of a Witness Statement written on 08/16/22 by Registered Nurse (RN) #515 revealed Resident #53 was in his bed at 7:00 P.M. RN #515 stated she received shift change report from the day shift nurse and began medication administration to the residents. At 8:05 P.M. RN #515 received a call from Resident #53's wife telling her Resident #53 was at the local drugstore and the police were with him. Resident #53 was escorted back to the facility by the police, and he was evaluated for injury. The DON was notified regarding the elopement. The statement further revealed after 7:00 P.M. Licensed Practical Nurse (LPN) 607 left the unit, the laundry aide and dietary aides entered and left the unit. No residents exited the unit at these times. The front door did not alarm in the lobby. An in-service was given for staff and a count of all residents was done with no other residents missing. The second State tested Nursing Assistant assigned to the secured unit arrived at 8:00 P.M. Interview on 08/17/22 at 4:14 P.M. with Maintenance Director (MD) #503 revealed he began working for the facility on 08/01/22. MD #503 confirmed the door to the secured unit did not close without being forcefully pulled shut and needed to be fixed. MD #503 stated he had a lot of work to catch up on since he started, and the previous maintenance director did not leave details regarding work needing to be done. Review of MD #503's Witness Statement dated, 08/19/22, included Traveling Maintenance Director (TMD) #608 assisted with maintenance and adjustment of the facility doors. Observation on 08/25/22 at 7:50 A.M. of the door leading into the secured unit revealed it closed and latched without being forcefully closed after it was opened to allow entry into the unit. Interview on 08/25/22 at 7:56 A.M. with State tested Nursing Assistant (STNA) #538 revealed the door to the secured unit was fixed either 08/18/22 or 08/19/22, it took all day because the latching mechanism needed fixed. STNA #538 stated the code was changed when the door was fixed. Interview on 08/25/22 at 7:56 A.M. with Licensed Practical Nurse (LPN) #607 revealed on 08/16/22 Resident #53's wife took Resident #53 out of the facility for about three hours and brought him back at dinner time. LPN #607 stated Resident #53's wife did not stay after she brought him back to the facility. LPN #607 indicated after his wife left Resident #53 was a little more difficult to redirect and kept trying to leave the facility via the courtyard door. LPN #607 stated typically Resident #53 was at the exit doors frequently around dinner time and always messes with the exits around 6:00 P.M. to 7:00 P.M. LPN #607 stated visitors would hold the door open; the alarm would sound and Resident #53 would push buttons on the key pad and had often been seen trying to get out of the secured unit. LPN #607 confirmed Resident #53 tried to get out the emergency door leading to the outside and the secured door leading to the hall by the conference room. LPN #607 stated the door leading to the outside would sound an alarm when first pushed and could be opened after it was pushed on continuously for 15 seconds. LPN #607 stated if the emergency door alarm sounded for less than a minute the code on the keypad could turn the alarm off. LPN #607 stated if the alarm lasted more than a minute the emergency door alarm could only be turned off by using a special key and pressing a code on the keypad by the door. The key was only located on the charge nurse's key ring and the Administrator and MD #503 had keys as well. Observation on 08/25/22 at 7:56 A.M. revealed Resident #53's room was two doors away from the secured door leading to the hall by the conference room. This was the door which had to be forcefully closed when it was opened. Interview on 08/25/22 at 8:31 A.M. with Senior Administrator (SA) #606 revealed on 08/16/22 at 8:05 P.M. Registered Nurse (RN) #515 received a call that Resident #53 was found at a local drugstore, the police brought him back to the facility, he was evaluated and had no injuries. SA #606 stated RN #515 and STNA #414 saw Resident #53 in bed at 7:00 P.M. SA #606 indicated she believed a family member walked out of the secured unit and out the facility with Resident #53 and did not realize he was a resident. SA #606 indicated after Resident #53 eloped from the facility family members were educated to check with a staff member if they did not know a person attempting to leave the secured unit. SA #606 stated she did not feel the staff were neglectful and unsubstantiated the SRI. SA #606 stated visitors to the facility on [DATE] were called and none remembered anyone leaving the facility at the same time they did and the visitors stated door alarms did not sound. SA #606 stated Resident #53 did not have a wander guard because he showed no elopement tendencies and memory care unit residents did not have wander guards because it was a secured unit. SA #606 stated staff at the drugstore saw Resident #53, he looked confused, so they called the police. Interview on 08/25/22 at 9:22 A.M. with Maintenance Director (MD) #503 revealed the door leading to the secured unit by the conference room was fixed on 08/19/22. MD #503 stated TMD #608 helped him replace the hinges. MD #503 stated the hinges were shot and the Assisted Living Maintenance Director told him the previous Maintenance Director might have bent the hinges when he worked on the door. MD #503 stated one door would hit the other door and would be unable to close, the door was not sitting correctly in the door frame and the door had to be pulled hard to close it so it locked. MD #503 stated the code was changed and the door hinges were replaced and now the door closed and locked without having to be forcefully pulled shut. Interview on 08/25/22 at 10:01 A.M with STNA #414 revealed she worked second shift on 08/16/22 and was present when Resident #53 eloped from the facility. STNA #414 stated around 7:00 P.M. she saw Resident #53 sitting on his bed. STNA #414 indicated after she saw Resident #53, she sat at the nurse's station to catch up on her charting. STNA #414 stated Registered Nurse (RN) #515 arrived at 7:00 P.M. for her shift, received report from LPN #607 and after report was given LPN #607 left the unit. STNA #414 stated she was the only STNA present in the secured unit and RN #515 was the only nurse present from 7:00 P.M. to 8:05 P.M. STNA #414 indicated a little after 8:00 P.M. a female called into the unit for the nurse, RN #515 answered the call and was told Resident #53 was at the drugstore. STNA #414 stated a head count was immediately done to make sure all other residents were accounted for. STNA #414 stated she did not get up from her seat at the nurse's station until the phone rang at 8:05 P.M. because she had a lot of charting to do. STNA #414 indicated she did not hear a door alarm from 7:00 P.M. to 8:05 P.M. STNA #414 stated Resident #53's room was two doors away from the exit leading to the hall by the conference room, the door was hard to pull close and that was how Resident #53 likely left the secured unit. STNA #414 stated Resident #53 probably caught the door before it was locked and the alarm sounded. STNA #414 stated the red button on the wall outside the secured unit needed to be pushed to keep the alarm from sounding when the door was opened, and Resident #53 probably slipped out when the door was not locked. STNA #414 stated the door had to be pulled hard to close and sometimes there was a few second delay before the alarm would sound. STNA #414 stated she would have to run down the hall help close the doors for guests who did not know the door was broken. STNA #414 stated the door was broken for a while, she did not know how long, but it could have been a couple months. STNA #414 revealed the door was fixed after Resident #53 eloped, and indicated it was hard to understand how Resident #53 was able to walk through two secured doors and leave the facility. Interview on 08/25/22 at 10:23 A.M. with SA #606 and the DON revealed the receptionist for the facility left at 7:00 P.M. and after she left no one was assigned to sit at the front desk. SA #606 stated the door alarms were checked and all worked appropriately. SA #606 stated some visitors knew the code to get out of the facility and if they did not know the code, they would need to ask a staff member to open the door for them. SA #606 stated if any of the doors leading to the outside were pushed an alarm would sound and if the door was pushed for 15 seconds it would open but would still alarm and a code would need to be entered into the keypad by the door. Observation on 08/25/22 at 10:57 A.M. with the DON and SA #606 revealed a fence surrounded the facility property on three sides and the route to the drugstore included a walk on a sidewalk near a busy road past an entrance to a busy shopping area. The drugstore was located on the corner of two roads with high traffic and was approximately one quarter mile distance from the facility. Interview on 08/25/22 at 11:14 A.M. with Resident #53's wife revealed it was very upsetting to get a call from police Resident #53 was wandering around outside. Resident #53's wife stated he might not be as lucky as this time if he gets out again. Resident #53's wife stated the intersection could be dangerous where police found him, and her first concern was a safety issue. Resident #53's wife stated he could have been really hurt or worse. Interview on 08/25/22 at 12:25 P.M. with Nurse Practitioner (NP) #609 revealed she was notified Resident #53 eloped from the facility. NP #609 stated she saw Resident #53 unofficially after he eloped from the facility but did not document the visit or charge him for a visit. NP #609 stated Resident #53 was high risk for not knowing how to get back to the facility and not able to take care of himself. NP #609 stated Resident #53 possibly might try to cross the street, but she thought he might be too scared to attempt it. Review of the facility policy titled Elopement Policy, revised 07/25/18 revealed the facility would identify residents with potential and or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility would implement its policies and procedures immediately to locate the resident in a timely manner. Residents identified at risk of elopement would have interventions immediately implemented to reduce the resident's risk of elopement. Residents identified at risk would have their picture and face sheet placed in a binder that was kept in an area accessible by staff. This deficiency substantiates Master Complaint Number OH 250.

Based on observation, record review, interview, and facility policy review, the facility failed to timely initiate and provide adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm for Resident #18, who was admitted to the facility on [DATE]. Resident #18 was dependent on two staff assistance for bed mobility and required [CONDITION(S)] care. Resident #18 developed a posterior neck pressure wound on 12/15/21. Continued treatments were not administered as ordered and by 06/13/22, Resident #18's pressure wound had reoccurred, received inadequate treatments, and required mechanical debridement. This resulted in actual harm for Resident #38, who was admitted to the facility on [DATE], was dependent on two staff assistance for bed mobility and required [CONDITION(S)] care. On 05/02/22, Resident #38 developed a posterior neck pressure ulcer, and by 06/06/22, due to improper and lack of wound treatments the pressure ulcer declined and developed [CONDITION(S)] which required antibiotic treatment. This resulted in actual harm for Resident #41, who was admitted to the facility on [DATE], was dependent on one staff assistance for bed mobility, and had severe cognitive impairment. Resident #41 had skin areas identified upon admission including to the right and left heel with no descriptive information. By 05/09/22, Resident #41's right and left heel pressure ulcers required debridement. From 05/26/22 to 05/30/22, Resident #41 was treated at the hospital for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm for Resident #73, who was admitted to the facility on [DATE], was extensive one staff assistance for bed mobility, dependent on one staff assistance for transfers, and was assessed to be at low risk for the development of pressure ulcers. On 04/25/22, an open area was identified on the left lateral side of the foot. There were no wound treatments or assessments completed until 06/13/22 when the area was identified as a left lateral foot unstageable pressure wound (full-thickness skin and tissue loss in which the extent of the ulcer cannot be confirmed because it is obscured by slough or eschar) and required sharp debridement. This affected four Residents (#18, #38, #41 and #73) of eight residents identified with pressure ulcers. The facility census was 97. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE]. Resident #18 was transferred to the hospital on 01/27/22 and returned on 02/02/22 and was transferred to the hospital again on 04/05/22 and returned on 04/06/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had severe cognitive impairment assessed as rarely or never understood. Resident #18 was dependent on two staff assistance for bed mobility and was dependent on one staff assistance for toileting. Transfers did not occur. The assessment indicated Resident #18 was always incontinent of urine and bowel. Review of the plan of care initiated 04/02/21 revealed Resident #18 was at risk for impaired skin integrity related to confined to bed all or most of the time, incontinence, on a [CONDITION(S)], a history of pressure ulcers, and required staff to reposition. Interventions included to apply protective barrier cream after incontinent episodes; assist with turning and repositioning as needed; and treatments per physician orders. Review of the pressure ulcer risk assessment completed 08/29/21 revealed Resident #18 was at high risk for the development of pressure ulcers. There were no additional pressure ulcer risks completed after 08/29/21. Review of the skin grid pressure assessment dated [DATE] revealed an original wound development of the left posterior neck which measured 2.0 centimeters (cm) length by 3.4 cm width by 0.2 cm depth and described as a stage 3 pressure ulcer (full-thickness skin loss in which subcutaneous fat may be visible but bone, tendon or muscle are not exposed) with maceration and a faint odor. Review of Resident #18's physician orders revealed an undated order for a pressure reducing mattress to the bed which was discontinued on 04/05/22, an order dated 02/28/21 to change [CONDITION(S)] ties as needed which was discontinued on 01/27/22, and an order dated 09/24/21 to apply an abdominal dressing (ABD) under the left side of the neck underneath the [CONDITION(S)] ties every shift for a protective dressing for the skin which was discontinued on 10/13/21. There were no additional protective dressing orders initiated after 10/13/21 prior to the onset of the stage 3 left posterior neck pressure ulcer. On 12/16/21, an order was initiated for a treatment to the left posterior neck to cleanse with soap and water, pat dry, apply triad (a wound paste used for moist wound beds) to absorb and secure with an ABD four times daily, and to not allow the [CONDITION(S)] ties to touch the skin. The order was discontinued on 01/27/22. Review of the weekly skin grid pressure assessments dated on 12/22/21, 12/29/21, 01/05/22, 01/12/22, 01/19/22 and 01/26/22 revealed the left posterior neck stage 3 pressure ulcer was assessed for healing until Resident #18 was transferred to the hospital on 01/27/22. Review of interdisciplinary team progress note dated 02/03/22 revealed Resident #18 was readmitted to the facility on [DATE] with an ulcer to the coccyx. There was no assessment of the wound. Review of the medical record revealed no skin assessment upon return from the hospital on 02/02/22. Review of Resident #18's physician orders revealed an order dated 02/03/22 for a treatment to the coccyx to wash with normal saline, pat dry, and apply a foam dressing daily, which was discontinued on 02/25/22. A new order was initiated on 02/25/22 for triad paste to the sacrum topically every shift for the skin, which was discontinued on 04/05/22. Review of the medical record revealed no skin grid pressure assessments and no wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weekly skin grid pressure assessment dated on 02/16/22 revealed a posterior neck pressure wound documented as not a new area with no origination date. The area measured 1.0 cm length by 2.5 cm width by 0.1 cm depth. The wound stage was documented as not available. There was no documented appearance or status of the wound. The wound drainage was minimal with odor. Review of the weekly skin grid pressure assessment dated on 02/21/22 revealed a posterior neck pressure wound documented as not a new area with no origination date. There was no documentation of wound measurements, or a general appearance of the wound. The drainage was described as minimal with odor and the status of the wound was not documented. The area was documented as healed. Review of Resident 18's physician orders revealed no treatment order for the posterior neck pressure wound from 02/16/22 through 02/21/22. On 02/25/22, an order was initiated for a treatment to the posterior neck to cleanse with normal saline, pat dry, apply an ABD daily and as needed, which was discontinued on 04/05/22 when Resident #18 was transferred to the hospital. Review of the weekly skin grid pressure assessment dated on 03/28/22 revealed a posterior neck pressure wound, stage 3, documented as not a new area with no origination date. There was no documentation of wound measurements. The wound was described as 100 percent epithelial healed on last wound report and was a check for continued healing. The drainage was described as minimal serosanguinous (thin and watery and pink in color) with odor. The status of the wound was described as improved and healed on 02/21/22. Review of the medical record revealed no wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note dated 04/06/22 revealed Resident #18 returned from the hospital. There was no documentation of a skin assessment. Review of the respiratory progress note dated 04/12/22 revealed Resident #18 had copious secretions. It was recommended for [CONDITION(S)] ties to be changed daily to prevent skin breakdown. Review of physician/nurse practitioner (NP) progress note dated 04/15/22 revealed pressure ulcers and to reference wound report. Thick yellow secretions were noted in [CONDITION(S)] collar. Review of respiratory note dated 04/18/22 revealed due to neck wounds and copious secretions it was recommended for [CONDITION(S)] ties to be changed out daily to prevent further skin breakdown and promote healing of current neck wounds, and to keep area as dry as possible. Review of physician/NP progress note dated 04/22/22 revealed pressure ulcers and to reference wound report. Review of Resident #18's physician orders revealed on 04/12/22 an order the medical revealed a treatment to cleanse the neck with normal saline, pat dry and apply an ABD daily and as needed, which was discontinued on 06/08/22. An order initiated 04/07/22 to change the [CONDITION(S)] collar and mask weekly on Sundays and as needed was discontinued on 04/13/22 and was re-initiated on 04/13/22 to change weekly on Tuesdays. There were no physician orders to change the [CONDITION(S)] collar or [CONDITION(S)] ties daily as recommended to prevent further skin breakdown and promote healing of neck wounds as noted in the progress note dated 04/18/22. Review of the skin grid pressure assessment dated [DATE] revealed a posterior neck pressure wound was identified with an origination date of 06/06/22. The pressure ulcer stage was documented as not available, measured as 4.0 cm length by 0.3 cm width by 0.2 cm depth. There was no general wound appearance documented. There was erythematous (redness) surrounding the wound with light serosanguinous drainage. The status of the wound was not described. Review of the medical record revealed there were no weekly skin grid pressure assessments completed after 06/08/22. Review of the facility wound tracking log dated week ending 04/25/22 revealed Resident #18 had a posterior neck stage 3 pressure ulcer which originated in the facility on 12/15/21 which was closed for two weeks, healed on 02/28/22, with a continued treatment. Review of the Treatment Administration Record (TAR) for May 2022 and June 2022 revealed the treatment to the neck dated 04/12/22 to cleanse with normal saline, pat dry, apply an ABD daily and as needed daily was not completed as ordered during day shift on 05/21/22, 05/23/22, 05/25/22, 05/28/22, 05/29/22 and 06/03/22. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan for the wound was to cleanse with a wound cleanser, pat dry, apply xeroform (occlusive dressing to promote wound healing) to wound bed and ABD pad to cover daily and as needed; perform routine [CONDITION(S)] care including daily drain sponge changes and weekly neck tie changes; an air mattress; and a strict regimen of turning and repositioning every two hours and as needed. The treatment plan was provided to the wound care nurse verbally and written. Review of Resident #18's physician orders revealed an order dated 06/08/22 for a treatment to cleanse the wound bed with normal saline, pat dry, apply xeroform and cover with ABD daily and as needed, which was discontinued on 06/20/22. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The soiled dressing was removed with dirty odor and positive strike through (the dressing barrier was breached, and bacteria can access the wound), it was dried into the wound bed and black mold was beginning to form on the xeroform. The wound nurse was made aware of the dressing changes to be done daily. The wound measured 4.0 cm length by 0.3 cm width by 0.2 cm depth and was debrided mechanically. There was no change in treatment. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The soiled dressing was removed with dirty odor and positive strike through, it was dried into the wound bed and black mold was beginning to form on the xeroform. The wound nurse was made aware of the dressing changes to be done daily. The wound measured 4.0 cm length by 0.3 cm width by 0.2 cm depth and was debrided mechanically. There was no change in treatment. Review of the TAR for June 2022 revealed the treatment dated 06/08/22 to the wound bed to cleanse with normal saline, pat dry, apply xeroform, and cover with ABD daily and as needed were signed as completed prior to the wound physician's examinations on 06/13/22 and 06/20/22. 2. Review of the medical record for Resident #38 revealed an admitted [DATE]. Resident #38 was transferred to the hospital on 04/23/22 and returned on 04/26/22 and was transferred to the hospital again on 06/27/22 and returned on 06/30/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #38 had severe cognitive impairment and was assessed as rarely or never understood. Resident #38 was dependent on two staff assistance for bed mobility, transfers, and toileting. The assessment indicated Resident #38 was always incontinent of urine and bowel. Review of the plan of care initiated 02/10/22 revealed Resident #38 had impaired skin integrity due to a wound to the posterior neck and had potential for alteration in skin integrity. Interventions included to assist with turning and repositioning as needed; a pressure redistribution mattress to bed; use barrier cream with showers and incontinence care; and treatments per physician orders. Review of the pressure ulcer risk assessment completed on 11/22/21 revealed Resident #38 was at moderate risk for the development of pressure ulcers. A repeated pressure ulcer risk assessment was not completed until 04/26/22 which determined Resident #38 was at very high risk for the development of pressure ulcers. Review of the skin grid pressure assessment dated [DATE] revealed a posterior neck stage 3 pressure ulcer with no origination date. There were no wound measurements documented. The wound was described as 100 percent granular with minimal drainage. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical device related pressure injury to the posterior neck was sustained from [CONDITION(S)] tie and [CONDITION(S)] oxygen mask straps embedded in the neck. The wound was a stage 3 pressure ulcer which measured 0.3 cm length by 7.8 cm width by 0.2 cm depth and macerated wound edges. At the time of the examination, the xeroform was not in place and the serosanguineous drainage dried causing the [CONDITION(S)] ties to embed in the wound. The treatment plan was to cleanse with wound cleanser, apply xeroform then an ABD daily and as needed. The treatment plan was either written or given orally. Review of Resident #38's physician orders revealed an order dated 04/27/22 to turn and reposition every two hours every shift which was discontinued on 06/27/22. There were no orders initiated for a treatment to the posterior neck wound prior to 05/11/22. Review of the skin grid pressure assessment dated [DATE] revealed a posterior neck stage 3 pressure ulcer with no origination date. The wound measured 0.3 cm length by 9.0 cm width by 0.1 cm depth. The wound was described as 100 percent granular with an irregular ovoid shape, full thickness with epithelial bridges in between. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The xeroform was not in place again this week and the serosanguineous drainage dried causing the [CONDITION(S)] ties to embed in the wound. The wound measured 0.3 cm length by 9.0 cm width by 0.1 cm depth with macerated wound edges and black moldy drainage. The wound was declined. Review of the skin grid pressure assessment dated [DATE] revealed a posterior neck stage 3 pressure ulcer with no origination date. The wound measured 0.3 cm length by 9.0 cm width by 0.1 cm depth. The wound was described as 100 percent granular with an irregular ovoid shape, full thickness with epithelial bridges in between. Review of Resident #38's physician orders revealed an order dated 05/11/22 to apply xeroform and an ABD to behind the neck daily and as needed which was discontinued on 06/27/22. Review of the skin grid pressure assessment dated [DATE] for Resident #38 revealed it was not completed. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The xeroform was not in place again this week and the serosanguinous drainage dried causing the [CONDITION(S)] ties to embed in the wound. The wound measured 0.3 cm length by 9.0 cm width by 0.1 cm depth with macerated wound edges and black moldy drainage. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There were new findings of surrounding wound [CONDITION(S)]. The xeroform dressing was not in place again as ordered. Routine dressing changes were not completed. The wound measured 2.0 cm length by 10.0 cm width by 0.2 cm depth with redness, warmth and swelling surrounding the wound. There was black moldy drainage. The wound declined due to improper wound treatment and lack of treatments completed. There was [CONDITION(S)] surrounding the wound. [MEDICATION(S)] (antibiotic) was ordered for seven days. Review of the skin grid pressure assessment dated [DATE] for Resident #38 revealed a posterior neck stage 3 pressure ulcer with an origination date of 02/21/22. The wound measured 2.0 cm length by 10.0 cm width by 0.2 cm depth. The wound was described as 100 percent granular with surrounding [CONDITION(S)] and minimal drainage. Review of Resident #38's medical record revealed there were no weekly skin grid pressure assessments completed between 05/16/22 and 06/08/22 and after 06/08/22 for the posterior neck stage 3 pressure ulcer. Review of the TAR for May 2022 and June 2022 revealed the order dated 05/11/22 to apply xeroform and an ABD to behind the neck daily and as needed was not completed as ordered on 05/21/22, 05/23/22, 05/26/22, 05/28/22, 05/29/22, 06/03/22, 06/08/22, 06/10/22, 06/13/22 and 06/16/22. 3. Review of the medical record for Resident #41 revealed an admitted [DATE]. Resident #41 was transferred to the hospital on 05/26/22 and returned on 05/30/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #41 had severe cognitive impairment and was assessed as rarely or never understood. Resident #41 was dependent on one staff assistance for bed mobility, transfers, and toileting. The assessment indicated Resident #41 had a urinary catheter and was always incontinent of bowel. Review of the plan of care initiated 06/24/22 revealed Resident #41 was at risk for impaired skin integrity related to incontinence of bowel and dependent with mobility. Interventions included to apply protective barrier cream after incontinent episodes and as needed; assist with turning and repositioning as needed; a pressure redistribution mattress to bed; and provide incontinence care as needed. Review of the pressure ulcer risk assessment completed on 04/04/22 revealed Resident #41 was at high risk for the development of pressure ulcers. Review of the admission assessment with baseline care plan dated 04/04/22 revealed skin areas to the left buttock, right heel, left heel, and left lateral foot. There were no measurements or a description of the wounds. Review of Resident #41's physician orders revealed an order dated 04/05/22 for a treatment to the left heel and left lateral foot to cleanse with normal saline, cover heel with xeroform and ABD with Eucerin moisturizer to surrounding skin and leg with light gauze wrap every 48 hours and as needed, which was discontinued on 04/11/22, and an order dated 04/05/22 to apply menthol [MEDICATION(S)] ointment 0.44-20.6 percent topically every shift for incontinent care to bilateral buttocks and sacrum which was discontinued on 05/26/22, and orders dated 04/05/22 to turn and reposition every two hours every shift and float heels when in bed every shift which were discontinued on 05/26/22. There were no physician orders initiated for the right heel area identified on the 04/04/22 admission assessment. Review of Resident #41's medical record revealed there were no weekly skin grid assessments completed for the skin areas identified on the 04/04/22 admission assessment. Review of the weekly skin grid pressure assessments dated on 04/11/22 revealed a left heel unstageable pressure ulcer documented as present upon admission with an origination date of 03/20/22. The wound measured 5.0 cm length by 2.0 cm width by undetermined depth. The general appearance was described as debridement for necrotic tissue, and drainage was moderate. The left lateral medial area was healed. Review of the weekly skin grid pressure assessments dated 04/18/22, 04/25/22, 05/02/22 and 05/09/22 revealed completed assessments for Resident #41's left heel pressure ulcer. On 05/09/22, the left heel pressure wound measured 4.0 cm length by 3.2 cm width by 0.1 cm depth, was described as a stage 3 area and had declined. The weekly skin grid pressure assessment completed on 05/16/22 was not completed. Review of Resident #41's physician orders revealed an order dated 04/11/22 for a treatment to the left heel to cleanse with normal saline, pack with collagen, cover with ABD, wrap with kerlix daily, which was discontinued on 05/26/22. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound was debrided manually and a new dressing change to cleanse with wound cleanse, apply collagen powder, then an ABD and gauze wrap daily was made. The right heel stage 3 pressure wound was also debrided at the beside with orders to cleanse the right heel with wound cleanser, apply collagen, an ABD and gauze wrap daily and as needed. Review of Resident #41's physician orders revealed there was no order for the right heel pressure wound as initiated on the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The right heel treatment plan was to clean with wound cleanser, apply collagen, cover with ABD, wrap with gauze wrap daily and as needed. Review of the TAR for May 2022 revealed there were no treatments administered to the right heel from 05/01/22 and when Resident #41 was transferred to the hospital on 05/26/22. Review of the hospital discharge information dated 05/26/22 to 05/30/22 revealed Resident #41 was admitted for altered mental status and pressure injury of the deep tissue of the right heel. Intravenous antibiotics were administered during the hospital stay. Treatment orders upon discharge included to cleanse the right and left heels with wound cleanser, cover with xeroform gauze, an ABD and Eucerin moisturizer to surrounding skin and leg with light gauze wrap daily and as needed; apply to the sacrum, coccyx, and buttocks a [MEDICATION(S)], [MEDICATION(S)] and vitamin A and D ointment mixture twice daily and as needed without a foam dressing or may use Vaseline gauze and ABD to cover. Review of Resident #41's physician orders revealed an order dated 05/30/22 for a treatment to the feet, ankles, and heels to cleanse with wound cleaner, apply three packages of xeroform, then apply an ABD and wrap with gauze wrap daily and as needed; and a treatment to the sacral area to apply [MEDICATION(S)], [MEDICATION(S)] and vitamin A and D ointment twice daily and as needed without a foam dressing or may use Vaseline gauze and ABD to cover. Review of the admission assessment with baseline care plan dated 05/30/22 revealed skin areas to the sacrum, left foot, and right foot. There were no measurements or a description of the wounds. Review of Resident #41's medical record revealed there were no weekly skin grid assessments completed for the skin areas identified on the 05/30/22 admission assessment. Review of the nursing progress note dated 05/30/22 revealed Resident #41 had dressing for the feet. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The right heel stage 3 pressure wound plan was to continue with wound cleanser, apply collagen to wound bed, cover with ABD and wrap with gauze wrap daily and as needed. Review of the weekly skin grid pressure assessment dated [DATE] revealed Resident #41 had a stage 3 pressure area to the left heel which measured 4.0 cm length by 1.5 cm width by 0.1 cm depth and was debrided at the bedside to promote healing. Review of Resident #41's physician orders revealed an order dated 05/30/22 for a treatment to the feet, ankles, and heels to cleanse with wound cleaner, apply three packages of xeroform, then apply an ABD and wrap with gauze wrap daily and as needed and to apply to the sacral area [MEDICATION(S)], [MEDICATION(S)] and vitamin A and D ointment twice daily and as needed without a foam dressing or may use Vaseline gauze and ABD to cover; an order dated 06/08/22 to cleanse the right heel with normal saline, apply collagen to the wound bed, cover with an ABD, wrap with gauze wrap daily and as needed which was discontinued on 06/17/22; an order dated 06/17/22 to cleanse the left heel with normal saline, apply collagen to the wound bed, cover with an ABD, wrap with gauze wrap daily and as needed which was discontinued on 06/20/22; and an order dated 06/20/22 to cleanse the left heel with normal saline, apply an ABD and wrap with gauze wrap daily and as needed. Review of Resident #41's medical record revealed there were no weekly skin grid pressure assessments completed for the right heel on or after 06/08/22, and none completed for the left heel after 06/08/22. 4. Review of the medical record for Resident #73 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #73 had no cognitive impairment. Resident #73 required extensive one staff assistance for bed mobility and was dependent on one staff assistance for transfers and toileting. The assessment indicated Resident #73 was occasionally incontinent of urine and always incontinent of bowel. Review of the plan of care initiated 04/23/22 revealed Resident #73 had an activities of daily living (ADL) self-care deficit related to impaired mobility and visual impairment and was incontinent of bowel and bladder. Interventions included to inspect for skin breakdown and intervene when needed; provide bed mobility and toileting of one staff assistance, and transfers of two staff assistance; and encourage to use the call light when needed. There were no focus or interventions in the care plan regarding the risk for impaired skin integrity. Review of the pressure ulcer risk assessment completed on 04/22/22 revealed Resident #73 was at low risk for the development of pressure ulcers. A repeated pressure ulcer risk assessment completed on 05/13/22 revealed Resident #73 was at low risk for the development of pressure ulcers. Review of the skin observation completed for admitted d 04/29/22 revealed Resident #73's skin was intact. There were no skin impairments identified. Review of NP progress notes dated on 04/25/22, 04/27/22, 05/17/22, 05/24/22 and on 06/13/22 revealed Resident #73 had an open area to the lateral side of the left foot. On 06/13/22, Resident #73 was requested to be seen by wound management in the facility. Review of Resident #73's physician orders revealed an order dated 04/23/22 for skin checks biweekly and an order dated 04/25/22 for skin checks weekly on day shift. There were no treatment orders for the open area to the lateral side of the left foot identified on 04/25/22 through 06/13/22. Review of Resident #73's medical record revealed there were no weekly skin assessments completed for the open area identified on 04/25/22. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . An order was given to cleanse the wound with wound cleanser, apply skin prep, cover with an ABD, and wrap with gauze wrap daily and as needed. An air mattress was recommended. Review of Resident #73's physician orders revealed an order dated 06/16/22 to cleanse the left foot, pat dry, apply skin prep, cover with an ABD, and wrap with gauze dressing daily. There was no order for an air mattress. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The old dressing was not intact. There area was debrided sharply manually with a #15 blade and forceps to improve wound healing and reduce the risk of infection. The wound measured 1.5 cm length by 1.2 cm width by 0.2 cm depth. A new treatment was ordered to cleanse, apply collagen to the wound bed, cover with an ABD and wrap with gauze daily and as needed. Review of Resident #73's medical record revealed there were no weekly skin assessments completed for the left lateral foot unstageable pressure wound identified on 06/13/22 or thereafter. Interview on 07/05/22 at 11:44 A.M. with Registered Nurse (RN) #350 and Director of Nursing (DON) reviewed and verified the above findings for Resident #38. RN #350 indicated substituting for having no wound nurse and was only making rounds with the wound doctor. The DON verified skin grids were supposed to be completed independently from the wound physician, on admission and weekly with treatment initiated for new identified areas. The DON stated staffing was an issue and past DON's were working on the floor which contributed to lack of tracking so there were things that fell by the wayside and assessments did not get completed. The DON verified the facility still did not have a nurse to oversee wound care, but weekly wound logs were being updated and stated for now the weekly wound grids were too much to keep up. Interview on 07/05/22 at 6:05 A.M. with RN #401 revealed it was better to have two nurses to complete al

Based on observation, interview, review of the Medication Administration Record (MAR), review of facility policy titled Insulin Administration, and review of the Medication Technician job description, the facility failed to administer insulin according to physician orders resulting in significant medication errors affecting four residents (Residents #89, #74, #68, and #19). This resulted in Immediate Jeopardy with actual harm or likelihood of actual harm including [CONDITION(S)] (high blood sugar), which could lead to hospitalization and death. This affected four of 32 residents residing on the second floor. The facility identified 38 residents as receiving insulin. The facility census was 93. On 05/26/22 at 4:40 P.M. Administrator #305 and Regional Administrator #590 were notified Immediate Jeopardy began on 05/25/22 at approximately 10:06 A.M. when Medication Technician (MT) #850 stated she was unable to administer insulin for Residents #89, #74, #68 and #19 because she was not qualified and there was not a licensed nurse assigned to the unit to administer insulin. On 05/25/22 Resident #19 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to administer the medication as ordered resulted in a blood sugar of 380 milligrams per deciliter (mg/dl) (normal 70-100 mg/dl) at 4:23 P.M. and a second blood sugar of 493 mg/dl with no time documented as to when the blood sugar was obtained. Resident #89 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 2:00 P.M. The failure to administer the medication as ordered resulted in a blood sugar reading of 344 mg/dl. Resident #74 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .M. at 11:42 A.M., and there was no documentation the 11:00 A.M. or 4:00 P.M. sliding scale insulin was administered and no recorded blood sugar readings. Resident #68 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy was removed on 05/27/22 when the facility implemented the following: · 05/26/2022 at 5:30 P.M., Residents #89, #74, #68 and #19 were assessed by Regional Quality Assurance Nurse (RQAN) #303 and found with no adverse reactions. All four residents' medical care plans were reviewed as well as a physical assessment completed with no adverse outcomes. RQAN #303 ran a Medication Audit Report for 05/25/2022 to 05/26/22 and all residents were reviewed for potential to be affected related to late or missed medications. All eight resident's medical care plans were reviewed as well as a physical assessment completed with no adverse outcomes. · 05/26/2022 at 5:41 P.M., RQAN #303 notified Physician #301, and Physician #302 regarding insulin not administered as ordered for Resident #19, #68 and #74 with no noted adverse reactions. No new orders were given. At 5:45 P.M., RQAN #303 notified Medical Director #300 regarding insulin not being administered as ordered for Resident #89. · 05/26/22 at 6:45 PM, The Ad hoc Quality Assurance Project Improvement (QAPI) committee met to review the Immediate Jeopardy and notified Medical Director #300 of the Immediate Jeopardy situation and removal plan. Administrator #305, Regional Administrator #590, RQAN #303, Medical Director #300 and Acting Director of Nursing (ADON) #595 were in attendance during this meeting. · 05/26/2022 at 7:30 P.M. All Nurses (7/7 RNs, 13/13 LPNs) and Medication Technicians (3/3) were educated on the Medication Administration Policy and Procedure. The facility had no contracted employees. In the event contracted staff would be employed, Director of Nursing (DON) #306, Registered Nurse (RN) #307 or designee would provide education on the policies prior to start of their shift. Medication Technicians would not be responsible for administering medications to any residents that required narcotics, insulin or had feeding tubes. The facility would always assign a specific nurse to cover the unit in addition to a medication technician to ensure all medications and treatments would be given as ordered on time. This education was transmitted via the company Paycom Notification Center to each individual staff member by Administrator#305. Nurses and Medication Technicians would be provided written education prior to working their next shift by DON #306, RN #307, or designee. · On 5/27/2022, Administrator #305, Regional Administrator #590, RQAN #303, Medical Director #300 and ADON #595 reviewed the QAPI to address pharmacy services. Administrator #305, Regional Administrator #590 and the Minimum Data Set (MDS) Director were in attendance during this meeting. · 05/27/22, audits by DON #306, RN #307/designee were initiated and to be conducted on three medication pass audits randomly three times a week to ensure medications were administered as ordered and on time. Audits would continue for the period of one months' time. DON #306 and Administrator #305 would be responsible for completing three medication pass audits at random, three times per week to ensure all medications were administered as ordered and on time. All audits to be kept in Administrator #305's office. At the end of the one-month audit period a QAPI meeting would be held to determine if the facility needed to extend supervision of the medication administration. · 05/27/22, ongoing interviews by DON #306, RN #307/designee would be conducted to interview residents three times a week to ensure they were receiving their medications timely. Interviews would be completed for the period of one months' time. DON #306 and Administrator #305 would be responsible for completing three resident interviews at random three times per week to ensure all their medications were administered as ordered and on time. All audits to be kept in Administrator #305's office. At the end of the one-month audit period a QAPI meeting would be held to determine if the facility needed to extend supervision of the medication administration. Although the Immediate Jeopardy was removed on 05/27/22, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine further action if required. Findings Include: 1. Review of Resident #89's medical records revealed Resident #89 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #89 had intact cognition. Review of the care plan dated 04/19/22 revealed Resident #89 had the potential for impaired metabolic status related to diabetes. Interventions included to administer medications as indicated by physician orders. Review of current physician orders for May 2022, revealed Resident #89 was ordered [MEDICATION(S)] (fast acting insulin) 12 units upon rise (no time frame indicated), [MEDICATION(S)] (fast acting insulin) 12 units in the afternoon (11:00 A.M. to 2:00 P.M.) and [MEDICATION(S)] sliding scale (insulin amounts vary depending on blood sugar) to be administered at 8:00 A.M., 11:00 A.M. and 4:00 P.M. Review of Resident #89's MAR for 05/25/22 revealed no documentation the [MEDICATION(S)], or [MEDICATION(S)] insulin were administered at 8:00 A.M., or 12:00 P.M. A corresponding progress note indicated medication was not given due to out of timeframe. Further review of the MAR revealed four units of [MEDICATION(S)] was administered at 2:09 P.M. by RN #790, for a blood sugar reading of 310 mg/dl, and 12 units of [MEDICATION(S)] was administered by RN #790 at 4:40 P.M. (this insulin was ordered to be given between 11:00 A.M. and 2:00 P.M.). Interview on 05/25/22 at 2:10 P.M. with MT #850 revealed she obtained Resident #89's blood sugar approximately 5-10 minutes prior and the blood sugar was 344 mg/dl. MT #850 further stated she was the only personnel who had access to the keys to the medication cart, and no nurse had approached her for the keys to the medication cart to obtain insulin or other medication. Interview on 05/25/22 at 4:17 P.M. with Resident #89 revealed his blood sugar was taken a few minutes ago and he was told by the nurse that his blood sugar was high. He stated the actual number was not told to him and he had been given 12 units of insulin. Resident #89 further stated he did not receive his insulin on previous occasions but could not recall specifics dates or times. Interview on 05/31/22 at 10:03 A.M. with ADON #595 revealed she had assisted MT #850 with some of her medication administration. ADON #595 stated she had given various insulins and narcotics during the shift however she had not documented the administration of the medications in a timely manner. ADON #595 said there were some medications that had not been administered on 05/25/22 but could not be more specific on what these medications were. 2. Review of Resident #74's medical records revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #74 had impaired cognition. Review of the care plan dated 04/13/22 revealed Resident #74 was at risk for hyper/[CONDITION(S)] (high and low blood sugars) related to diabetes and interventions included administer medications as ordered. Review of current physician orders for May 2022, revealed Resident #74 was ordered six units of [MEDICATION(S)] before meals at 8:00 A.M., 11:00 A.M. and 4:00 P.M. Review of Resident #74's MAR for 05/25/22 revealed the 8:00 A.M. dose of [MEDICATION(S)] was administered at 11:42 A.M. by ADON #595, and there was no documentation the 11:00 A.M. and 4:00 P.M. doses were administered. 3. Review of Resident #68's medical records revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed Resident #68 had intact cognition. Review of the care plan dated 04/16/22 revealed Resident #68 had an impaired metabolic status related to diabetes and interventions included monitor glucose levels and administer insulin as ordered. Review of current physician orders for May 2022, revealed Resident #68 was ordered [MEDICATION(S)] per sliding scale two times a day. Review of Resident #68's MAR for 05/25/22 revealed no documented blood sugar readings or insulin was administered upon rise (no time frame indicated) or at 4:00 P.M. 4. Review of Resident #19's medical records revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 03/24/22 revealed Resident #19 had impaired metabolic status related to diabetes and interventions included monitor glucose levels and administer insulin per physician orders. Review of the MDS assessment dated [DATE] revealed Resident #19 had intact cognition. Review of current physician orders for May 2022, revealed Resident #19 was ordered 40 units of [MEDICATION(S)] in the morning, 10 units of [MEDICATION(S)] before meals, and sliding scale coverage. During observation on 05/25/22 at 1:15 P.M. Resident #19 was yelling out for a nurse, upon entering Resident #19's room, he inquired about his insulin, and stated he had not received his morning or afternoon doses. Resident #19 stated he had already consumed his breakfast and lunch and stated his sugar was probably going to be high. Interview with RN #790 at 1:23 P.M. revealed RN #790 was not aware Resident #19 had not received his insulin. RN #790 said she would speak with Resident #19. At 1:27 P.M., RN #790 entered Resident #19's room and he informed her he had not received his insulin and his blood sugar had not been checked. Resident #19 also told the nurse this had occurred before. RN #790 informed Resident #19 she would have to wait until MT #850 returned to the floor because she did not have keys to the medication cart. Interview on 05/25/22 at 2:08 P.M. with RN #790 revealed she obtained Resident #19's blood sugar and it was 390 mg/dl. RN #790 administered Resident #19's standard order of 10 units of [MEDICATION(S)]. Review of Resident #19's MAR for 05/25/22 revealed no documentation the [MEDICATION(S)] which was due upon rise (no time frame specified) was administered. Further review revealed the 8:00 A.M. ordered 10 units of [MEDICATION(S)] was documented as not given due to it was outside of the time frame (blood sugar was 170), 11:00 A.M. dose was not documented, and no blood sugar reading was recorded on the MAR, and the 4:00 P.M. dose was administered at an unknown time (no time was recorded), with a blood sugar reading of 493 mg/dl. Further review of the MAR revealed the sliding scale [MEDICATION(S)] due at 8:00 A.M. had not been given due to outside of the timeframe, 11:00 A.M. dose was administered at 2:08 P.M. with a blood sugar reading of 380 mg/dl, and the dose due at 4:00 P.M. had not been documented as given. Interview on 05/31/22 at 10:03 A.M. with ADON #595 and Regional Administrator #590 revealed several medications had not been documented accurately and some had not been given. ADON #595 stated she had made some errors in documentation but was not specific, and stated it was a crazy day. Review of the Medication Technician job description effective 11/29/21 revealed responsibilities included delivery of routine oral, inhalation and topical medications under direct supervision of a licensed nurse. Review of the facility policy titled Insulin Administration revised 09/14 revealed only appropriately licensed personnel shall draw and administer insulins and check blood glucose readings per physician orders. This deficiency substantiates Complaint number OH 653.

Based on observation, record review, interview, review of staffing policies and facility assessment, the facility failed to ensure adequate staffing to meet the needs of residents related to incontinence care, self-determination, monitoring of residents, and assistance for other activities of daily living for dependent residents. This resulted in Immediate Jeopardy on 09/14/20 when one unit (The Woods) did not have a nurse assigned to care for the residents on the night shift. In addition, the lack of adequate staffing resulted in delayed incontinence care (affecting Residents #61, #119, #2, #136, and #118) delayed or skipped assistance out of bed (affecting Residents #61, #2, and #67) delayed call light response (affecting Residents #61 and #37) inadequate ostomy care (affecting Resident #119) inadequate or skipped hygiene or bathing care (affecting Residents #2, #35, and #67) and a lack of assistance at mealtime (affecting Resident #35). The lack of adequate staffing placed all residents at risk for the likelihood of serious harm, serious injury or death. The facility census was 131. On 10/21/20 at 1:25 P.M., the Administrator and the Director of Nursing (DON) were notified that a situation of Immediate Jeopardy was present starting on 09/14/20 when the facility failed to ensure sufficient staff was available to meet the care needs of its residents. This included adequate number of nurses and STNAs to provide assistance with activities of daily living, incontinence care, assistance out of bed and prompt response to call lights.- The Immediate Jeopardy was removed on 10/17/20 when the facility implemented the following corrective actions: · On 09/15/2020, newly hired State tested Nurse Aide (STNA) #921 and #922, started their floor orientation. · On 09/15/2020, LPN #923, resumed her position as a floor nurse at the facility. · Beginning 09/16/2020, Recruiting Director #924, initiated keyword searches to comb through Indeed's resume database. Any resumes that contained select key words, such as LPN, Skilled Nursing, etc., were sent a direct message encouraging the individual to submit an application. A total of 350 people received the direct message. · Beginning 09/17/2020, the Administrator initiated a weekly meeting with Nursing Management, DON and/or Unit Managers, Staffing Coordinator #213, Human Resources Director #209, floor STNAs, and Licensed Nurses. Meeting topics included recruitment, hiring, retention, current care needs/acuity and assignments, management support for direct care tasks, and general staffing issues. Minutes are taken for the meeting as part of the facility's Quality Assurance and Performance Improvement efforts. · Beginning 09/17/2020 at 11:00 am, the Administrator is having weekly meetings with Regional Director of Operations (RDO) #925, Assistant Administrator and DON to discuss staffing, open positions, and agency use. · On 09/17/2020, newly hired STNA #926, began her floor orientation. · On 09/18/2020, the facility hired four new nursing employees who started floor orientation on the following dates: STNA #927 on 10/05, STNA #928 on 09/19, STNA #929 on 09/25 and RN#930 on 10/01. · On 09/25/2020, the facility hired STNA #931. She began her floor orientation on 10/09. · On 10/01/2020, the facility hired LPN #932. She began her floor orientation on 10/09. · On 10/02/2020, the facility hired four new nursing employees who started floor orientation on the following dates: STNA #933, hasn't started yet, STNA #934 on 10/02, STNA #935 on 10/02 and STNA #936 on 10/02. · On 10/06/2020, the facility hired LPN #937. She began her floor orientation on 10/09. · On 10/07/2020, the findings from the weekly staffing meetings were discussed at the Quality Assurance Performance Improvement (QAPI) meeting attendees included, without limitation, the Administrator, DON, and Medical Director. · On 10/09/2020, the facility hired one new employee: STNA #938 who started floor orientation on 10/19. · On 10/13/2020, Recruiting Director #924 hosted a virtual hiring event. Thirty-five responded, three attended and applied. · On 10/16/2020, the facility hired five new nursing employees who started floor orientation on the following dates: Caregiver #939 on 10/20, Caregiver #940 on 10/19, STNA #941 on 10/19, STNA #942 on 10/22 and STNA #943 on 10/22. Caregivers are staff not traditionally licensed/state tested through the traditionally approved STNA process. Their tasks are assisting residents with activities of daily living as appropriate within their training. · On 10/17/2020, the Administrator and DON reviewed and revised the facility self-assessment to reflect current staffing needs. The assessment revealed the need for 4-6 charge/floor nurses per shift as well as 6-10 nursing assistants. We also support the nursing department with 2-3 Unit Managers. Management also assist as needed to ensure the resident care needs are met. The facility also hired a new position, an Assistant Administrator on 9/11/20 to assist in recruiting and retaining appropriate staff as well as helping to assess staffing needs on an ongoing basis. The facility used the Health Services Advisory Group facility template as the guide for the Facility Assessment, which considers among other items, the acuity and care needs of the residents. This tool is widely used in the industry to comprehensively assess the facility and its needs. · On 10/17/2020, the Nursing Manager-On-Call program was enhanced to include off-shift hours and support for direct care staff, as needed, related to census fluctuations, staff absences, and acuity changes. · On 10/17/2020, a Manager-On-Duty schedule was enhanced to ensure that a manager is in the facility daily. The Manager-On-Duty will conduct walking rounds, review resident care concerns, and address staff, resident, and family issues. Any concern or issue that cannot be immediately resolved will be escalated to the Administrator. All concerns and resolutions will be reviewed by the QAPI committee. · On 10/22/2020, the facility made offers to several new employees, who are being scheduled for general orientation. These new employees are: Caregiver #944, STNA #945, Caregiver #946, LPN #947, and Respiratory Therapist #948. General orientation was scheduled for October 23, 2020. · On 10/22/2020, the facility initiated a sign-on bonus for Registered Nurses (RNs) Licensed Practical Nurses (LPNs) and STNAs as an incentive to recruit additional nursing staff. · On 10/22/2020, RDO #925 educated the Administrator on daily staffing reviews and ensuring that adequate staffing levels are scheduled to meet the resident's needs. · Beginning 10/23/2020, the Administrator, DON, Staffing Coordinator #213 and Human Resources Director #209 will conduct a daily staffing review to determine whether staffing levels are sufficient, based on current resident needs, for the following 24 hours. Weekend staffing will be reviewed every Friday. If the staffing review reveals a deficiency in staffing levels, Scheduler #213 will call current employees to inquire whether anyone wants to pick-up extra shift(s). For staffing needs that remain unfulfilled, Scheduler #213 will call a staffing agency to obtain coverage. Presently, the facility is under contract with four staffing agencies. If no coverage can be obtained from the staffing agencies, the Nursing Manager-On-Call will cover the opening. · On 10/23/2020, the Administrator educated the DON, Human Resources Director #209, and Scheduler on daily staffing reviews and ensuring that adequate staffing levels are scheduled to meet the resident's needs. · Beginning 10/23/2020, the facility Administrator will complete 5 resident interviews per week for 4 weeks to ensure that the resident's care needs are being met. The results of these interviews will be reviewed during weekly QAPI meetings, with appropriate facility adjustments made, as necessary. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Interview with Licensed Practical Nurse (LPN) #204 on 09/21/20 at 6:18 A.M. revealed that on the night of 09/14/20, no residents on the Woods unit got any night-time insulin or medications. The nurse who was assigned to that unit called off and was never replaced. Last night (the night of 09/20/20), LPN #204 finished the 9:00 P.M. medication pass at 2:30 A.M. because she was covering so many residents. She caught one state tested nurse aide (STNA) sleeping at work and reported them, and they still worked at the facility. LPN #204 stated due to the workload, scheduled showers were sometimes not done and aides often could not respond reasonably to call lights. Interview with STNA #203 on 09/21/20 at 6:55 A.M. revealed that when the facility was properly staffed she could get her work done, however, twice last week it was not. This resulted in her being assigned care for 26 residents and she was unable to get all of her expected tasks done. Once last week there was no nurse assigned to the Woods unit for the night shift. Often second shift left work undone, such as overflowing linen and trash baskets and meal trays left in rooms. When they were staffed appropriately she could do assigned showers for residents, otherwise she could not. Interview with STNA #202 on 09/21/20 at 7:10 A.M. revealed that for the last four months the facility staffed three aides to 56 residents, which was not enough for her to do the work expected of her. She cared for roughly 30 residents on the current shift and said she was overwhelmed and could not finish her work. Call lights went unanswered for extended periods, and she had to ask people to wait for care so she could finish with others. STNA #202 ended the interview without giving further specifics, saying 'I need my job.' Interview with STNA #206 on 09/21/20 at 7:20 A.M. revealed she was a day shift worker who commonly cared for 28 residents, and on unusually good days was assigned care for 19 residents. Some residents required two staff to assist out of bed and had to remain bed bound against their wishes due to a lack of help. If she was lucky she had time to check and change incontinent residents once in an eight-hour shift due to the heavy workload. Residents with dementia did not receive as good care because staff had to respond to residents who were vocal about securing their own needs. Staff was not able to keep up with showers and hygiene needs of residents. STNA #206 stated she had never taken a lunch break while working at the facility due to the workload. She knew of events where STNAs slept during their shift and said the administration knew and took no action. She was the only aide covering the Woods unit today, including seven residents requiring feeding assistance. She said it was impossible for her to provide proper care for them all. Night shift did not get any residents up, leaving it all to day shift. Interview with STNA #201 on 09/21/20 at 7:30 A.M. revealed she felt the building was always very understaffed. For multiple nights in a row they had no nurse on the transitional care unit, necessitating the nurse from the Woods unit cover both. The facility often assigned only one aide per unit, which is not enough to give all residents the needed care. When she entered at 11:00 P.M. last night, every one of her residents was incontinent and needed full bed changes. She could tell they had not been changed for a long time because urine had completely soaked through their absorbent briefs and pads. Two of the residents were sitting in dry, crusty stool (which revealed it had been there long enough to dry). One time an aide left the floor for a 30-minute break and the staff found her sleeping on a couch an hour later. STNA #201 reported the event, and the facility took no action. Interview with STNA #205 on 09/21/20 at 7:52 A.M. revealed she worked the day-shift staff and often had to do work left over by the night shift. She said many aides were neglectful of residents and spent excessive time on their cell phones or left the floor without telling anyone. She commonly arrived to find residents incontinent, with night shift always having an excuse why they could not provide needed care. The unmanaged incontinence was substantial enough that she commonly had to begin her workday by changing entire beds for multiple residents. Night shift commonly failed to do morning hygiene and get-ups assigned to their shift, and STNA #205 did not have time to do their work as well as her own. Two staff members were required to use a Hoyer to get a resident up, and she commonly could not find help to do it. Interview with Resident #61 on 09/21/20 at 11:01 A.M. revealed three times last week the facility staffed one aide for 28 residents. On 09/14/20 the Woods unit did not have a nurse all night. Residents commonly sat in soiled briefs for multiple hours, and one aide was not enough to care for all of them. Resident #61 had previous skin breakdown from sitting in feces for so long. The facility management blamed the aides when this happened, but the aides did not have enough help to do the work expected of them. Resident #61 liked to get up shortly before lunch and required two staff to assist, and often had to wait for second shift to get him up instead. Sometimes he had to stay in bed all day because of a lack of staff. Staff did not answer his call light promptly. The resident added, on 09/20/20, he rang his call light from 7:09 A.M. to 8:14 A.M. for assistance with incontinence care. When staff responded, he told them he needed to be changed. The resident said he was not given the needed care until lunchtime. Interview with Resident #119 on 09/21/20 at 11:41 A.M. revealed he was often left lying in urine for hours at a time with no answer to his call light. He had a [MEDICAL CONDITION] which was supposed to be checked every two hours and no one had checked it all day. His ostomy bag had previously burst because staff waited too long to empty it. He was currently laying in a soiled brief and had done so since 9:00 A.M. He told his aide of the incontinence when she delivered breakfast, and he had not seen her since. Interview with Resident #119's nurse (unidentified) done immediately after the above interview revealed the resident's assigned STNA was on break. Interview with STNA #206 outside of Resident #119's room on 09/21/20 at 12:30 P.M. revealed she was not his aide today, but his nurse asked her to provide incontinence care. She said there were residents on her own hall she had not touched yet who were soaking wet due to her lack of time to care for them. The surveyor observed STNA #206 to appear harried and on the verge of tears. Observation of an incontinence care procedure for Resident #119 by STNA #206 on 09/21/20 at 12:30 P.M. revealed the resident's incontinence brief was wet and saturated all the way up to where it wrapped behind his buttocks (a sign of having urinated multiple times in the same brief without staff intervention). STNA #206 confirmed the above observations during the procedure. Observation on 09/21/20 at 1:53 P.M. revealed STNA #206 entered Resident #2's room. Resident #2 was in bed and asked when she would be getting up, and the STNA apologized that she could not get the resident up yet and acknowledged Resident #2 had been waiting for multiple hours to get up. The resident said she understood, and the STNA left the room with the resident's finished meal tray. Interview with Resident #2 on 09/21/20 at 1:55 P.M. revealed she sometimes went multiple weeks without being bathed. She had been waiting for a few hours to be Hoyer lifted out of bed, and said often Hoyer lifts disappeared or their batteries or chargers did not work. She had sometimes stayed in bed for days at a time because there were not enough staff to get her up. She had been waiting multiple hours to get up this morning. She was continent, but wore briefs because she had trouble moving, and sometimes was not changed promptly because of the lack of staff. Interview with Resident #37 on 09/21/20 at 2:49 P.M. revealed staff was not prompt when responding to call lights. He needed help toileting, and sometimes had to remain on the toilet for a long time waiting for staff to respond and help get him off the seat. Interview with the guardian of former Resident #136 on 09/23/20 at 10:23 A.M. revealed nurses would ignore the resident's call light, leaving him lying in urine for multiple hours at a time. When on the phone, the guardian overheard a nurse say to the resident, we'll get to it when we can. The guardian was relieved the resident was no longer resided at the facility. Interview with Resident #35 on 09/24/20 at 11:02 A.M. revealed he had been at the facility for three months and had been bathed only once. He said the facility often documented him as refusing to bathe, but he had only refused once. He received no assistance with hygiene care. A few days ago he rang the call light and asked an aide to feed him, she said she was too busy, turned off the call light, and left. He was quadriplegic and totally dependent on staff for care. Interview with Resident #2 on 09/24/20 at 11:43 A.M. revealed she was in bed and had been waiting to get up. She had not seen her STNA yet today. Interview with STNA #222 on 09/24/20 at 12:35 P.M. revealed she was not able to do showers and hygiene for residents as needed due to a lack of time to do all the work expected of her. Observation of the BIPPA (posted staffing information) on 09/28/20 at 2:40 P.M. revealed there were supposed to be seven STNAs on the morning (7:00 A.M. to 3:00 P.M.) shift that day. Observation during a tour at the same time revealed three STNAs providing care in the building. The surveyor observed heavy urine odors in much of the second-floor hallways, broadly detectable in the hallways of all second-floor units (Ponds, Woods, and Transitional Care Unit). Interview with STNA #217 on 9/28/20 at 2:42 P.M. revealed there were only two STNAs working as of this morning, although other facility staff was providing assistance. One STNA was assigned to the secured unit and one worked the unsecured unit on the first floor. She did not know who was working in the second-floor units or how much help they were getting. Interview with LPN #218 on 09/28/20 at 2:50 P.M. revealed she had no STNA on her unit (Woods) until one arrived very recently. Interview with Resident #67 on 09/28/20 at 3:08 P.M. revealed the facility was understaffed all of the time. Staff had to rush personal care, and she was always late for therapy because they were late getting her up. Her preferred get-up time was 11:00 A.M. and staff had not been able to accommodate that for quite some time. She was supposed to get showers twice per week, and did not get showered even once per week due to staffing. Staff often appeared hurried and frustrated. Interview with LPN #219 on 09/28/20 at 3:25 P.M. revealed she cared for the transitional care unit today, and had no STNA to help care for the residents until roughly 12:30 P.M. Other staff tried to help, but work such as get-ups, showers, and regular incontinence checks were not done. Interview with STNA #220 on 09/28/20 at 3:31 P.M. revealed she came in around noon because the facility needed help and texted her around 11:00 A.M. There were only two aides in the whole building when she entered, and she then became the only STNA working on the second floor. Many residents were incontinent, and she had to focus on the ones who had family visits scheduled to get them up, changed, and cleaned. She normally worked second shift (3:00 P.M. to 11:00 P.M.) and said she frequently had to do first shift's leftover work. She said activity workers and other staff helped to pass trays, but it was evident from the state of the residents today that no aides were working this morning on the second floor. She confirmed there was a urine smell in the hall. Interview with Resident #118 on 09/30/20 at 10:59 A.M. revealed the facility was very short staffed, and an aide was rarely available when needed. He has had to sit in his soiled brief for multiple hours because he could not find someone to change him. Staff sometimes hid and were missing from the floor for hours at a time. Interview with STNA #671 on 10/20/20 at 11:35 A.M. revealed the facility was almost always short of aides on the weekend and sometimes on weekdays. They had no agency aides or other effective means of replacing call-offs. When that happened, an aide would be expected to care for an entire unit of 26 residents on either the Woods or Ponds unit, many of whom required extensive assistance. When this happened, the aides had to skip scheduled showers and get-ups, and she could barely get all incontinent residents changed once during her shift. Review of the facility self-assessment revealed it was reviewed on 10/17/20 and updated 10/20/20. It indicated the average daily census ranged from 125-135. Based on census at the time of the assessment, it indicated 129 residents required assistance (either needing one or two staff to assist or were dependent on staff for care) to meet activities of daily living related to dressing, 130 residents needed assistance for bathing, 128 needed assistance to transfer, 104 needed assistance for eating, and 129 needed assistance for toileting. The facility estimated they needed four to six nurses and six to ten nurse aides each shift to meet resident needs. Review of the staffing list for 09/14/20 revealed no nurse and one nurse aide assigned to the Woods unit on the night shift (7:00 P.M. to 7:00 A.M.) and identified that there were 26 residents on the Woods unit that day. The total census was 131 on 09/14/20, and the facility identified four nurses and six aides at work from 11:00 P.M. to 7:00 A.M. that date. Review of the staffing list for 10/11/20 revealed the facility census was 128, and only five aides worked the morning (7:00 A.M. to 3:00 P.M.) shift, plus one who only worked until 10:00 A.M. On all other days reviewed (09/10/20 to 09/16/20 and 10/09/20 to 10/20/20) the facility appeared to meet the minimum staffing requirements established in it's facility assessment. Review of the facility's staffing list and accompanying observations on 10/20/20 at 11:15 A.M. and on 10/21/20 at 8:37 A.M. revealed the facility had six nurses and 10 STNAs providing direct resident care at these times. Interview with Resident #2 on 10/21/20 at 8:52 A.M. revealed she had no staffing concerns at that time. Interview with Resident #119 on 10/22/20 at 11:00 A.M. revealed he had no staffing concerns at that time. This deficiency substantiates Complaint Numbers OH 647, OH 115, OH 947, OH 413, OH 368, OH 270, OH 154, OH 610, OH 904, and OH 465.

Based on observation, record review and interview, the facility failed to identify a pressure sore for Resident #134 in a timely manner. This resulted in actual harm when the pressure ulcer was not identified until 08/30/20 and measured 7.0 cm by 2.5 cm, and 0.4 cm deep. On 09/02/20 the wound was assessed as unstageable (a pressure sore with tissue loss of unknown depth) due to necrosis (dead tissue) and was infected. Subsequently the resident was hospitalized for [REDACTED]. The facility census was 131. Findings include: Record review of Resident #134 revealed she was admitted on [DATE] and had [DIAGNOSES REDACTED]. She was identified by a Minimum Data Set 3.0 (MDS) assessment on 08/16/20 as needing extensive assistance for bed mobility and being frequently incontinent of bowel and bladder. The assessment also indicated the resident did not have any pressure ulcer but was at risk for the development of one. A wound assessment on 08/30/20 revealed the presence of a new pressure wound with small sanguineous drainage and moderate odor on her buttocks. The assessment measured the wound at 7.0 cm by 2.5 cm, and 0.4 cm deep. It gave no indication of the wound stage or status of the wound bed. An assessment on 09/02/20 identified the wound as an unstageable pressure ulcer which was completely covered by necrotic tissue. There was heavy serosanguinous drainage and moderate odor, was in-house acquired, and was deteriorating. The resident was sent to the emergency room that day for evaluation related to the wound infection. A note from the wound physician that day revealed she debrided the wound (removed the dead tissue) to a depth of 2.0 cm, revealing it to be a Stage 4 pressure sore (full-thickness loss of skin). The resident had not returned to the facility since being hospitalized for [REDACTED]. Interview with State tested Nurse Aide (STNA) #202 on 09/21/20 at 7:10 A.M. revealed that she was caring for about 30 residents the previous night, and was overwhelmed with the work. Call lights had to wait, and she had to ask people to wait for needed care so she could finish with others. Interview with STNA #206 on 09/21/20 at 7:20 A.M. revealed that when she was lucky if she had time to check and change incontinent residents once in an eight-hour shift due to the heavy workload. Interview with STNA #201 on 09/21/20 at 7:30 A.M. revealed the facility often assigned only one aide per unit, which was not enough to give all residents the needed care. When she entered at 11:00 P.M. the previous night, every one of her residents was completely incontinent and needed full bed changes. She could tell they had not been changed for a long time because their urine had completely soaked through their absorbent briefs and pads. Two of the residents were sitting in dry, crusty stool (which revealed it had been there long enough to dry in the air). She reported the event to management, and STNA #201 said they took no action. Interview with STNA #205 on 09/21/20 at 7:52 A.M. revealed she commonly arrived to work to find residents were incontinent, with night shift always having an excuse why they could not provide needed care. The unmanaged incontinence was substantial enough that she commonly had to begin her workday by changing entire beds for multiple residents. Observation during a tour on 09/28/20 at 2:40 P.M. revealed heavy urine odors in much of the second floor hallways, broadly detectable in the hallways of all upstairs units (Ponds, Woods, and Transitional Care Unit). Interview with Licensed Practical Nurse (LPN) #218 on 09/28/20 at 2:50 P.M. revealed she had no STNA on her unit (Woods) until one arrived very recently that afternoon. Interview with LPN #219 on 09/28/20 at 3:25 P.M. revealed she worked on the transitional care unit this day, and had no STNA to help care for the residents until roughly 12:30 P.M. Other staff tried to help, but work such as regular incontinence checks was not done. Interview with STNA #220 on 09/28/20 at 3:31 P.M. revealed she came in around noon because the facility needed help and texted her around 11:00 A.M. There were only two aides in the whole building when she entered (census 131), and she then became the only STNA working on the second floor. Many residents were incontinent, and she had to focus on the ones who had family visits scheduled to get them up, changed, and cleaned. She confirmed there was a urine smell in the hall. Interview with LPN #212 (the facility's wound nurse) and the Director of Nursing (DON) on 09/30/20 at 9:26 A.M. confirmed Resident #134's pressure ulcer was discovered on 08/30/20 and was unstageable at the time of discovery. The facility did an investigation and confirmed no staff saw the wound before it was identified on 08/30/20. They identified the wound as a potential Kennedy Ulcer (a type of pressure sore with a very deep and sudden onset). Interview with Resident #118 on 09/30/20 at 10:59 A.M. revealed he had had to sit while incontinent for multiple hours because he could not find someone to change him. Interview with Wound Doctor #235 on 09/30/20 at 3:14 P.M. revealed she was familiar with Resident #134 and cared for her in the facility. On her first assessment on 09/02/20 the wound measured 7.0 cm by 6.0 cm across and was infected. After consultation with the resident's primary service, they hospitalized her for further treatment. Wound Doctor #235 said that she did not suspect the wound to be a Kennedy Ulcer, as those were generally found in end-of-life situations and Resident #134 was not at that point. Wound Doctor #235 also said the resident had comorbidities placing her at risk for pressure sores, but would not identify Resident #134's wound as unavoidable. This deficiency substantiates Complaint Numbers OH 505, OH 590, OH 547, OH 413, OH 189, OH 154, OH 610, OH 904, and OH 019.

Based on observation, record review and interview, the facility failed to ensure a resident was safely turned in bed. Harm occurred when Resident #96, who was totally dependent on staff for care, fell out of bed while staff was providing care and sustained a left knee fracture. The facility also failed to provide adequate supervision to prevent a fall for Resident #61. The deficient practice affected two residents (Resident #96 and Resident #61) of four residents reviewed for falls. The facility census was 168. Findings include: 1. Review of the medical record revealed Resident #96 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive assistance of two persons for bed mobility. Review of a "late entry" progress note dated 03/12/15 at 10:30 A.M., revealed Resident #96 was receiving care from two State-tested Nurse Aides (STNA #1 and #2) and while the STNAs were turning the resident, the resident "continued to roll until she rolled out of bed" and onto her bilateral knees. The physician was notified and x-rays of both knees were ordered. Review of the progress note dated 03/12/15 at 10:32 P.M. revealed Resident #96 sustained a left knee fracture from the fall. The physician ordered the resident be sent to the hospital for evaluation and treatment. The resident was admitted to the hospital and returned to the facility on [DATE]. Review of a Patient Nursing Evaluation (part two) dated 03/12/15 at 4:15 P.M. revealed Resident #96's bed safety assessment was completed and indicated the resident was non-ambulatory, unable to get out of bed without assistance, and was totally immobile in bed. The resident was assessed as a medium fall risk and was unaware of her position in bed in proximity to the edge of the bed. Review of a Performance Improvement Form dated 03/16/15 revealed STNA #1 received counseling and a final written warning due to a resident under her care "rolled out of bed which resulted in an injury." The director of nursing (DON) documented a corrective action plan indicating STNA #1 was educated on the importance of having the orientee be "actively engaged" in the care of dependent residents. Review of the personnel file for STNA #2 revealed she resigned without notice on 03/15/15. Interview with the DON on 05/11/15 at 4:30 P.M. revealed an investigation of the fall was conducted but the DON would not permit the surveyor to read the investigation. The DON read the results of the fall investigation as follows: Two STNAs (STNA #1 and STNA #2) were in the room. STNA #1 turned Resident #96 on her side to provide incontinence care and stated the resident " just kept rolling". The DON stated STNA #2 was a new employee on orientation. STNA #2 was standing on the opposite side of the bed at the foot of the bed. STNA #2 stated the resident's foot slid off the bed, causing her "whole body to go down". STNA #2 stated STNA #1 came around the bed and when the nurse (unidentified) entered the room, the three of them returned Resident #96 to bed. The DON revealed STNA #1 was suspended and received a corrective action. The DON stated STNA #2 did not receive a corrective action, but she was verbally educated on the need to be actively involved in the care of dependent residents. Interview on 05/12/15 at 12:27 P.M. with Registered Nurse (RN) #4, revealed she had conducted the post-fall investigation. RN #4 verified STNA #2 was standing at the foot of bed observing, but not assisting in the resident's care. RN #4 verified she did not document the height of the bed at the time of the fall and verified the resident was not mobile in bed and did not resist care. The Administrator was present during the interview and stated she did not understand what the deficient practice was, and that the STNA had a lapse in judgment and this was an isolated incident. Observation of Resident #96 on 05/11/15 at 12:20 P.M. with STNA #5 revealed the resident was lying on her back and did not voluntarily move. An interview with STNA #5 at this time revealed the resident would grimace to show pain sometimes when moved; the resident was on a turn schedule and required two hour checks for bowel incontinence. STNA #5 stated Resident #96 had no fall precautions. Observation on 05/12/15 at 1:20 P.M. revealed Resident #96 lying on her left side and mucus was drooling from her mouth. RN #4, who was present in the room, cleansed the resident's mouth. The resident did not move during the care. 2. Review of the medical record for Resident #61 revealed an admission on 11/01/12 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive deficits, was totally dependent on two staff for bed mobility, transfers, dressing, toileting and hygiene. Resident #61 required a mechanical lift for transfers. Record review of progress notes dated 05/04/15 at 9:24 A.M. revealed Resident #61 was on her side and rolled out of bed onto the floor. The resident hit her head and right shoulder. Resident #61 complained of head pain and right shoulder pain. The note also revealed the resident was non-ambulatory. The physician was notified and the resident was transferred to the hospital for testing. The resident was not admitted to the hospital, the X-rays were normal and the resident had no injury. Interview with the DON and the corporate nurse (RN #6) on 05/11/15 at 3:40 P.M. revealed on 05/04/15 at approximately 8:45 A.M., STNA #3 was providing incontinence care to Resident #61 and found a small open area on the resident's coccyx. STNA #3 left the resident and went to the door to tell the nurse who was in the hallway. The DON stated when the STNA and the nurse entered the room, the resident was found with her knees on the floor and her head and hands on the side rail. Resident #61 had some noted swelling on her forehead. Interview with RN #4 on 05/12/15 at 1:15 P.M. revealed she documented the fall in the computer and did note the resident hit her head on the floor. RN #4 stated that was not really true, and that after she had investigated, she determined the resident hit her head on the side rail as she was sliding out of the bed. RN #4 revealed Resident #61 was assessed as a one person assist for bed mobility and verified the MDS indicated the resident was a two person assist, but that was not always true. RN #4 revealed she educated STNA #3 to make sure beds were lowered and residents were the middle of the bed before leaving their bedside. On 05/12/15 at 3:15 P.M. an interview with the DON verified Resident #61 was totally dependent and two staff should have been present when turning her. This deficiency substantiates allegations contained in Complaint Number OH 879.

Based on review of the medical record, review of facility investigative reports and interviews with facility staff, the facility failed to ensure care was provided in a timely manner for a resident with left hand swelling and a change in behavior. This affected one (Resident #57) of three residents reviewed for falls. The facility census was 164. Findings include: Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed as a high fall risk on admission. Review of the nursing note dated 02/16/15 at 10:45 P.M. revealed Resident #57 was found on the floor sitting on a matt next to her bed. The bed was in the low position and the call bell was in place. Resident #57 was assessed and displayed no injuries. The physician and the daughter were notified of the fall. Review of the nursing note dated 02/19/15 at 3:39 P.M., revealed Resident #57's left hand presented with swelling and the hand was tender to touch. The physician ordered an X-ray and the conclusion was moderate [MEDICAL CONDITION] of the left hand, but no fracture or dislocation was seen. Further review of the nursing notes revealed on 02/21/15, Resident #57 was medicated for pain, and her hand was swollen. On 02/22/15, the facility applied ice to Resident #57's left hand due to swelling. Resident #57 would only keep the ice on her left hand at intervals. On 02/24/15, the facility obtained a uric acid level due to continued pain to her left hand which was normal. Review of the nursing note dated 03/04/15 at 11:49 P.M. revealed Resident #57's left hand appeared swollen and the resident reported discomfort in her left hand. The family requested an X-ray of the left hand. The nurse notified the physician of the family's request. There was no documentation of the physician's response to the call. Review of the nursing note dated 03/05/15 at 2:43 P.M. revealed Resident #57 refused to be dressed by staff, was very lethargic, " throws her arms " , and screamed out to God when she was touched. Review of the nursing note dated 03/07/15 at 3:59 P.M. revealed Resident #57 became combative this morning when a state tested nursing assistant (STNA) attempted to get her up. Review of the nursing note dated 03/09/15 at 12:47 P.M. revealed Resident #57 became combative with staff during morning care. Resident #57 began kicking, yelling, punching, and grabbing, staff. The nurse assisted the wound doctor with Resident #57's wounds due to her combative behavior. Review of the medical record revealed no evidence of follow up with the physician from 03/04/15 through 03/14/15 related to Resident #57's increased pain, swelling, and resistance to care and there was no evidence an X-ray was repeated in this time. Review of the nurse ' s note dated 03/14/15 at 2:23 P.M. revealed an X-ray to the left hand was obtained. The X-ray conclusion revealed there was an acute left hand fracture involving the thumb and also soft tissue swelling. Interview with the Director of Nursing (DON) on 04/03/15 at 4:35 P.M. verified on 03/04/15, the family requested an additional X-ray due to the resident's pain and swelling. The DON verified Resident #57 had a change in condition, refused care, was yelling out, and was combative with staff during the following week. The DON verified the staff contacted the physician, but there was no follow up call to the physician until 03/14/15. The DON verified the facility did not attempt any further care or interventions when Resident #57 began to act out and refuse care. The DON verified the increased pain and swelling was due to the fracture and care was not provided. This deficiency is an incidental finding from the complaint investigation. This is an example of continued non-compliance from the complaint investigation dated 03/11/15.

Based on staff interview and medical record review, the facility failed to address swelling in a resident's feet and lower extremites resulting in avoidable, unstageable pressure ulcers to Resident #36's heels . This affected one of three residents reviewed for skin integrity risk management and had the potential to affect nine residents with facility acquired pressure ulcers. Findings include: A review of the medical record for Resident #36 revealed an admission date of [DATE] after an acute care stay in the hospital for a fall at home with trauma to the head and a closed [MEDICAL CONDITION] back. The medical record review also revealed a history of [MEDICAL CONDITION] of the lower extremities, cognitive and functional deficits due to mental [MEDICAL CONDITION] with developmental disabilities. Review of the nursing admission assessment titled Patient Evaluation, dated 01/24/13, revealed there were no skin concerns of the lower extremities. The admission assessment for pressure ulcer skin risk (Braden) completed 01/24/13 identified Resident #36 as a high risk for pressure ulcer developement. Nursing interventions implemented on admission included a pressure relief mattress, pressure relief boots, float heels and weekly and as needed skin assessments. A review of the weekly skin assessments and nursing progress notes for Resident #36 from admission through 02/12/13 revealed no skin impairment to her lower extremities. On 02/02/13 the Nursing Progress Note timed 7:05 P.M. revealed Resident #36 had non-[MEDICAL CONDITION] of the lower extremities (indicating mild swelling). No additional assessment information about the [MEDICAL CONDITION] is assessed until the note dated 02/04/13 at 2:20 P.M., when the progress note revealed the physician was contacted regarding an increase in the lower extremity [MEDICAL CONDITION] to pitting at two plus (more severe condition). Orders were obtained to change the diuretic to [MEDICATION NAME] 40 milligrams daily. That order was implemented on 02/06/13. No additional assessment was completed and no additional nursing interventions for care were implemented. A review of the Rehab Addendum Note dated 02/11/13, completed by both an occupational and physical therapist, revealed inappropriate gripper socks were placed on the Resident's feet for therapy sessions. Upon removal of the socks, both heels were noted to have pressure areas, which were communicated to nursing on 02/11/13. Further review of the medical record revealed nursing did not document an assessment for the change of condition of the left and right heels until 02/12/13 at 10:25 A.M., which revealed the right and left heels had unstageable pressure ulcers (not able to determine the depth of tissue destruction). Further review of the assessment did not identify the size or condition of the skin as well as a treatment plan or nursing interventions. On 02/13/13, an untimed order was written for wound treatment to both heels. The order revealed the right heel ulcer was a "stage three (full thickness tissue loss) and measured 10.6 centimeters (cm) by 11.9 cm." The order was to apply "calcium alginate ointment (removes dead tissue cells from the wound), cover with pad and kerlix (gauze) wrap." The tissue surrounding the stage three pressure ulcer on the right heel was labeled a deep tissue injury (intact blood filled blister) and orders were to "apply skin prep, cover with pad and wrap with kerlix to protect." The orders for the left heel read: "Fluid filled blister, apply skin prep daily, cover with pad and wrap with kerlix to protect, measurements are 14.4 cm by 17.4 cm." On 02/14 13, a wound specialist consult was completed and new orders for pressure ulcer care were initiated. Resident #36 had daily dressing changes through the remainder of his stay and was discharged with pressure ulcers and treatments to both heels on 03/04/13. On 03/26/13 at 10:30 A.M., an interview with Nurse Manager #6 and the Director of Nursing verified assessments of the lower extremity [MEDICAL CONDITION] were not documented in the medical record. At 11:30 A.M., interview with Nurse Manager #6 and the Administrator verified the notification of the skin integrity impairments was first recognized by the therapy department and after notification, the facility nursing staff did not document an assessment of the heels of Resident #36 until a day later. Additionally, the interview verified nursing staff did not contact the physician or obtain orders until two days after notification of the pressure ulcers found by therapy. The Administrator also revealed the two nurses involved were disciplined as a result of these events. This deficiency substantiates Complaint Number OH 403.