Every finding on record at Heritage Healthcare of Painesville

Based on review of personnel files and interview, the facility did not ensure tuberculosis testing was completed on or prior to the date of hire for the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #202, Human Resources/Payroll #205, State tested Nurse Aide (STNA) #212, Licensed Practical Nurse (LPN) #243, and LPN #238. This affected seven of the 12 personnel files reviewed and had the potential to affect all 52 residents residing in the facility. Findings include: Review of the personnel file for the Administrator revealed the date of hire was 07/03/24, and the tuberculosis test was not administered until 07/16/24. Review of the personnel file for the DON revealed the date of hire was 04/23/24, and the tuberculosis test was not administered until 07/16/24. Review of the personnel file for the ADON #202 revealed the date of hire was 06/12/24, and the tuberculosis test was not administered until 07/16/24. Review of the personnel file for Human Resources/Payroll #205 revealed the date of hire was 04/29/24, and the tuberculosis test was not administered until 07/16/24. Review of the personnel file for the STNA #212 revealed the date of hire was 06/10/24, and the tuberculosis test was not administered until 07/17/24. Review of the personnel file for the LPN #238 revealed the date of hire was 06/09/24, and the tuberculosis test was not administered until 07/17/24. Review of the personnel file for the LPN #243 revealed the date of hire was 07/25/24, and the tuberculosis test was not administered until 07/29/24. Interview on 09/18/24 at 12:59 P.M. with the Human Resources #205 verified the above findings.

Based on record review and interview, the facility failed to ensure showers/bed baths were provided to Residents #18, #23, and #29 as scheduled. This affected three residents (#18, #23, and #29) of five residents reviewed for showers. The facility census was 52. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included fracture of left pubis, dementia, Bell's palsy, chronic pain syndrome, and fracture of the fifth lumbar vertebra. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of shower/bathing task report for Resident #18 for 30-days revealed the resident received bed baths on 08/23/24, 08/27/24, 09/13/24, and 09/14/24. Review of the shower/bathing sheets for Resident #18 for two months revealed none had been completed, Interview on 09/15/24 at 11:33 A.M. Resident #18 stated she rarely got a bed bath. Staff never mentioned them to her. 2. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included end stage renal disease, dependence on renal dialysis, diabetes, and acute and chronic respiratory status. Review of the Medicare - 5 Day MDS 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of the shower/bathing task report for Resident #23 for 30-days revealed the resident had received a shower or bed bath on 0 8/18/24, 08/22/24, 08/23/24, 08/26/24, 09/14/24, and 09/15/24. Review of the shower/bathing sheets for Resident #23 for two months revealed the resident had a bed bath on 08/01/24, on 08/12/24, and had refused on 08/26/24. Interview on 09/15/24 at 12:51 P.M. Resident #23 stated she didn't get her bed baths when she was supposed to. 3. Review of the medical record for Resident #29 revealed a readmitted [DATE]. Diagnoses included fracture of left humerus, fracture of pubis, repeated falls, orthopedic aftercare, and intervertebral disc displacement lumbar region. Review of the Medicare Five-Day MDS 3.0 assessment dated [DATE]revealed Resident #29 was cognitively intact. Review of the shower/bathing task report for Resident #29 for 30-days revealed on 08/23/24 and 08/27/24 the resident refused a shower/bath. The resident received a bed bath on 09/13/24 and 09/14/24. Review of the shower/bathing sheets for Resident #29 for two months revealed on 09/08/24 the form was blank regarding a bath/shower and appeared to be a skin check only and on 09/10/24, the resident refused. Interviews on 09/15/24 at 2:13 P.M. and on 09/17/24 at 5:31 P.M., Resident #29 stated she was not allowed showers at first, but now she was able to have them. She had not received a shower in a while. When one was offered, it was at night, and she preferred to go to bed early. She wanted her showers during the day. Interview on 09/18/24 at 11:33 A.M. with the Director of Nursing (DON) verified those were all the shower sheets available. The documentation in Point Click Care (PCC), the electronic medical record, was lacking. Very few showers/bed baths were documented.

Based on observation, interview, and record review, the facility failed to ensure Resident #39 received wound care according to physician's orders. This affected one resident (#39) of one resident reviewed for pressure ulcers. The facility census was 52. Findings include: Record review of Resident #39 revealed he was admitted to the facility on [DATE] and had diagnoses including diabetes, atrial fibrillation, and end stage renal disease. He was admitted with unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to both heels as well as two pressure sores to his gluteus. The gluteus pressure sores had since healed, and the heel pressure sores progressed to stage III pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling). Review of wound assessments revealed the wounds had decreased in size since admission and the most recent assessment on 09/10/24 identified the right heel to measure 1.4 by 1.6 centimeters (cm) with a depth of 0.3 cm, and the left heel measured 1.5 by 2.0 centimeters with a depth of 0.3. Resident #39 had physician's orders dated 08/28/24 to have daily dressing changes to both heels. Review of his September treatment administration record (TAR) revealed the dressings were changed on 09/02/24, 09/03/24, 09/05/24, 09/08/24, and 09/12/24, 09/13/24, 09/14/24, and 09/15/24 with refusals documented on 09/06/24, 09/09/24, 09/10/24, 09/11/24, and 09/16/24. Interview with Resident #39 on 09/17/24 at 9:17 A.M. revealed he did not receive regular wound care, although his wounds have improved since his admission. Observation of a wound care procedure for Resident #39 by Assistant Director of Nursing (ADON) #202 and Wound Physician #901 on 09/17/24 at 11:31 A.M. revealed the pressure sore dressings on both of Resident #39's heels were dated 09/10/24. The dressing change revealed the wounds were stage III pressure sores with no clear evidence of infection. The left heel wound measured 1.4 cm by 1.8 cm with a depth of 0.4 cm, and the right heel wound measured 1.0 cm by 1.7 cm with a depth of 0.2 cm. Interview with ADON #202 on 09/17/24 at 12:09 P.M. confirmed the above observation. She confirmed the previous dressings were the same dressings she applied when doing her weekly wound rounds on 09/10/24.

Based on review of personnel files and interview, the facility did not ensure an annual evaluation was completed for stated tested nurse aide (STNA) #225. This affected one of the 12 personnel files reviewed and had the potential to affect all 52 residents residing in the facility. Findings include: Review of the personnel file for STNA #225 revealed the most recent annual evaluation for STNA #225 was completed on 05/05/23. Interview on 09/18/24 at 12:54 P.M. with Human Resources/Payroll #205 confirmed the most recent evaluation was dated 05/05/23.

Based on review of personnel files and interview, the facility did not ensure pre-employment reference checks were completed for the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #202, Human Resources/Payroll #205, Licensed Practical Nurse (LPN) #248, and LPN #243. This affected six of the 12 personnel files reviewed and had the potential to affect all 52 residents residing in the facility. Findings include: Review of the personnel file for the Administrator, DON, ADON #202, Human Resources/Payroll #205, LPN #248, and LPN #243 did not contain documented evidence reference checks were completed but did contain documentation the abuse registry checks were completed. Interview on 09/18/24 at 1:03 P.M. with Human Resources/Payroll #205 revealed the reference checks for the Administrator, DON, ADON #202, and Human Resources/Payroll #205 were completed by the corporate office and were not included in their personnel files maintained at the facility. It was confirmed the personnel records for LPN #248 and #243 did not contain documented evidence that reference checks were completed. Interview on 09/18/24 at 3:08 P.M. with Human Resources/Payroll #205 revealed the corporate office was contacted and copies of the reference checks requested; however, the corporate office was unable to locate them.

Based on observation, interview, record review, and policy review the facility failed to maintain a clean and sanitary environment. This affected nine residents (#9, #10, #15, #20, #21, #23, #27, #32 and #33) and had the potential to affect all 46 residents residing in the facility. Findings include: Observation on 08/01/23 at 9:10 A.M. revealed a strong odor of urine from the center of the 200-hallway while walking toward the end of the hallway. There were a few black gnats flying within the hallway. Resident #32 was observed in the assigned room with the window partially open, sitting up in a wheelchair and spraying air freshener toward the center of the room. There were several small black gnats flying around the room. Interview at the time of the observation with Resident #32 stated the staff assisted when needed but was able to toilet independently except when urinating in the toilet it also got onto the floor but could not be prevented. Resident #32 indicated housekeeping cleaned no more than every other day because they were shorthanded, and the staff knew about how urine would get onto the floor. Resident #32's bathroom door was opened. There was a pungent odor of ammonia like urine which radiated from the bathroom which caused coughing when first smelled. There were numerous black gnats flying inside the bathroom and crawling around on the sink, toilet, walls, floor, and door. It was necessary to cover the mouth and nose to prevent breathing the gnats in and difficult to enter the bathroom due to the odor causing difficulty with breathing. There was a large puddle on the floor in front of the toilet of yellow liquid which appeared to be urine which had a shallow depth. The edges of the entire puddle were a dark dried brown ring. Along the edges of the floor from the door around the bathroom wall in front of and adjacent to the toilet had dark dried brown areas. Interview at the time of the observation with Resident #32 stated doing the best with it as possible and left the window partially open due to the odor. Interview on 08/01/23 at 9:16 A.M. with the Administrator verified the above observation and stated being aware of Resident #32 urinating on the floor but had never gone into Resident #32's bathroom. The Administrator indicated the facility had a housekeeping problem for the past two months. There were only two housekeepers, and the housekeeping director was off on leave. There was a struggle to staff the department so at times there was only one housekeeper which caused cleaning to not get completed as often as needed. After leaving Resident #32's bathroom, Resident #9's bathroom was observed with dirt and debris on the floor and a cobweb in the bottom corner of the floor in front of the toilet. The Administrator verified the observation. Interview on 08/01/23 at 9:33 A.M. with the Administrator confirmed being aware of the gnats in the building for at least the past two weeks and was working on a transition with pest control. The facility was sold, and the new company had not worked out contract agreements with the new owners so there was a wait to get it completed. The last pest control visit was in May 2023. Interview on 08/01/23 at 9:39 A.M. with Maintenance Director (MD) #351 stated the company transitioned in May 2023 and was aware of the problem with Resident #32's bathroom. MD #351 indicated a deep cleaning was completed not too long ago but was unsure when. MD #351 confirmed the gnats were flying around the facility for at least the past two weeks and had not attempted to do anything about it, assuming pest control would show up. The pest control was contacted but there was a payment issue, so it was unknown what to do in the interim. Interview on 08/01/23 at 9:44 A.M. with Human Resources Director (HRD) #320 verified Resident #32 had a problem with urinating on the floor and indicated the staff tried to clean it up as soon as it happened. Observation of the environment on 08/01/23 at 10:18 A.M. revealed multiple black gnats flying within each of the four resident care hallways, the dining room and at two nurse's stations. Resident #10's floor had dirt and debris and was sticky as there was a sound of adherence while stepping around the room. Resident #20's floor had visible dirt and debris. Resident #15's floor had visible dirt and debris, and the bedside table had dried spills and food debris. Resident #27's bedside table had visible dirt and debris. Interview on 08/01/23 at 10:39 A.M. with State tested Nursing Assistant (STNA) #305 confirmed there was a urine odor throughout the 200-hall. STNA #305 indicated never going into Resident #32's bathroom because Resident #32 was independent with toileting. STNA #305 verified the problem with gnats had been ongoing since May 2023. The gnats were down every resident hallway and were landing on residents' food. Someone had set out cups of apple cider vinegar before and some would die in the cup, but it was not solving the problem. Observation at the time of the interview revealed one gnat flying around STNA #305. STNA #305 verified housekeepers completed the bare minimum of sweeping and dumping trash, and indicated the floors and bathrooms were not cleaned. Overall, the facility was dirty including bedside tables. Interview on 08/01/23 at 10:57 A.M. with Licensed Practical Nurse (LPN) #304 verified housekeepers did not clean well in resident areas for at least two months or more. The hallways were buffed but not resident floors. Resident #32's room had a pungent odor, and housekeeping could not keep up. LPN #304 indicated not seeing deep cleaning completed. The Administrator was looking for volunteers, but none were present. Residents had complained which were referred to housekeeping. LPN #304 confirmed the gnats were a problem for at least two months and nothing was seen being done about it. The gnats were in rooms, hallways, resident rooms, and were getting on residents' food during meals. Interview on 08/01/23 at 11:12 A.M. with LPN #328 verified odors were down the 200-hall because of Resident #32's room and urinating on the floor. Housekeepers usually cleaned Resident #32's room, but they were not always available, so the nursing staff tried to do it. LPN #328 confirmed the floors and tables were generally dirty despite trying to keep up. Interview on 08/01/23 at 11:38 A.M. with STNA #325 stated when housekeepers were not available for Resident #32's room, the nursing staff would try to help when possible. Resident #32's room was not deep cleaned recently but indicated it should be on at least a weekly basis. STNA #325 indicated the cleaning completed was not enough because at times there was only one housekeeper, especially on the weekends. So, sweeping and trash being emptied was completed but other cleaning was not. STNA #325 confirmed the gnats were a problem for at least two months, but no one was seen coming in to take care of it. The gnats were in the dining room, resident rooms, and getting into residents' food during meals. Observation in the dining room during the lunch meal on 08/01/23 at 12:32 P.M. of Resident #10 revealed a black gnat was flying above the lunch meal. Resident #10 swatted the gnat away from the meal. Interview on 08/01/23 at 12:35 P.M. with Resident #23 stated housekeepers mostly swept the floor and emptied the trash but indicated wiping tables and other needed cleaning was not completed. Observation at the time of the interview revealed a bedside table with dried spills and food debris prior to the lunch meal being served. Interview on 08/01/23 at 12:39 P.M. with Resident #9 stated not liking the urine odor in the air and gnats were a problem. Observation at the time of the interview revealed two black gnats flying around within the room, dried spills and food debris on the bedside table, and a urine odor in the air. Resident #9 complained of gnats getting onto the food during meals. Resident #9 indicated housekeepers mostly swept the floor and emptied the trash, but other cleaning was not done. Interview on 08/01/23 at 12:45 P.M. with Resident #21 stated housekeeping was not good enough because they only swept the floor and emptied the trash. Observation of the floor at the time of the interview revealed dirt and debris. Interview on 08/01/23 at 1:17 P.M. with Housekeeper #302 verified having only one or two housekeepers for at least six months and working alone on the weekends. Only some cleaning was completed, and deep cleaning was not completed as often as scheduled. Resident #32's room needed cleaning daily, but other rooms needed to get done. The gnats were a problem for the last two months but there was nothing housekeeping could do for it. Interview on 08/01/23 at 1:25 P.M. with Housekeeper #338 stated there were only two housekeepers with the director gone on a leave of absence. The floors were scrubbed daily but only the hallways not resident rooms because the machine could not fit into most of the resident rooms. Housekeeper #338 confirmed working alone at times and would go as fast as possible, but some cleaning was skipped, especially wiping surfaces and dusting. Deep cleaning was also not always completed. Resident #32's room needed deep cleaning practically every day but there was not enough staff to do it with a facility of 52 rooms, common areas and a dining room; it was too much. Interview on 08/01/23 at 1:32 P.M. with STNA #314 denied mopping up Resident #32's bathroom despite Resident #32 urinating on the floor but indicated trying to help when possible. STNA #314 verified there was not enough housekeeping to keep up with the overall cleaning since there was only one or two of them. Interview on 08/01/23 at 1:42 P.M. with STNA #341 confirmed trying to help clean Resident #32's bathroom but it was a constant problem. Resident #32 did not always inform staff after urinating. Resident #32 refused to wear incontinence briefs. A bedside commode did not work, urinals were not big enough, and Resident #32 did not comply with using a basin to catch the urine. The window was kept open, and a fan was used sometimes to help with the odor. STNA #341 verified housekeeping was not able to do enough cleaning although being told to do more than just empty the garbage. Interview on 08/01/23 at 1:54 P.M. with the Director of Nursing (DON) verified never being in Resident #32's bathroom but was knowledgeable of the urinating problem. The DON indicated the housekeeping manager had bleached the floors and left a mop and bucket for daily cleaning but could not be certain if it was still being done. Air fresheners were hung in the hallways and the Administrator worked with the housekeeping manager to be more on top of it. The DON stated it was not a nursing problem but a housekeeping problem. Observation on 08/02/23 at 9:29 A.M. of Resident #33 locomoting independently in a wheelchair using the hallway handrail with the right hand to pull self along toward hall 100 near the administrative offices. Standing within the area was Marketing Director #323 and Human Resources Director #320. Resident #33 expressed toward the nearby staff of needing more housekeeping to clean the dust and dirt especially the handrails because they were filthy. The nearby staff did not interact with Resident #33. Interview at the time of the observation with Resident #33 stated the handrails were filthy then ran the right hand over the handrail and displayed the right fingers to show any dirt visible on the right fingers. Review of the housekeeping schedules from 05/28/23 to 07/22/23 revealed one to two housekeepers scheduled daily. There were three days within the timeframe of three scheduled housekeepers. Review of the pest control service reports from 01/31/23 to 05/05/23 revealed monthly pest inspections and treatments were provided monthly. On 05/05/23 there was no pest or rodent activity. There were no services completed after 05/05/23. Review of the QAPI (Quality Assessment and Performance Improvement) form dated 07/19/23 revealed a problem of cleanliness. The root causes were lack of staffing, lack of recruitment, housekeeping supervisor not holding staff accountable, lack of staffing which limited ability to follow deep cleaning schedule, and maintenance director not properly trained. Tasks included to ask other employees to assist with cleaning but there were no volunteers on 07/21/23; set cleaning days in August 2023 with staff invited to attend; housekeeping staff educated on 07/20/23; recruit and hire additional housekeeping staff; recreate deep cleaning schedule to make feasible for housekeeping staff to complete; complete environmental rounds every two weeks; and work with pest control to address no visits since company transition due to a payment issue. Review of the facility policy, Safe and Homelike Environment, revised 10/01/22, revealed the facility would provide a safe, clean, comfortable, and homelike environment; and housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly and comfortable environment. This deficiency represents non-compliance investigated under Master Complaint Number OH00144865 and Complaint Number OH00144722.

Based on observation, interview, record review, and facility policy review the facility failed to maintain effective pest control. This affected three residents (#9, #10 and #32) and had the potential to affect all 46 residents residing in the facility. Findings include: Observation on 08/01/23 at 9:10 A.M. revealed a strong odor of urine from the center of hallway 200 while walking toward the end of the hallway. There were a few black gnats flying within the hallway. Resident #32 was observed in the assigned room with the window partially open, sitting up in a wheelchair and spraying air freshener toward the center of the room. There were several small black gnats flying around the room. Interview at the time of the observation with Resident #32 stated the staff assisted when needed but was able to toilet independently except when urinating in the toilet it also got onto the floor but could not prevent it. Resident #32 indicated housekeeping cleaned no more than every other day because they were shorthanded, and the staff knew about how urine would get onto the floor. Resident #32's bathroom door was opened. There was a pungent odor of ammonia like urine which radiated from the bathroom which caused coughing when first smelled. There were numerous black gnats flying inside the bathroom and crawling around on the sink, toilet, walls, floor, and door. It was necessary to cover the mouth and nose to prevent breathing the gnats in and difficult to enter the bathroom due to the odor causing difficulty with breathing. There was a large puddle on the floor in front of the toilet of yellow liquid which appeared to be urine which had a shallow depth. The edges of the entire puddle were a dark dried brown ring. Along the edges of the floor from the door around the bathroom wall in front of and adjacent to the toilet had dark dried brown areas. Interview at the time of the observation with Resident #32 stated doing the best with it as possible and left the window partially open due to the odor. Interview on 08/01/23 at 9:16 A.M. with Administrator verified the above observation and stated being aware of Resident #32 urinating on the floor but had never gone into Resident #32's bathroom. Administrator indicated the facility had a housekeeping problem for the past two months. There were only two housekeepers, and the housekeeping director was off on a leave. There was a struggle to staff the department so at times there was only one housekeeper which caused cleaning to not get completed as often as needed. Interview on 08/01/23 at 9:33 A.M. with Administrator confirmed being aware of the gnats in the building for at least the past two weeks and was working on a transition with pest control. The facility was sold, and the new company had not worked out contract agreements with the new owners so there was a wait to get it completed. The last pest control visit was in May 2023. Interview on 08/01/23 at 9:39 A.M. with Maintenance Director (MD) #351 stated the company transitioned in May 2023 and was aware of the problem with Resident #32's bathroom. MD #351 indicated a deep cleaning was completed not too long ago but was unsure when. MD #351 confirmed the gnats were flying around the facility for at least the past two weeks and had not attempted to do anything about it, assuming pest control would show up. The pest control was contacted but there was a payment issue, so it was unknown what to do in the interim. Observation of the environment on 08/01/23 at 10:18 A.M. revealed multiple black gnats flying within each of the four resident care hallways, the dining room and at two nurse's stations. Interview on 08/01/23 at 10:39 A.M. with State tested Nursing Assistant (STNA) #305 verified the problem with gnats had been going on since May 2023. The gnats were down every resident hallway and were landing on residents' food. Someone had set out cups of apple cider vinegar before and some would die in it but it was not solving the problem. Observation at the time of the interview revealed one gnat flying around STNA #305. Interview on 08/01/23 at 10:57 A.M. with Licensed Practical Nurse (LPN) #304 confirmed the gnats were a problem for at least two months and nothing was seen being done about it. The gnats were in rooms, hallways, resident rooms, and were getting on residents' food during meals. Interview on 08/01/23 at 11:38 A.M. with STNA #325 confirmed the gnats were a problem for at least two months but no one was seen coming in to take care of it. The gnats were in the dining room, resident rooms, and getting into residents' food during meals. Observation in the dining room during the lunch meal on 08/01/23 at 12:32 P.M. of Resident #10 revealed a black gnat was flying above the lunch meal. Resident #10 swatted the gnat away from the meal. Interview on 08/01/23 at 12:39 P.M. with Resident #9 stated not liking the urine odor in the air and gnats were a problem. Observation at the time of the interview revealed two black gnats flying around within the room, dried spills and food debris on the bedside table, and a urine odor in the air. Resident #9 complained of gnats getting onto the food during meals. Interview on 08/01/23 at 1:17 P.M. with Housekeeper #302 verified having only one or two housekeepers for at least six months and working alone on the weekends. Only some cleaning was completed, and deep cleaning was not completed as often as scheduled. The gnats were a problem for the last two months but there was nothing housekeeping could do for it. Interview on 08/01/23 at 1:25 P.M. with Housekeeper #338 stated there were only two housekeepers with the director gone on a leave of absence. Housekeeper #338 confirmed working alone at times and would go as fast as possible, but some cleaning was skipped, especially wiping surfaces and dusting. Deep cleaning was also not always completed. Review of the housekeeping schedules from 05/28/23 to 07/22/23 revealed one to two housekeepers scheduled daily. There were three days within the timeframe of three scheduled housekeepers. Review of the pest control service reports from 01/31/23 to 05/05/23 revealed monthly pest inspections and treatments were provided monthly. On 05/05/23 there was no pest or rodent activity. There were no services completed after 05/05/23. Review of the QAPI (Quality Assessment and Performance Improvement) form dated 07/19/23 revealed a problem of cleanliness. The root causes were lack of staffing, lack of recruitment, housekeeping supervisor not holding staff accountable, lack of staffing which limited ability to follow deep cleaning schedule, and maintenance director not properly trained. Tasks included to ask other employees to assist with cleaning but there were no volunteers on 07/21/23; set cleaning days in August 2023 with staff invited to attend; housekeeping staff educated on 07/20/23; recruit and hire additional housekeeping staff; recreate deep cleaning schedule to make feasible for housekeeping staff to complete; complete environmental rounds every two weeks; and work with pest control to address no visits since company transition due to a payment issue. Review of facility policy, Safe and Homelike Environment, revised 10/01/22, revealed the facility would provide a safe, clean, comfortable, and homelike environment; and housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Review of facility policy, Pest Control, revised April 2014, revealed the facility made every attempt to ensure a pest free environment by maintaining an effective pest control program. Inspections were completed on a regular basis by maintenance or housekeeping staff and on a routine basis by the contracted pest control agency. Pest sightings were documented and reviewed each visit by the pest control agency. This deficiency represents non-compliance investigated under Master Complaint Number OH00144865 and Complaint Number OH00144722.

Based on record review, observation and interview, the facility did not ensure cold food temperatures were being appropriately monitored to prevent risk of food born illness. This had the potential to affect all 47 residents receiving meals from the kitchen. Findings include: Review of the food committee minutes, dated 05/18/23, revealed a concern that cold foods were not always served cold. Observation on 06/27/23 at 8:06 A.M. revealed a tray full of cups of milk and orange juice was sitting at the 100 hall nursing station. The tray nor milk and orange juice cups were not on ice nor had any other obvious method of being kept cold. Aides took drinks from the tray and put them on meal trays as they entered resident rooms to serve breakfast. This was noted to still be ongoing as of 8:24 A.M. Interview with Nurse Aide #201 following the above observations confirmed drinks were pre-poured and served from an unrefrigerated tray. She said sometimes staff served it that way and sometimes they poured drinks for one resident at a time from pitchers kept in ice. Interview with Resident #17 on 06/27/23 at 2:52 P.M. revealed milk was sometimes not served cold. Interview with Resident #42 on 06/27/23 at 3:04 P.M. revealed cold drinks were often served lukewarm with meals. Interview with Dietary Manager (DM) #302 on 06/28/23 at 7:43 A.M. revealed the facility served drinks including milk by dispensing pitchers held in ice and sent to the units where they were then distributed by nursing aides. DM #302 said he did not have a food temperature thermometer capable of measuring below 50 degrees Fahrenheit (F) to ensure cold foods were kept at 41 degrees or below, as the thermometer he had did not go below 50 degrees F. DM #302 explained he began work at the facility two months ago and during that time did not have a thermometer capable of measuring lower than 50 degrees F, so cold food temperaturs were not being monitored. DM #302 said he had been meaning to order a thermometer that could measure cold food temperatures. This deficiency represents noncompliance investigated under OH00143459.

Based on record review, interview and observation, the facility failed to ensure pressure sore dressing changes were done according to physician orders. This affected one resident (Resident #6) out of three residents reviewed for pressure sores. The total census was 47. Findings include: Record review of Resident #6 revealed she was admitted [DATE] and had diagnoses including Parkinson's Disease, major depressive disorder, unspecified psychosis, and diabetes. She had an order dated 06/14/23 for her left heel wound to be treated every Monday, Wednesday, and Friday with a saline cleanse, betadine, and foam dressing. The care was documented done as ordered, including on Monday, 06/26/23. Review of her most recent wound assessment on 06/21/23 revealed the wound was a blister acquired 05/17/23 which progressed to an unstageable wound which appeared to be healing and measured 0.5 by 0.5 centimeters with no drainage or odor. Interview with Resident #6 on 06/27/23 at 11:38 A.M. revealed her wound dressing was not changed regularly by staff. Observation of a wound care procedure for Resident #6 on 06/28/23 at 10:38 A.M. by Licensed Practical Nurse (LPN) #203 and Wound Physician #601 revealed the previous dressing on her left heel was dated 06/24/23 (a Saturday), and appeared to be a taped gauze dressing instead of the foam dressing ordered by the physician. The wound measured 0.3 by 0.7 centimeters and had no drainage or odor. Interview was conducted on 06/28/23 at 11:02 A.M. with LPN #203 who verified during the wound observation Resident #6 did not have the correct dressing in place according to physician orders, and the dressing had last been changed on 06/24/23 (a Saturday) which was not according to the physician orders for every Monday, Wednesday and Friday treatments. This deficiency represents noncompliance investigated under OH00143560.

Based on observation, interview, record review and policy review, the facility failed to ensure residents were assisted with activities of daily living including bathing and transfers. This affected three (Residents #5, #18 and #34) of four residents reviewed for activities of daily living. The census was 48. Findings include: 1. Review of Resident #18's medical record revealed an admitted [DATE] and diagnoses included fracture of right foot, chronic constrictive pericarditis, and muscle wasting and atrophy, multiple sites. Review of Resident #18's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Resident #18 required extensive assistance of one staff member for bed mobility, was total dependence of two staff members for transfers and toilet use. Resident #18 was always incontinent of urine and bowel. Review of Resident #18's care plans dated 04/25/23 did not reveal a care plan for activities of daily living. Review of the facility shower schedule, undated, revealed Resident #18 was scheduled to receive showers Tuesday and Friday evenings. Review of Resident #18's shower sheets dated 05/01/23 through 05/14/23 revealed Resident #18 had a bed bath on 05/09/23. There was no further documentation Resident #18 had bathing completed. Review of Resident #18's physician orders dated 04/26/23 revealed non weight bearing right foot, and must keep fracture boot on every shift for orthopedic care. Review of Resident #18's physician orders dated 05/04/23 revealed Resident #18 required one person assist with use of slide board for functional transfers. During observation on 05/15/23 at 3:51 P.M., Resident #18 was sitting in a wheelchair in her room and was wearing a fracture boot on her right foot. Resident #18's hair was greasy on top and along the sides of her face. During interview on 05/15/23 at 3:51 P.M. Resident #18 stated she did not get bed baths twice a week like she was supposed to. Resident #18 stated she did not take showers right now because she fractured her foot and had to wear a fracture boot. Resident #18 stated the last time her hair was washed was about ten days ago, and she wished it was more often. Resident #18 indicated she asked STNA #451 at 2:45 P.M. to assist her into bed before she left at 3:00 P.M. Resident #18 stated STNA #451 told her someone would be in to help or she would come back before she left. Resident #18 stated STNA #451 did not come back to assist her before she left the facility and neither did any other STNA's. Resident #18 stated she needed to lay down, had been waiting for over an hour, and she asked STNA #451 to help her before she left because after 3:00 P.M. 2. Review of Resident #5's medical record revealed an admitted [DATE] and a re-entry date of 04/07/22. Resident #5's diagnoses included fracture of shaft of left fibula, need for assistance with personal care, Parkinson's Disease, type two diabetes mellitus with diabetic neuropathy and bipolar disorder. Review of Resident #5's Quarterly MDS assessment, dated 04/19/23, revealed Resident #5 was cognitively intact. Resident #5 required extensive assistance of one staff member for bed mobility, extensive assistance of two staff members for transfers, and had total dependence of one staff member for toilet use. Resident #5 was always incontinent of bowel. Resident #5 had a pressure ulcer. Review of Resident #5's care plan revised 03/29/23 included Resident #5 had an activities of daily living self-care performance deficit and assist with activities of daily living (for example, dressing, grooming, personal hygiene, locomotion, oral care, etcetera) as needed. Review of Resident #5's shower schedule undated revealed Resident #5 was scheduled to have showers during the day on Wednesday and Saturday. Review of Resident #5's shower sheets dated 05/01/23 through 05/14/23 revealed one shower sheet was filled out for 05/13/23 and did not specify if Resident #5 had a shower, bed bath, or refused. During interview on 05/15/23 at 2:05 P.M., Resident #5 could not remember the last time she had a shower or bed bath. 3. Review of Resident #34's medical record revealed an admitted [DATE] and diagnoses included dementia, heart failure, and need for assistance with personal care. Review of Resident #34's quarterly MDS assessment, dated 04/06/23, revealed a Brief Interview for Mental Status was not completed as Resident #34 was rarely or never understood. Resident #34 required extensive assistance of one staff member for personal hygiene. Resident #34 was total dependence and a one person physical assist for bathing. Review of Resident #34's care plan revised 04/11/23 included Resident #34 needed assistance for activities of daily living and would be clean, odor-free and appropriately dressed on a daily basis. Interventions included staff would assist as needed with daily hygiene and would assist with showering Resident #34 as per facility policy weekly. Review of Resident #34's shower schedule undated revealed Resident #34 was scheduled for showers on day shift on Wednesday and Sundays. Review of Resident #34's State tested Nursing Assistant (STNA) electronic medical record charting from 04/14/23 through 05/14/23 revealed on 05/10/23 documentation revealed Resident #34 received a shower. There was no further documentation Resident #34 received additional showers or bed baths. Review of shower sheets from 05/01/23 through 05/14/23 did not reveal any shower sheets for Resident #34. During observation on 05/15/23 at 7:53 A.M., Resident #34's hair was greasy. During interview on 05/15/23 at 2:37 P.M., STNA #409 confirmed Resident #34's hair looked greasy. STNA #409 stated Resident #34 had an appointment at the hair salon and the greasy look could be the product used on her hair, but the stylist washed Resident #34's hair only if she was specifically requested to. STNA #409 stated she did not shower Resident #34 or wash her hair recently, and did not always have Resident #34 assigned to her. Review of the facility policy titled Resident Care revised June 2018, included typical personal hygiene for a resident would include care of the skin to include routine and as needed bathing, foot care, shampoo and grooming of the hair per resident preference. Residents would be bathed or assisted to shower or bathe routinely and as needed per their preference with foot care given per order, need. This deficiency represents non-compliance investigated under Complaint Number OH00141719.

Based on observation, interview, record review and policy review, the facility failed to ensure a low air loss mattress was properly inflated to promote healing of a pressure ulcer. This affected one (Resident #5)of three residents reviewed for pressure ulcers. The facility census was 48. Findings include: Review of Resident #5's medical record revealed an admitted [DATE] and a re-entry date of 04/07/22. Resident #5's diagnoses included fracture of shaft of left fibula, need for assistance with personal care, Parkinson's Disease, type two diabetes mellitus with diabetic neuropathy and bipolar disorder. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, revealed Resident #5 was cognitively intact. Resident #5 required extensive assistance of one staff member for bed mobility, extensive assistance of two staff members for transfers, and had total dependence of one staff member for toilet use. Resident #5 was always incontinent of bowel. Resident #5 had a pressure ulcer. Review of Resident #5's wound care notes dated 05/10/23 and written by Wound Nurse Practitioner (WNP) #463 revealed Resident #5 had a Stage III sacral pressure ulcer, tissue bed was 75 percent granular and 25 percent slough, and measurements were a length of 1.5 centimeters (cm), width 1.0 cm and depth 0.1 cm. Resident #5 had a left heel stage three pressure ulcer, wound bed was 100 percent granular, and measurements were length of 4.0 cm, width of 2.0 cm, and depth 0.1 cm. During observation on 05/11/23 at 12:32 P.M., Resident #5 was lying at an angle in bed, her right leg hanging off the side of the bed and the head of bed was elevated about 30 degrees. Resident #5 stated her back hurt and she told an unidentified nurse about it a half hour ago. State tested Nursing Assistant (STNA) #412 was in the room at the time of the observation and confirmed Resident #5 was lying in an awkward position and in pain. STNA #412 lowered the head of her bed until she was administered medication for pain. During observation on 05/11/23 at 1:12 P.M. Resident #5 was lying on a low air loss mattress but the mattress was not turned on and inflated. Resident #5 was resting on the uninflated mattress on a steel bed frame. STNA #412 confirmed the low air loss mattress was not on, stated Resident #5 was recently moved from another room to the current room and the staff must have forgot to turn the mattress back on when they moved her. STNA #412 pressed the power button to turn the mattress on. Nurse #416 walked into the room and stated Resident #5 was recently moved and the staff must have forgotten to turn the mattress back on once the move was complete. STNA #412 stated she did not notice the mattress was not turned on and it was off all day since she arrived at 7:00 A.M. During interview on 05/11/23 at 2:30 P.M., the Director of Nursing (DON) stated she did not know what time Resident #5 was moved from her room but checking the electronic record indicated it was on 05/10/23 at 4:43 P.M. The DON confirmed Resident #5's low air loss mattress was not turned on and functioning appropriately for about 19 hours. During interview on 05/17/23 at 11:06 A.M., Wound Physician (WP) #464 and the Assistant Director of Nursing, Wound Nurse (WN) #430 stated if Resident #5's low air loss mattress was not turned on and inflated it could cause a pressure injury. During observation on 05/17/23 at 11:06 A.M., WP #464 and WN #430 revealed Resident #5 was lying in bed and her heels were resting directly on the low air loss mattress and were not offloaded. Observation of Resident #5's left heel revealed a known pressure injury found when Resident #5 was readmitted to the facility from the hospital and a new area, dark red in color and about the size of a dime. WP #464 stated the new area of the left heel was a blood blister deep tissue pressure injury and length was 1.5 cm, width 3.0 cm and depth unable to be determined. WP #464 stated heels should be offloaded and an offloading boot should be used. Observation revealed an offloading boot was in Resident #5's room and WP #464 placed it on her left foot after treatment was completed. Review of the facility policy titled Pressure Injury Prevention and Management revised 08/22/22 included the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal pressure ulcer, injury, prevent infection and the development of additional pressure ulcers, injuries. Evidence-based interventions for prevention would be implemented for all residents who were at risk or who had a pressure injury present. Basic or routine care interventions could include, but were not limited to redistribute pressure, provide appropriate, pressure-redistributing support surfaces. Review of Owners Manual for PressureGuard APM2 and PressureGuard APM2 Safety Supreme air therapy support surface undated, included the PressureGuard APM2 models were powered, flotation therapy mattresses providing a pressure management surface for the prevention and treatment of pressure ulcers. The inflation system consists of four urethane air cylinders in standard models that run head to foot underneath the body and the foam topper. These cylinders perform the alternating pressure therapy and the lateral rotation therapy. Cylinders inflate and deflate in a fixed ten minute cycle. The cycles and inflation levels were designed to provide and maintain low interface pressures throughout the mattress, and to redistribute peak interface pressure points during the alternating cycle. Comfort level selection allowed selection of air cylinder firmness within a relatively small range. Press softer or firmer button to achieve desired setting. Begin in the softest setting, then adjust for comfort as desired. This is an incidental deficiency discovered during the course of this complaint investigation.

Based on record review and interview the facility failed to ensure there was documented evidence intravenous antibiotics were administered per physician orders. This affected one resident (#8) of three residents reviewed for intravenous antibiotics. The facility census was 50. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including a fracture of the lower left radius and cellulitis. Review of the Medicare -5 Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had intact cognition. Resident #8 required supervision for bed mobility, transfers, walking, locomotion, dressing, toilet use, and personal hygiene. Review of the physician orders for March 2023 revealed Resident #8 had an order for Cefazolin Sodium Injection Solution Reconstituted 2 gram (antibiotic) intravenously every eight hours for wound care starting 02/28/23. Review of medication administration records (MAR) for March 2023 revealed no documented evidence Resident #8 received Cefazolin Sodium Injection Solution Reconstituted 2 gram intravenously on 03/01/23 at 10:00 P.M., 03/02/23 at 6:00 A.M., 03/03/23 at 6:00 A.M., 03/04/23 at 6:00 A.M., 03/06/23 at 6:00 A.M. 03/07/23 at 6:00 A.M., 03/08/23 at 10:00 P.M., 03/09/23 at 6:00 A.M., 03/12/23 at 6:00 A.M., 03/21/23 at 6:00 A.M. and 2:00 P.M. (There were 11 instances from 03/01/23 through 03/21/23 where the medication was not documented as administered as ordered by the physician). Review of the nursing progress notes dated 03/01/23 through 03/22/23 revealed no information related to the resident not receiving Cefazolin as ordered. Interview on 03/22/23 at 10:27 A.M. with Resident #8 revealed he received his intravenous antibiotics as ordered by the physician. Interview on 03/22/23 at 3:50 P.M. with the Administrator verified there was no documented evidence Resident #8 received the intravenous antibiotic for the dates noted. Interim Director of Nursing (DON) #208 was also unable to account for the missing documentation. This deficiency represents non-compliance investigated under Complaint Number OH00140941.

Based on observation, interview, and policy review the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect all residents residing in the facility who receive meals. The facility identified two residents (#32 and #52) with physician's orders for nothing by mouth (NPO). The facility census was 58. Findings include: Observation on 01/04/23 beginning at 9:40 A.M. revealed the kitchen floor had accumulated grime in addition to food spills from breakfast. In the walk-in refrigerator there was uncooked bacon and pork sausage stored on the second shelf instead of the bottom shelf even though there was a sign as to where items were to be placed. The floors in the walk-in refrigerator were dirty and there were splashes on the walls behind the storage racks. The refrigerator and freezer temperature logs were not completed. There was no thermometer in the refrigerator. These findings were verified by the Dietary Manager (DM) #368 who was from another facility to assist. The reach-in refrigerator had drips down the outside and inside the bottom was dirty with beverage spills and crumbs of dried food. The oven had a dirty front panel, dirty handles, and the top was dusty/greasy. The stove top had burnt on food, food crumbs, and food spills. The burners had not been wiped out recently and had accumulated burnt-on food. The steam table wells were covered with lids that were greasy. These findings were verified by Facility DM #310 at the time of the observation. Observation on 01/04/23 at 12:41 P.M. revealed the steamtable had food spills from previous meals and new food pans were in place. This was verified by Cook #363. Review of the undated facility policy titled Sanitary Conditions revealed all foods would be appropriately stored. Foods would be stored off floors, covered, labeled, and dated. The policy revealed all equipment would be maintained in clean and sanitary fashion. This deficiency represents non-compliance investigated under Complaint Number OH00138584.

Based on observation, interview and record review, the facility failed to serve meals in a timely manner. This had the potential to affect all residents residing in the facility who receive meals. The facility identified two residents (#32 and #52) who received nothing by mouth (NPO). The facility census was 58. Findings include: Review of the Daily Happening for Wednesday 01/04/23 revealed mealtimes were scheduled: 7:30 A.M. to 8:30 A.M. for Breakfast, 12:30 P.M. to 1:30 P.M. for Lunch, and 5:40 P.M. to 6:30 P.M. for dinner. The activities department passed a copy of the Daily Happenings newsletter to all residents each morning. Interviews on 01/04/23 from 9:15 A.M. to 3:31 P.M. and on 01/05/23 from 9:10 A.M. to 9:34 A.M. with six alert and oriented residents (#18, #20, #30, #35, #39, and #44) revealed the food was rarely served on time and was sometimes extremely late. Observation on 01/04/23 at 12:25 P.M. revealed tray line started at 12:47 P.M., not at 12:30 P.M. as scheduled. Observation on 01/04/23 at 1:27 P.M. revealed the lunch trays for the 300-unit arrived. All lunch trays were passed on the unit by 1:40 P.M. which was past the posted times. Observation on 01/04/23 at 1:43 P.M. revealed the 200-unit trays arrived. All trays were passed on the unit by 1:53 P.M. which was past the posted times. Interview on 01/04/23 at 1:45 P.M. with Dietary Manager (DM) #310 revealed meal service ran late. This deficiency represents non-compliance investigated under Complaint Number OH00138584.

Based on observation and interview, the facility failed to serve palatably hot food. This had the potential to affect all residents residing in the facility who receive meals. The facility identified two residents (#32 and #52) with physician's orders for nothing by mouth (NPO). The facility census was 58. Findings include: Observation on 01/04/23 from 1:41 P.M. to 1:53 P.M. revealed the trays for the 200-hall left the kitchen at 1:41 P.M. Staff began passing the trays at 1:43 P.M. All the trays on the unit were passed by 1:53 P.M. Observation on 01/04/23 at 1:53 P.M. revealed the chicken in mustard sauce was 123 degrees Fahrenheit (F), the mashed potatoes were 126 degrees F, and the succotash was 110 degrees F. The temperatures were taken by Dietary Manager (DM) #310 who verified the temperature of the food was not adequately hot. This deficiency represents non-compliance investigated under Complaint Number OH00138584.

Based on observation, interview, and record review the facility failed to serve meals in a timely manner. This had the potential to affect all residents residing in the facility who receive meals. The facility identified two residents (Resident's #36 and #260) with physician's orders for nothing by mouth (NPO). The facility census was 55. Findings include: Upon entry on 10/24/22 at 8:30 A.M. a list of mealtimes was requested and received. Review of the list indicated mealtimes were 7:30 A.M. for breakfast, 11:30 A.M. for lunch, and 5:30 P.M. for dinner. Observation on 10/24/22 at 8:58 A.M. revealed staff passing breakfast trays on the 100-unit. Observation 10/24/22 at 11:30 A.M. revealed six residents sitting in dining room waiting for lunch meal. Observed residents filtering into dining room for lunch meal from 11:31 A.M. to 12:00 P.M. At 12:00 P.M. observed administrator enter kitchen. Interview on 10/24/22 at 12:10 P.M. with Administrator revealed dinner mealtime was changed to 5:30 P.M. during week of 10/14/22. The Administrator indicated the updated dinner mealtime was posted for resident notification. The Administrator reported the lunch mealtime was also supposed to be changed to 12:30 P.M. however it had not been posted to notify residents. The Administrator indicated as of 10/24/22 lunch meal should be at 12:30 P.M. The Administrator provided updated list of mealtimes with lunch as 12:30 P.M. Observations on 10/24/22 from 12:10 P.M. to 12:50 P.M. revealed residents continued to wait in dining room for lunch. At 12:43 P.M. observed residents asking staff when meals would be ready. Lunch trays for dining room began to be served at 12:50 P.M. and was completed by 1:10 P.M. Observation on 10/24/22 at 1:07 P.M. revealed family member approached the administrator asking where the hall trays were. The Administrator told the family member the mealtime was changed. The family member was unaware of any changes to mealtimes. Observation on 10/24/22 at 12:45 P.M. revealed 100-unit lunch trays arrived. Observation on 10/24/22 at 1:01 P.M. revealed 300-unit lunch trays arrived. Observation on 10/24/22 at 1:18 P.M. revealed 200-unit lunch trays arrived. Observation on 10/24/22 at 1:23 P.M. revealed 400-unit lunch trays arrived. Observations on 10/25/22 revealed 100-unit breakfast trays were delivered at 8:13 A.M. and 200-unit breakfast trays were delivered at 8:28 A.M. Observation of a resident standing on 200-unit at 8:32 A.M. complaining to staff while standing by meal cart. The resident was upset trays were late. Staff asked the resident to wait patiently, and the resident indicated he had been waiting and now the food would be cold by the time they passed it. Breakfast meal trays were delivered to 300-unit at 8:19 A.M. and 400-unit at 8:33 A.M. Interviews on 10/24/22 from 10:15 A.M. to 12:41 P.M. and on 10/25/22 at 9:41 A.M. with Residents #14, #24, #33 #37, #48, and #52 revealed meals were often late. Residents indicated lunch was usually around 1:00 P.M. - 1:30 P.M. and dinner around 6:30 P.M. - 7:00 P.M. Residents were unaware of mealtime changes, had not given input for mealtime changes, and had not been notified of the change. Interview on 10/25/22 at 11:25 A.M. with Corporate Dietitian #51 and Dietary Manager #8 revealed mealtimes were now 7:30 A.M. for breakfast, 12:30 P.M. for lunch, and 5:30 P.M. for dinner. Corporate Dietitian #51 indicated the Administrator was informed the week of 10/14/22 to push back dinner to 5:30 P.M. Dietary Manager #8 indicated mealtimes were adjusted last week but the change to lunch meal was not posted to inform the residents, so they were confused. Dietary Manger #8 indicated the order in which trays were served was first 100-unit, then 300-unit, then dining room, then 200-unit, and last 400-unit. Interview on 10/25/22 at 3:56 P.M. with the Administrator and Dietary Manager #8 revealed the expectation for meal service was 30 minutes to serve all trays. Observation on 10/27/22 at 8:30 A.M. revealed breakfast trays had arrived at 200-unit. Interview on 10/27/22 at 12:39 P.M. with Registered Dietitian (RD) #45 revealed mealtimes need to be reviewed as they have been different than what was posted. RD #45 indicated he hoped to work with the new dietary manager on having consistent mealtimes. RD #45 indicated he was unaware there had been mealtime changes to 12:30 P.M. for lunch and 5:30 P.M. for dinner. Review of the Activities Daily Happenings handouts from 10/17/22 to 10/24/22 revealed as of 10/21/22 mealtimes were 7:30 A.M. for breakfast, 11:30 A.M. for lunch, and 5:30 P.M. for dinner.

Based on observation, interview, and policy review the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect all residents residing in the facility who received meals. The facility identified two (Resident's #36 and #260) with nothing by mouth (NPO) diet orders. The facility census was 55. Findings include: Observations on 10/24/22 from 9:00 A.M. to 9:15 A.M. of facility kitchen revealed the double door reach in cooler had a tray with seven bowls of uncovered and undated beets and a second tray was a bowl of mandarin oranges and seven bowls of apples which were uncovered and undated. Additionally, in the double door reach-in cooler was an unidentified covered bowl without date and a pot of vegetable soup covered with plastic wrap with no label or date. In the single door reach-in cooler there was a spill down back of cooler. Observation of the microwave revealed food splatter on the inside top and sides. Observation of food splatter on the inside of the door of kitchen. Observation of the walk-in cooler revealed a bag of lettuce hanging out of box which was ripped open in the middle. The bag was uncovered and had no date. Observation of the walk-in freezer revealed a frozen bag of alfredo sauce on the floor under the racks and a bag of ice on the floor next to the rack. Interview on 10/24/22 at 9:15 A.M. with Corporate Dietitian #51 confirmed the above findings at the time of the observation. Review of the undated facility policy titled Sanitary Conditions revealed all foods would be appropriately stored. Foods would be stored off floors, covered, labeled, and dated. The policy revealed all equipment would be maintained in clean and sanitary fashion.

Based on interview, record review, and policy review, the facility failed to ensure documentation was completed on five residents (Residents #26, #30, #37, #48, and #262) of 25 residents reviewed for documentation. The facility census was 55. Findings include: 1. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes for Resident #26 revealed on 08/27/22 at 11:44 P.M. paged Physician (MD) #56 regarding the resident for an unknown reason. At 11:52 P.M. MD #56 returned the page and ordered [MEDICATION(S)] (an anti-nausea medication) 8 milligrams three times a day as needed for nausea as well as an abdominal x-ray. Further review revealed the last documentation regarding Resident #26 was on 08/30/22 by Social Services Designee (SSD) #37. 2. Review of the medical record for Resident #30 revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired and had fallen prior to admission. Review of the progress notes for Resident #30, dated 09/14/22 at 6:03 P.M., revealed the resident was admitted to the facility with no information regarding where the resident had been admitted from or why he was admitted to the facility. The last documentation for Resident #30 was dated 09/16/22 at 12:10 P.M. by SSD #37 when the resident's care conference was held. No further documentation was found. 3. Review of the medical record revealed Resident #262 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing documentation revealed a note dated 10/04/22 was not entered into the electronic medical record until 10/20/22. Interview with the Director of Nursing (DON) on 10/27/22 at 12:07 P.M. confirmed the nurses' documentation was poor. She in-serviced the staff on documentation but had not noticed improvement. A second interview with the DON on 10/31/22 at 11:28 A.M. revealed she expects the nurses to document all changes, when they speak with the family/responsible party, or new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Charting and Documentation policy, last reviewed July 2017, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 4. Review of the medical record for Resident #37 revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #37 had intact cognition. Review of Progress Notes from February 2022 to April 2022 revealed no indication of how Resident #37's wound occurred and no indication of blister opening to wound. Review of Progress Notes from March 2022 revealed no progress note indicating Resident #37 had acquired blister on 03/28/22. Noted on 03/20/22 Resident #37 was noted to have right lower extremity phlebitis and area was reddened with large blister in center. Review of facility Skilled Nurse's Note assessment dated [DATE] revealed Resident #37's skin was within normal limits. Review of facility Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #37 had blister to right lower leg. The blister measured 3.5 centimeters (cm) x 4.0 cm. The assessment indicated skin condition was acquired on 03/28/22. Review of facility assessments from March 2022 revealed no documentation of situation causing blister or hematoma to right lower extremity. Review of facility progress note dated 04/04/22 revealed Resident #37 was sent to hospital for antibiotics and assessment of right leg wound. Review of Care Plan dated 04/01/22 revealed Resident #37 had actual area of skin impairment of open hematoma to right lower extremity. Interventions included evaluate for pain, observe and document wound weekly, elevate legs, and wound treatments as ordered. Review of facility Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #37 had wound to right lateral tibia that was acquired 03/28/22 related to trauma. The wound measured 9.5 cm x 8.0 cm x 0.6 cm. Interview on 10/24/22 at 10:42 A.M. with Resident #37 revealed she could not remember exact dates but indicated around April 2022 she was making her bed and leaned on controls of motorized wheelchair. Resident #37 indicated when she leaned on controls the wheelchair moved forward and knocked her onto bed. Resident #37 indicated she hit her right lower leg on metal bar holding mattress in place on bed frame. Resident #37 indicated hitting her leg caused a large hematoma. Interview on 10/27/22 at 11:42 A.M. with Resident #37 revealed at first the wound was just a bruise then became a blister. Resident #37 indicated the physician sent her to the hospital when she returned, she wanted a shower and the dressing was removed causing the blister to burst. Resident #37 indicated the area became a large wound that the facility had been treating with various methods until present. Interview on 10/31/22 at 11:30 A.M. with the DON verified lack of documentation in Resident #37's medical record related to the incident causing the wound. Review of the facility Charting and Documentation policy, dated July 2017, revealed all services provided to the resident or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. Documentation shall be objective, complete, and accurate. 5. Review of the medical record for Resident #48 revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 annual assessment dated [DATE] revealed Resident #48 had intact cognition. Review of the progress note dated 07/19/22 revealed Resident #48 complained of right knee pain. The physician was notified of the pain, and new orders were received for as needed Tylenol and a [MEDICATION(S)] daily. Review of the progress note dated 07/20/22 revealed Resident #48 continued to complain of right knee pain. The physician was notified, and new orders were received to obtain an x-ray of knee. An X-ray was obtained and resulted in acute distal femur fracture. The physician was again notified, and an order was obtained to send the resident to the emergency room for further evaluation. Review of the Radiology Interpretation report dated 07/20/22 revealed acute fracture not displaced with noted osteopenia and [CONDITION(S)] changes. Review of the progress notes from July 2022 revealed no indication of the situation which led to Resident #48 complaining of right knee pain. Review of the assessments from July 2022 revealed no indication of the situation which led to Resident #48 complaining of right knee pain. Review of the progress note dated 10/11/22 revealed Resident #48 was ordered a two view x-ray of the left knee for pain. Review of progress notes from October 2022 revealed no indication of situation which led to Resident #48 complaining of left knee pain. Review of assessments from October 2022 revealed no indication of situation which led to Resident #48 complaining of left knee pain. Review of Radiology Interpretation report dated 10/11/22 revealed impression of osteopenia and [CONDITION(S)] of left knee with small avulsion fracture of level of medical tibial plateau. Review of care plan dated 07/21/22 revealed Resident #48 was at risk for pain related to history of fracture of right distal femur. Interventions included encourage use of affected limb, evaluate pain, provide medications as ordered, handle gently, maintain body alignments, and therapy evaluation as ordered. Interview on 10/24/22 at 10:49 A.M. with Resident #48 revealed back in July 2022 she was working on transfers with therapy. Resident #48 indicated during therapy she felt weak and tried to sit. When trying to sit Resident #48 indicated she missed the wheelchair. Resident #48 indicated this caused her leg to break. Resident #48 then reported she began working with therapy again once she could bear weight in October 2022. Resident #48 indicated the same occurrence happened and she fractured her knee. Interview on 10/31/22 at 11:32 A.M. with the DON indicated the facility had quality assurance file for fractures; however, the DON verified the lack of documentation in Resident #48's medical record related to incidents causing fractures on 07/19/22 and 10/11/22. Review of the facility Charting and Documentation policy, dated July 2017, revealed all services provided to the resident or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. Documentation shall be objective, complete, and accurate.

Based on observation, staff interview, and facility policy review the facility failed to have a well-maintained environment. This affected nine resident occupied rooms (rooms #102, #105, #107, #108, #110, #202, #205, #207, #303). The facility census was 55. Findings include: An environmental tour was conducted on 10/27/22 between 12:00 P.M. and 12:15 P.M. with the Maintenance Supervisor #32. The following was verified and observed at the time of the tour: Room #102 had one extra-large sheet of vinyl adhesive applied to the wall behind the bed, which was partially coming off the wall. Behind the sheet of vinyl were four large holes in the wall. Room 105 had one medium size hole in the brown wooden hollow bathroom door with white patching material partially covering the hole. Room 107 had one large white patched area on the wall between the two televisions and four large white patched areas on the wall next to the bed closest to the hallway. Room 108 had four extra-large white patched areas on the wall across from the bathroom door. Room 110 had 13 medium white patched areas around the television on the wall. Room 202 had 20 small white patched areas and one large white patched area around the television on the wall. Room 205 had two long and narrow strips of missing wallpaper behind the headboard of the bed closest to the window. Room 207 had five small white patched areas under the television and fifteen gouged areas with drywall exposed between the closet and the bathroom. Room 303 had an approximate two-inch area of different colored paint on all four walls near the ceiling. Review of undated facility policy titled Resident Rights revealed residents had a right to a safe, clean, and comfortable and homelike environment and the facility was to provide maintenance services necessary to maintain a comfortable interior.

Based on medical record review, staff interviews, and facility policy review, the facility failed to notify Resident #50's physician and resident representative of significant weight changes. This affected one (Resident #50) of three residents who were reviewed for nutrition. The facility census was 55. Findings include: Review of medical record for Resident #50 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set (MDS) 3.0 annual assessment, dated 10/03/22, revealed moderately impaired cognition; independent with no staff assistance for set-up for bed mobility, transfers, walk in room and corridor, locomotion, dressing, toilet use, and personal hygiene; and supervision with staff assistance for set-up for eating. Review of Resident #50's physician orders revealed a 10/24/22 diet order of regular diet, regular texture, regular thin consistency liquids with small portions; Boost pudding (supplement) two times a day; Boost Breeze (supplement) three times a day; frozen nutrition treat (supplement) daily in the evening; and [MEDICATION(S)] one tablet 7.5 milligrams (mg) by mouth at bedtime for appetite stimulant. Review of Resident #50 weights revealed weights of 108.6 pounds on 04/01/22, 104.6 pounds on 05/06/22, 105.9 pounds on 06/06/22, 94.6 pounds on 07/14/22, 93.6 pounds on 07/20/22, 93.0 pounds 08/05/22, 84.6 pounds on 09/05/22, 84.0 pounds on 09/22/22, 86.2 pounds on 09/29/22, 87.8 pounds on 10/06/22, 84.0 pounds on 10/11/22, and 86.8 pounds on 10/13/22. Resident #50 experienced a significant weight loss of 11.3 pounds, 10.6 percent (%), from 06/06/22 to 07/14/22 and a significant weight loss of 8.4 pounds, 9%, from 08/05/22 to 09/5/22. Review of the 08/28/22 dietary progress notes for Resident #50 revealed the resident had shown a significant weight loss with the resident consuming 25-50% of most meals documented and Frozen nutrition treat, Boost Pudding, and Boost Breeze supplementation were in place to promote weight maintenance/gain. Fair-good intake of supplement per Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence the physician or the resident representative was notified of the significant weight loss. Interview with Dietitian #53 on 10/27/22 at 12:38 P.M. confirmed Resident #50 had a significant weight loss from 06/06/22 to 07/14/22 of 10.6% and another significant weight loss of 9% from 08/05/22 to 09/05/22. He stated, if the resident representative or physician were notified, it should be documented in the medical record. He confirmed there was no documented evidence in Resident #50's medical record the resident representative or physician were notified of the significant weight losses from 06/06/22 to 07/14/22 and 08/05/22 to 09/05/22. He stated he had only been working at this facility since September 2022. Review of care plan dated 03/09/21 revealed Resident #50 was at risk for alteration in nutrition related to being underweight, having had significant weight loss, and having inadequate oral intakes. Goal was to maintain or gain weight until the 106 pounds to 116 pounds range was reached. Interventions included obtain resident's weight per protocol and report to the dietitian, physician, and family of unplanned and undesirable weight changes. Review of progress notes for Resident #50 from 06/01/22 to 10/27/22 revealed there was no documented evidence the resident representative or the physician were notified of the significant weight losses of 10.6% from 06/06/22 to 07/14/22 and of 9% from 08/05/22 to 09/05/22. Interview on 10/31/22 at 12:40 P.M. with Licensed Practical Nurse (LPN) #16 stated the facility should notify the doctor and resident representative of any resident significant change, and an example of a significant change would be a significant weight loss. Review of the facility document titled Interdisciplinary Team Care Conference Summary, dated 09/14/22, revealed Resident #50 currently weighed 85 pounds and 95 pounds in July 2022. Resident #50's guardian did not attend, and the facility had left a voice mail message with no indication of what was left on the voicemail. There was no documented evidence Resident #50's resident representative or doctor were notified of the weight loss. Interview with the Administrator on 10/31/22 at 12:15 P.M. confirmed there was no way of knowing if the guardian was notified of the weight loss from the care conference summary, and there was no documented evidence the doctor was notified from looking at the care conference summary sheet. Review of the undated facility policy title Notification of Changes revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances required notification included significant change in the resident's physical condition. Review of the facility policy titled Charting and Documentation, with a revised date of July 2017, revealed changes in a resident's condition shall be documented in the resident medical record which was to include the notification of family and physician if indicated. This is a recite to the complaint survey dated 10/06/22.

Based on observation, interviews, record review, review of the facility investigation, and review of the policy on elopement, the facility failed to provide adequate supervision resulting in one resident (Resident #2) with diagnoses including moderate cognitive impairment, hallucinations, and [CONDITION(S)], eloping from the facility. This resulted in Immediate Jeopardy on 11/07/21 at approximately 7:45 P.M. when Resident #2 exited the facility without staff knowledge and staff failed to respond appropriately to a sounding door alarm. The likelihood of actual harm that was Immediate Jeopardy occurred when Resident #2 left the facility through the facility's front entrance door and walked approximately three tenths of a mile behind a shopping plaza during the evening hours in 45-degree Fahrenheit weather wearing shorts and a T-shirt and sustained injuries including scrapes and abrasions to his extremities and shoulder pain. Staff were unaware the resident was gone until the resident's responsible party notified the facility at 9:00 P.M. on 11/07/21 after the local sheriff department found Resident #2 at 8:25 P.M. This affected one of three residents reviewed for elopement risk. The facility census was 53. On 11/09/21 at 4:56 P.M., the Administrator was notified Immediate Jeopardy began on 11/07/21 at approximately 7:45 P.M. when Resident #2, who had diagnoses including [CONDITION(S)] and hallucinations, and was moderately cognitively impaired, eloped from the facility and was found approximately three tenths of a mile sitting in the mud between a storage container and a dumpster behind a shopping plaza. Resident #2 was heard yelling for help by community members from a nearby condominium who then called the local sheriff department. The local sheriff transported Resident #2 to the hospital for treatment as he reported hitting his head on a metal rail. Staff was unaware the resident was gone until the resident's responsible party notified the facility at 9:00 P.M. on 11/07/21, after the local sheriff informed her Resident #2 was found at 8:25 P.M. The facility determined State tested Nursing Assistant (STNA) #815, STNA #832, STNA #837, and Licensed Practical Nurse (LPN) #872 heard the front door alarm, which had a keypad and a 15 second push release and a keypad to override the alarm, and staff turned the alarm off without any investigation. These staff did not report the alarm to any other staff, did not check the area in and around the facility for residents and did not report the alarm to supervisory nursing staff. Facility staff did not account for all residents. Resident #2 returned to the facility on [DATE] and was assessed to have two abrasions to his right upper arm, two abrasions to his right lower arm, four abrasions to his right lower knee, and pain in his right shoulder. The Immediate Jeopardy was removed on 11/11/21 when the facility implemented the following corrective actions: · A head count was completed by the nurse, LPN #872, on 11/07/21, at 9:49 P.M. and reported to the Director of Nursing (DON), Interim DON #873, and the Administrator. The DON arrived at facility at 10:30 P.M. and completed a second head count confirming the resident census. · Resident #2's attending physician was notified by LPN #872, on 11/07/21 at 9:00 P.M. The Medical Director was notified of Resident #2's elopement by the Administrator on 11/10/21 at 3:30 P.M. · By 11/08/21, all residents were assessed for elopement by the DON, Interim DON #873, and Regional Nurse #874. As a result of the assessments, no other residents were identified at risk for elopement. An elopement binder at each nurse's station will have any residents identified as an elopement risk for staff review. All staff were educated, including agency staff, on 11/08/21 to review the elopement binder at the start of each shift. The DON or designee will audit five residents weekly for three months. Audits will be reviewed by Quality Assurance and Performance Improvement (QAPI) monthly with recommendations for changes to be made as necessary. · Staff education was started on 11/07/21, and completed for all staff on 11/08/21, by the DON regarding proper response to door alarms and facility elopement procedures. Agency staff will be required to sign off on education received regarding the facility elopement and door alarm procedures at the start of their shift. · On 11/08/21, a wander guard (alarmed monitoring device) was placed on Resident #2 upon return from the hospital at 2:25 A.M. · On 11/08/21, at 2:25 A.M., a one-to-one sitter for Resident #2 was implemented and a staff member will sit with him each day, on each shift, to prevent another elopement. · Exit door alarms were tested by the Administrator and were found to be working properly on 11/08/21. At 8:00 A.M. Exit doors will be tested weekly by the Administrator or designee beginning 11/11/21. Results will be reviewed in QAPI monthly. · The Administrator or designee will conduct random audits starting 11/09/21, of three staff, three times per week for four weeks to test staff knowledge of responding to alarms and elopement procedures. Results will be reviewed in QAPI monthly. · Elopement drills were conducted on 11/11/21 at 12:00 P.M., 4:18 P.M. and at 8:30 P.M. by the Administrator, and will be conducted on each shift weekly by the Administrator or designee for four weeks, then quarterly thereafter. Results will be reviewed in QAPI monthly. · Newly admitted residents will have an elopement assessments completed upon admission within four hours. The DON or designee will review the elopement assessment for accuracy within 24 hours and will continue indefinitely. · The facility had Maintenance Company #875 ensure proper function of all facility door alarms on 11/11/21 at 11:44 A.M. and was contracted to check them at least four times per year thereafter. · Interviews on 11/15/21 from 6:16 A.M. through 9:25 A.M. with STNA #809, STNA #829, STNA #868, STNA #882, LPN #817, LPN #819, Receptionist #833, and Dietary Staff #828 confirmed an elopement drill and education had been conducted by the Administrator on 11/11/21 for all staff. Although the Immediate Jeopardy was removed on 11/11/21, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses including [CONDITION(S)], hallucinations, hypertension, [CONDITION(S)] heart disease, peripheral vascular disease, dizziness, and giddiness. Review of admission paperwork, dated 10/14/21, revealed Resident #2 was recently started on an antipsychotic medication for hallucinations at night and was only oriented to person and place at times. Review of the Wander Elopement Assessment, completed 10/16/21, revealed Resident #2 scored a zero out of ten points which indicated he was not at risk for elopement. The assessment inaccurately indicated Resident #2 had no cognitive impairment on admission and did not have a diagnosis of hallucinations. Review of the speech therapy evaluation, dated 10/18/21, revealed Resident #2 had mild to moderate cognitive-linguistic deficits and difficulties with problem-solving and thought organization. Review of the care plan, dated 10/18/21, revealed Resident #2 had a self-performance deficient for activities of daily living, was at risk for falls, had abnormal bleeding due to anticoagulant therapy, and had impaired psychiatric mood status related to depression. Interventions included to provide assistance with personal care as needed; to maintain items in reach; educate resident to use call light; to avoid activities that could result in injury; and to administer medications as ordered. There was no care plan related to Resident #2's diagnosis of hallucinations. Review of the Admission Minimum Data Set (MDS) 3.0 assessment, dated 10/22/21, revealed Resident #2 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of nine. Scores of eight to 12 indicate moderate cognitive impairment. This assessment indicated Resident #2 required extensive two staff assistance for bed mobility and transfers, supervision one staff assistance for walking in the room, eating and personal hygiene, supervision with set-up assistance for walking in the corridor, limited assistance with one staff for locomotion on and off the unit and toileting, and extensive assistance with one staff for dressing. Resident #2 was frequently incontinent of urine, occasionally incontinent of bowel. Review of the local Sheriff's report, dated 11/08/21 at 3:33 P.M., revealed an incident occurred on 11/07/21 at 8:25 P.M. in a parking lot area. The report was completed by Sheriff Deputy #878 who indicated he responded to a welfare check near condominiums due to several people from the area who reported hearing a male yelling for help between the condominiums and a department store. Sheriff Deputy #878 reported Resident #2 was found in a parking lot behind the department store after he heard the elderly male yelling for help. The resident was found sitting in the mud between a storage container and dumpster. The resident was identified by a hospital bracelet on his right wrist and was found wearing only a pair of shorts and a T-shirt. Resident #2 stated to Sheriff Deputy #878 he was outside for about a half hour and was coming from the library which was attached to a school nearby, and further stated he had his chair down the steps there while motioning to the area of the [NAME] behind him. Sheriff Deputy #878 indicated there was no stairs in the area nor was there a chair seen anywhere nearby him, and Resident #2 believed he was in another city and could see his friend's white house across the street while gesturing towards a white shipping container nearby. Sheriff Deputy #878 reported no other houses or structures visible from where they were and contacted the local fire department to assist and evaluate Resident #2. Sheriff Deputy #878 indicated the resident had visible scrapes on his knees and legs which was presumed from falling as Resident #2 stated he had fallen earlier nearby and may have hit his head on a railing. While medics attended to Resident #2, dispatch located a phone number for Resident #2's representative and contacted her by phone. Resident #2's representative told the deputy he belonged at the nursing facility nearby as he was sent there following a recent hospital stay. Resident #2's representative also indicated Resident #2 had the beginning stages of dementia due to [CONDITION(S)] and was very confused with a tendency to hallucinate, which Deputy #878 indicated was consistent with his interaction. Sheriff Deputy #878 said the nursing facility was found to be unaware that Resident #2 had walked away from the facility. Sheriff Deputy #878 reported the resident's representative intended to contact the facility immediately and he documented an intent to contact the facility also. Resident #2 was transported to the local hospital for further care due to concerns with his confusion, possible injuries sustained and exposure to the elements, as it was only 45 degrees. Sheriff Deputy #878 then responded to the facility and spoke with LPN #872 who stated she had just spoken with Resident #2's representative and would contact the DON. LPN #872 stated she was in a different area of the facility but learned staff had heard an alarm of some sort, and supposedly canceled it without checking for the cause of the alarm. Therefore, no one was aware Resident #2 had walked away from the facility. LPN #872 stated the last time she saw Resident #2 in person was around 7:30 P.M. on 11/07/21. Review of written witness statement by STNA #815, dated 11/07/21, revealed Resident #2 was observed at the facility's front entrance door at 7:00 P.M. and the resident stated to STNA #815 he called the police to pick him up while approaching the door. STNA #815 indicated she remained at the door while receiving report for the oncoming shift and then left. STNA #815 reported observing the resident wandering the building until 7:45 P.M. when STNA #837 and she provided care for Resident #2 in his room, which was located at the end of the hall. When both STNAs reach the other end of the hall, LPN #872 asked the STNAs if they heard an alarm sounding and they answered no. LPN #872 requested the STNAs to check every door but by the time LPN #872 reached the front of the building there was no alarm. Staff did not continue checking doors. After finishing shift report at the nurse's station, Resident #2's representative called the facility, was upset, and spoke to LPN #872. Review of a written statement by LPN #872, dated 11/07/21, revealed she heard a door alarm sounding at approximately 8:30 P.M. and indicated she checked the front door but when she got to the front door there was no alarm sounding. LPN #872 reported STNA #815 was at the front door and stated there was no alarm sounding and a resident on the COVID-19 unit needed medication. At 9:00 P.M., STNA #815 informed LPN #872 Resident #2's representative was on the phone. Review of a written statement by STNA #832, dated 11/07/21, revealed they last saw Resident #2 at the nurse's station while preparing the snack cart. STNA #82 said Resident #2 told the nurse he wanted to leave and heard the nurse tell him, not tonight, it is too late and that he should try to go to bed. Resident #2 then walked away. Review of a written statement by STNA #829, dated 11/07/21, revealed no knowledge of Resident #2 leaving the building until receiving a call from the local sheriff's office. The STNA indicated last seeing the resident standing at the nurse's station at the 100/200 hall and then he walked away toward the opposite side of the building. Review of local hospital emergency department report, dated 11/08/21 at 12:36 A.M., revealed Resident #2 arrived in the emergency department by ambulance after he was reportedly found outside behind a store building. Resident #2 reported he was taking something to church but somehow ended up somewhere else and was about to be mugged by some strangers, but someone helped him, and he ended up slipping and falling into some bushes. Resident #2 reported hitting his head when falling but did not pass out and told them he thought he was taking an anticoagulant medication. Resident #2's Computed Tomography (CT) scan for his head and neck due to the fall and possible head injury were negative. Review of the Wander Elopement Assessment completed 11/08/21 at 1:11 A.M., revealed Resident #2 scored a four out of ten points which indicated he was not at risk for elopement. The assessment inaccurately indicated Resident #2 had no history of leaving the facility without needed supervision or leaving the facility without informing the staff. On, 11/08/21 a focus on risk for elopement care plan was added for Resident #2 with interventions to include the resident to wear a wander guard and for staff to promptly check if the alarm system sounded to ensure residents were safe and remained in the facility. Review of physician orders after Resident #2 returned to the facility on [DATE] at 2:25 A.M. revealed an order to increase his evening dose of [MEDICATION(S)] (an antipsychotic) from 50 milligrams to 75 milligrams (mg) daily at bedtime and continue 25 mg daily in the morning; an order for a wander guard to his right ankle and for staff to check placement every shift; and staff to cleanse abrasions to his right arm and right knee with normal saline, pat dry and apply triple antibiotic ointment and leave open to air daily and as needed. Observation on 11/09/21 at 10:52 A.M. revealed Resident #2 resting in bed with STNA #801 sitting in the room. Interview on 11/09/21 at 10:56 A.M. with LPN #857 confirmed Resident #2 eloped from the facility on 11/07/21 and the now had a one-on-one sitter since returning to the facility. Interview on 11/09/21 at 11:00 A.M. with STNA #842 verified Resident #2 attempted to leave the facility on 11/08/21 at 5:00 P.M. but was unsuccessful due to the one-on-one sitter's redirection. Interview on 11/09/21 at 12:34 P.M. with the Administrator confirmed the facility had alarms on four exit doors (front entrance, 200 hall, employee entrance and 300 hall) which are checked weekly. The codes on the doors were known only by the employees, and each door had the same code which was changed every month. The Administrator indicated the employees were trained on the alarm system on hire but was uncertain of any other training, and verified the doors locked when alarmed but would release after 15 seconds as required for emergency evacuations. The Administrator confirmed after the alarms were activated, the alarms would remain sounding until deactivated with a bypass code, and wander guards worked on only the front door and employee entrance doors. Interview on 11/09/21 at 12:42 P.M. with Interim DON #873 verified Resident #2's admission assessment for elopement was inaccurate. Interim DON #873 also confirmed Resident #2's assessment for elopement completed on 11/08/21, after he eloped, was inaccurate as the assessment indicated Resident #2 had no history of leaving the facility without informing the staff. Interview on 11/09/21 at 1:26 P.M. with the Administrator verified Resident #2 was the only resident with a wander guard alarm and confirmed the facility did not complete a written investigation report with a determination for cause of Resident #2's elopement or the immediate interventions put into place after the incident on 11/07/21. The Administrator verified the facility determined the staff turned the front entrance alarm off using the bypass code without investigating for a possible resident elopement. The Administrator said they could not identify which specific staff member turned the alarm off when Resident #2 left the building. Interview on 11/09/21 at 2:25 P.M. with Resident #2's representative revealed Resident #2 had a history of wandering and falling at home which she confirmed the facility was made aware. She reported the local sheriff's office contacted her on 11/07/21 at approximately 9:00 P.M. and notified her of Resident #2's whereabouts behind a department store by a dumpster. She stated she contacted the facility and talked with a nursing assistant who informed her an alarm had sounded but no one knew why it sounded. Interview on 11/10/21 at 8:32 A.M. with Receptionist #833 confirmed knowing codes to the alarm system but verified no formal training on alarms had been provided. Receptionist #833 confirmed the facility did not perform elopement drills in the past two years since he/she worked there. Observation on 11/10/21 at 3:30 P.M. of Resident #2 revealed the resident was in bed and appeared to be sleeping with STNA #842 sitting in a chair nearby. Interview on 11/15/21 at 6:16 A.M. with STNA #809 and STNA #868 confirmed Resident #2 was discharged to another facility with a secured unit on 11/11/21. Telephone interview on 11/15/21 at 9:05 A.M. with LPN #872 reported she completed medication administration on the 100 hall when she heard an alarm sounding, but she was unsure of what door and what time that happened. LPN #872 said she went to the front entrance door to investigate and the alarm was no longer sounding. LPN #872 said an aide informed her a resident needed medication, so she went back to her duties and did not investigate any further. LPN #872 stated approximately one-half hour later a nursing assistant told her Resident #2's representative was on the phone and was very upset because Resident #2 was found outside the nursing facility by the sheriff. Interview on 11/15/21 at 9:13 A.M. with STNA #839 confirmed working until 7:11 P.M. on 11/07/21 when Resident #2 eloped from the facility. STNA #839 stated Resident #2 requested to leave the facility multiple times during her shift. STNA #839 verified Resident #2 was sitting at the front entrance doors when she left the building at the end of her shift. Telephone interview on 11/15/21 at 9:55 A.M. with STNA #815 confirmed working on 11/07/21 and seeing Resident #2 at the front entrance and then in his room about 7:45 P.M. Interview on 11/15/21 at 11:11 A.M. with LPN #817 confirmed working on 11/07/21 and clocked out at 7:30 P.M. LPN #817 verified when leaving, Resident #2 was standing by the 300/400 hall nurse's station which is located closest to the front entrance door, and Resident #2 asked the nurse for a ride home. Interview on 11/15/21 at 11:48 A.M. with Speech Therapy #876 verified Resident #2 had mild to moderate cognitive impairment and poor safety awareness on admission. Interview on 11/15/21 at 11:52 A.M. with Occupational Therapy #877 confirmed Resident #2 experienced hallucinations while being treated by therapy staff in his room such as seeing a girl sitting in a chair. Interview on 11/15/21 at 12:49 P.M. with Administrator confirmed the facility only had two of the four doors with wander guard alarms installed which were the front entrance and the employee entrance. The 200 hall and 300 hall doors do not have a wander guard alarm installed. Resident #2 would continue one to one supervision. The Administrator verified the contracted Maintenance Company #875 visited the facility on 11/11/21 to check all the facility door alarms and verified proper functioning. Interview on 11/16/21 at 5:50 P.M. with Sheriff Deputy #878 verified the incident which occurred on 11/07/21 involving Resident #2 leaving the nursing home unsupervised and indicated Resident #2 was wearing footwear when found. Review of the facility policy titled, Elopement Policy, dated 07/25/18, revealed the facility will identify residents with potential or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Review of alarm manufacturer user guide titled, Delayed Egress Exit Alarm Controller, dated 08/29/06, revealed staff bypass mode enable the doors to remain unlocked for a preset period of time. During this time, anyone can pass through the secured door. This deficiency substantiates Master Complaint Number OH 359.

Based on observation, interview, record review, and facility policy review the facility failed to ensure adequate pressure relieving interventions and treatments were ordered and implemented to prevent and treat pressure ulcers for Resident #23. Actual harm occurred on 09/27/21 when Resident #23, who required extensive assistance with one staff for bed mobility and was always incontinent of urine and bowel, was admitted with a Stage IV (a full thickness tissue loss with exposed bone, tendon or muscle) sacral pressure ulcer, developed an unstageable (a full thickness tissue loss covered by extensive necrotic tissue) right buttock pressure ulcer which was not promptly and consistently treated resulting in deterioration and the need for sharp debridement on 10/20/21 to reduce the risk of infection and improve wound healing. This affected one resident (Resident #23) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 05/07/21 revealed Resident #23 had impaired skin integrity to the sacrum. Interventions included to assist resident with turning and reposition as needed; consult a dietitian as needed; dietary supplement as ordered; encourage good nutrition and hydration; encourage to reposition herself if able; if resident refuses intervention or treatment encourage compliance to minimize further skin impairment; pressure redistribution mattress to bed; treatments per physician orders; and provide a non-irritating surface to reduce friction or shearing forces. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #23 was at moderate risk for developing pressure ulcers. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was alert, oriented and had intact cognition. Resident #23 required extensive assistance from one staff member for bed mobility, dressing and personal hygiene, was dependent on two staff assistance for toileting and transfers, and required one staff physical assistance in part of the bathing activity. The assessment indicated Resident #23 had a urinary catheter, was always incontinent of bowel, and had a Stage IV pressure ulcer which was present upon admission. Review of the dietary progress note dated 09/09/21 revealed Resident #23 had an acute hospital stay with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders revealed an order dated 09/09/21 for a regular diet, no added salt, ice cream (vanilla or strawberry) or Jell-O with lunch and dinner; an order dated 09/10/21 for multiple vitamin and minerals daily and for nutritional supplement 240 milliliters daily with meals for wound healing; an order dated 09/12/21 to cleanse her sacral wound with normal saline, pat dry, lightly pack with calcium alginate (highly absorbent dressing) and cover with a foam dressing daily and every eight hours as needed; and an order dated 09/20/21 for yogurt with every meal. Review of the facility wound assessment dated [DATE] at 4:06 P.M. revealed Resident #23 had a Stage IV sacral pressure ulcer which measured 7.0 centimeters (cm) in length, 5.5 cm in width and 2.0 cm deep with 25 percent necrotic (dead, dying tissue) tissue present. There was moderate drainage and the area surrounding the ulcer was macerated. This assessment indicated the physician was notified that morning at 10:00 A.M. and the treatment to lightly pack with calcium alginate and cover with foam dressing was to continue. Review of facility wound assessment dated [DATE] at 4:07 P.M. revealed Resident #23's unstageable right buttock pressure ulcer measured 5.0 cm in length, 1.5 cm wide and no depth measurement was recorded as it was covered 100 percent with necrotic tissue. Redness was noted surrounding the pressure ulcer tissue. This e assessment indicated this pressure ulcer was a newly identified in-house acquired pressure ulcer for Resident #23. The physician was notified on 09/22/21 at 10:00 A.M. and ordered a triad cream to (wound paste that absorbs moderate levels of wound drainage) be applied and to cover with a foam dressing. Review of facility wound assessment dated [DATE] at 4:06 P.M. revealed Resident #23's Stage IV sacral pressure ulcer measured 8.0 cm in length, 2.0 cm wide and 2.0 cm deep and had 75 percent necrotic tissue, macerated surrounding wound tissue, moderate drainage, and was deteriorating. The assessment indicated the physician was notified on 09/22/21 (date appears to be erroneous) at 10:00 A.M. and the treatment in place for calcium alginate and cover with a foam dressing daily was ordered to continue. Review of physician orders dated 09/28/21 revealed nursing staff were to cleanse Resident #23's right buttock pressure ulcer with normal saline, pat dry, apply triad cream and cover with a foam dressing twice daily and as needed. There was no physician order written [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review of the wound physician's progress notes dated 09/29/21 at 7:45 A.M. revealed Resident #23's unstageable right buttocks pressure ulcer treatment was to cleanse with normal saline, pat dry, apply triad to wound bed and cover with border foam twice daily and as needed. The physician indicated the resident's compliance was poor and recommended Resident #23 off load her heels from the bed with pillows or use offloading boots, ordered an air mattress, and said for staff to encourage her to turn and reposition. Review of the wound evaluation progress notes dated 09/29/21 revealed Resident #23's unstageable right buttock and the stage IV sacral pressure ulcers were unchanged and treatment orders were to be continued. Review of the Treatment Administration Record (TAR) for September 2021 revealed the physician order dated 09/12/21 for nursing staff to cleanse Resident #23's sacral wound with normal saline, pat dry, lightly pack with calcium alginate and cover with a foam dressing daily was not documented as completed on 09/23/21, 09/24/21, 09/27/21 and 09/30/21 on day shift; and the order dated 09/28/21 for nursing staff to cleanse her right buttock with normal saline, pat dry, apply triad cream and cover with a foam dressing twice daily was not documented as completed on 09/30/21 at RISE (which was 7:00 A.M. to 7:00 P.M.). Review of the wound physician's progress notes dated 10/06/21 at 7:45 A.M. revealed Resident #23's unstageable right buttock pressure ulcer dressing was not intact. The pressure ulcer had minimal drainage with 100 percent hard, yellow, black necrotic tissue. The physician indicated to continue the same treatment and recommendations from the wound evaluation visit on 09/29/21 at 7:45 A.M. Review of facility wound assessment dated [DATE] at 12:47 P.M. revealed Resident #23 had an unstageable right buttock pressure ulcer which measured 5.0 cm in length, 1.5 cm wide and had no depth measurement recorded as it was covered 100 percent with necrotic tissue. The ulcer was draining and deteriorating. The assessment indicated the physician was notified on 10/06/21 at 12:00 P.M. and a new treatment was ordered. Review of physician orders for October 2021 revealed no change in Resident #23's right buttock pressure ulcer treatment as indicated on the 10/26/21 wound assessment. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed Resident #23's unstageable right buttocks pressure ulcer was debrided by sharp manual debridement (removal of unhealthy tissue by cutting it off) to reduce the risk of infection and promote wound healing. The wound measured 4.0 cm in length, 1.7 cm wide and 0.2 cm deep. The treatment ordered was to cleanse with normal saline, pat dry, apply triad cream to the wound bed and cover with border foam twice daily and as needed. Review of nutrition therapy progress/quarterly note dated 10/21/21 revealed Resident #23 was independent with feeding and had good oral nutritional supplement intake of yogurt with meals and a liquid nutritional supplement of eight ounces three times daily. Resident #23's current body weight of 242 pounds was a significant weight loss in one month, which was expected after she returned the hospital. This nutritional assessment indicated Resident #23's diet and nutritional supplement were appropriate with her increased nutritional needs related to wounds and ice cream, Jell-O and fresh fruit were added with lunch and dinner. Review of the TAR for October 2021 revealed the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 7:00 P.M. and not documented as completed on 10/04/21, 10/06/21, 10/07/21, 10/08/21, 10/09/21, 10/10/21, 10/13/21, 10/16/21, 10/20/21, 10/21/21, 10/25/21 and 10/26/21 for the evening or night shift from 7:00 P.M. to 7:00 A.M. Review of physician orders revealed an order dated 10/28/21 to admit Resident #23 to hospice services for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/01/21 at 9:12 A.M. with Resident #23 revealed she received a new bed recently with a low air loss mattress which she loved since it was bigger and now, she was not afraid to turn in bed. Observation on 11/02/21 at 8:07 A.M. and 10:25 A.M. revealed Resident #23 lying in bed, reclining on her back with her head slightly elevated. Observation on 11/02/21 at 2:00 P.M. revealed Resident #23 lying in bed reclining on her back. Licensed Practical Nurse (LPN) #857 turned Resident #23 onto her side for the pressure ulcer treatment. There was no dressing covering Resident #23's sacral pressure ulcer and a foam dressing covering the right buttocks pressure ulcer was dated 11/02/21. Interview at that time with Resident #23 revealed State tested Nursing Assistant (STNA) #842 had removed the dressing on her sacrum after she had a bowel movement and the STNA cleaned the wound with soap and water. LPN #857 stated STNA #842 had reported to her earlier at approximately 11:30 A.M. that the dressing was removed with care and the area was cleaned. LPN #857 indicated she only had time to complete the dressing change on Resident #23's right buttock pressure ulcer so she left the sacrum pressure ulcer uncovered. Observation of the sacral pressure area at that time with LPN #857 revealed a large open area with a beefy red wound base and no signs of infection. Interview on 11/02/21 at 2:18 P.M. with STNA #842 confirmed Resident #23 had a bowel movement around 12:00 P.M. and her sacral pressure ulcer dressing was removed. STNA #842 indicated he cleaned the pressure ulcer with soapy washcloths and rinsed it with water. STNA #842 verified he reported his actions to LPN #857 who changed Resident #23's dressing on her right buttocks pressure ulcer but LPN #857 did not have time to put a dressing on the sacral pressure ulcer. Interview on 11/02/21 at 3:20 P.M. and review of the medical record with the DON confirmed all the dates when Resident #23's pressure ulcer treatments for her right buttock pressure ulcer and her sacral pressure ulcer were not documented as completed in September 2021 and October 2021. The DON verified insufficient staff contributed to the treatments not being provided for Resident #23. The DON stated nursing assistants were not permitted to remove dressings and wash pressure ulcers and nurses were to take the time to dress the pressure ulcers as needed. There was a physician order dated 11/03/21 for a low air loss mattress to be used for Resident #23's bed every shift. Review of Resident #23's care plan was not revised until 11/03/21 to include her right buttock pressure ulcer under the impaired skin integrity care plan and no additional interventions were added or changed. Interview on 11/03/21 at 8:48 A.M. with LPN #826 confirmed pressure ulcer treatments, turning and repositioning and incontinence care were not completed or not completed timely due to insufficient staff. Interview on 11/03/21 at 1:25 P.M. with the DON confirmed Resident #23's right buttock pressure ulcer was not identified until it was unstageable and developed in the facility on 09/22/21. The DON verified Resident #23 was on a standard air mattress until her admission to hospice services, when she was provided a specialty low air loss mattress. The DON verified there were no additional interventions put into place or revised after Resident #23's admission for maintenance of skin integrity or pressure ulcer prevention. Interview on 11/04/21 at 10:31 A.M. with the DON confirmed there were no treatment orders for Resident #23's right buttock unstageable pressure ulcer, which was discovered on 09/22/21, until 09/28/21. The DON verified the treatment orders were not changed despite documentation that they should have been changed on 10/06/21, 10/13/21 and on 10/20/21 and the treatment was not changed when the right buttock pressure ulcer was deteriorating. The DON verified there was no documentation in the medical record to indicate Resident #23 was non-complaint with turning and repositioning. The DON verified the issue was not always having enough staff to complete rounds, turning and re-positioning, and completing treatments as ordered. Review of facility policy titled, Wound Care, dated 11/20/18, revealed it was the policy of the facility to provide therapeutic treatment to heal wounds, and to document the assessments, care and treatments administered. This deficiency substantiates Complaint Number OH 119.