Every finding on record at Highland Oaks Health Center

Based on review of the substitution log and interviews, the facility failed to ensure menus were followed. This had the potential to affect 84 of 84 residents receiving meals from the kitchen. The facility census was 85. Findings include:Review of the substitution log revealed the following:05/20/26 the menu item ham salad was replaced with egg salad due to not having enough ham salad.05/21/26 the menu item Dijon blackberry chicken was replace with chicken kiev and chicken cordon bleu due to not having enough Dijon blackberry chicken.05/23/26 the menu item carrots was replaced with mixed vegetables due to not having enough carrots.05/24/26 the menu item diced potatoes was replaced with mashed and baked potatoes due to not having diced potatoes.05/25/26 the menu item carrots was replaced with sweet potatoes due to not having carrots.05/26/26 the menu item sweet potatoes was replaced with baked beans due to being out of sweet potatoes.07/04/26, 07/05/26, and 07/06/26 the menu items shelled eggs was replaced with scrambled eggs due to being out of shelled eggs.07/06/26 the menu item bacon was replaced with sausage due to not having any bacon. Interview on 07/06/26 at 1:23 P.M. with Dietary Manager (DM) #155 revealed the facility receives food deliveries on Mondays and Thursday. DM #155 stated the morning of 07/06/26, sausage had to be served instead of bacon because they ran out of bacon on 07/05/26, and shelled eggs ran out as well but they substituted with scrambled eggs. Interview on 07/06/26 at 2:50 P.M. with Resident #84 revealed the kitchen runs out of bacon and uses sausage as a substitute but they use sausage that is very bland and not seasoned. Interview on 07/07/26 at 8:05 A.M. with Resident #45 revealed she does not always get the meals she orders but gets what the kitchen has instead. Interview on 07/07/26 at 8:18 A.M. with Certified Nursing Assistant (CNA) #130 revealed the facility ran out snacks last week and they will run out of food items but offer a substitute if they have one. Interview on 07/07/26 at 8:30 A.M. with Resident #63 revealed when the kitchen runs out of something, they will substitute but the substitute is often grilled cheese. Interview on 07/07/26 at 9:21 A.M. with Registered Nurse (RN) #125 revealed on 07/06/26 there was no bacon or eggs for breakfast because the facility ran out. Interview on 07/07/26 at 9:40 A.M. with CNA #201 revealed the kitchen runs out of food weekly. Interview on 07/07/26 at 10:40 A.M. with Anonymous Nurse (AN) #202 revealed the food portions at the facility can be skimpy at times. Interview on 07/07/26 at 12:57 P.M. with Dining Assistants (DA) #140 and #160 revealed DM #155 does not order enough food for the kitchen but she will not spend money to buy enough. Once, the menu was for turkey roast but there were only three small roasts so portion sizes were served smaller so every resident could have some. DA #140 stated food delivery trucks will come on Monday and they will have bacon on Tuesday and Wednesday, will be out on Thursday morning but the truck will come Thursday so they will have bacon again on Friday and Saturday, but not enough for Sunday or Monday. Interview on 07/07/26 at 1:50 P.M. with DM #155 confirmed the findings on the substitution log. DM #155 stated when they run out of an item, they offer a substitution and since she started approximately a month ago, they call the dietician to get approval for substitutions. Review of an undated job description titled Dietary Manager Job Description revealed it is the manager's job to order food and supplies while maintaining inventory and budget control. This deficiency represents non-compliance investigated under Master Complaint Number 3044780, Complaint Number 3035793.

Based on record review and staff interview, the facility failed to ensure a resident's physician was notified when a medication ordered for the treatment of hypotension (low blood pressure) was not available to be administered as ordered. This affected one (Resident #89) of three residents reviewed for medications. The facility census was 87. Findings include:Record review for Resident #89 revealed an admission date of 03/09/26 with diagnoses including chronic obstructive pulmonary disease (COPD), acute on chronic respiratory failure with hypoxia, malignant neoplasm (cancer) of an unspecified part of an unspecified bronchus/ lung, dependence on supplemental oxygen, heart failure, syncope (dizziness) and collapse, sepsis, and shock. Review of progress notes for Resident #89 revealed on 03/21/26 Resident #89 was discharged to the hospital for an evaluation following an unwitnessed fall with complaints of hip pain after the fall. Review of Resident #89's Discharge Summary from the hospital with a discharge date of 03/31/26 at the time of 10:58 A.M. revealed she was returning to the facility with an order for Midodrine (medication used to treat symptomatic orthostatic hypotension) 10 milligrams (mg) three times a day before meals. The hospital records indicated Resident #89 was last given Midodrine 10 mg by mouth (po) as ordered three times a day, with last dose administered on 03/31/26 at 10:22 A.M. The next scheduled dose would have been due at 5:00 P.M. Review of Resident #89's physician's orders revealed the resident's initial order for the Midodrine written on 03/31/26 was for the resident to receive 10 mg po three times a day (TID) for her blood pressure. Review of Resident #89's medication administration record (MAR) for March 2026 revealed the facility set up the administration times for the Midodrine 10 mg three times a day as AM, Mid, and HS. On 03/31/26 the Mid dose was not administered and a code 9 was marked in the box. The legend at the end of the MAR identified the code 9 meant other/ see progress notes. Review of Resident #89's nurses' progress notes revealed a nurse's note dated 03/31/26 at 5:10 P.M. that indicated the scheduled dose of Midodrine 10 mg due at that time was not able to be administered as ordered due to the facility waiting on the pharmacy to deliver that medication. Review of Resident #89's MAR for April 2026 revealed the resident was not documented to have received her scheduled doses of Midodrine for either the AM dose or the mid-day dose on 04/01/26. The first documented dose of Midodrine given to the resident was on 04/01/26 for her scheduled HS dose. Further review of Resident #89's progress notes revealed a nurse's note dated 04/01/26 at 8:13 A.M. that indicated the resident's Midodrine 10 mg was not administered as ordered for her blood pressure as the medication had been ordered and not available for administration. There was no documented evidence in the progress notes of the physician having been notified of the resident not receiving her Midodrine 10 mg, as ordered three times a day since 03/31/26, due to it not being available. On 04/20/26 at 3:50 P.M., an interview with the Director of Nursing (DON) revealed she was not able to find any evidence of Resident #89's physician being notified of Resident #89's Midodrine not being given as ordered during the evening hours of 03/31/26 or the morning and noon hours of 04/01/26. The DON verified it was not given as ordered due to the Midodrine not being made available by their contracted pharmacy. The DON stated she would have expected the resident's physician to be notified when a medication was not available for administration as ordered. The DON verified the findings on the March and April 2026 MARs. This deficiency resulted from incidental findings during investigation of Complaint Number 2976676.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident's baseline care plan was developed and the resident and/ or their representative received a copy of the baseline care plan within 48 hours of admission. This affected one (Resident #89) of three residents reviewed for care plans. The facility census was 87. Findings include:Review of Resident #89's closed medical record revealed and admission date of 03/09/26 with diagnoses including chronic obstructive pulmonary disease, sepsis, shock, malignant neoplasm (cancerous tumor) of an unspecified part of an unspecified bronchus/ lung, heart failure, pneumonia, dependence on supplemental oxygen, unspecified fall, and fracture of the nasal bones. Review of Resident #89's admission Observation Assessment (nursing admission assessment) dated 03/09/26 revealed the nurse admitting the resident failed to document any part of the assessment for the resident upon her admission. The last page of the assessment included a place to document if the resident and /or family had been given a copy of the Admission/ Baseline Care Plan Summary and that section was also left blank. Review of Resident #89's Baseline Care Plan dated 03/09/26 revealed minimal documentation was completed on that form. It did identify the resident's primary language as being English and her allergies as being to be determined but the rest of the baseline care plan was blank. Further review of Resident #89's medical record revealed there was a second Baseline Care Plan that was dated 03/13/26. That baseline care plan was mostly complete with only a few sections on the form not being completed. It was not signed as having been received by the resident or her representative and was not completed within the 48 hours of admission. Further review of Resident 89's medical record revealed a care plan was initiated on 03/10/26 for a fall with injury, discharge planning, and full code advance directive. On 03/11/26 care plan diagnoses were added for potential for alteration in activities. This care plan did not meet the requirement of a comprehensive care plan in place of a baseline care plan within 48 hours of admission. On 04/20/26 at 11:35 A.M., an interview with the Director of Nursing (DON) revealed she was not able to find evidence of a baseline care plan being developed for Resident #89, upon her admission to the facility on [DATE]. The DON confirmed nurses were not completing the residents' baseline care plans within 48 hours following admission as required. The DON stated she had educated the nurses and was trying to take that on herself to make sure they were done, but there were not enough hours in the day to keep up with everything she needed to get done. The DON identified and verified another baseline care plan had a creation date of 03/13/26, but that was not completed within the 48 hours of admission and no further evidence of care planning to meet the requirement. Review of the facility's policy titled Care Plans Baseline dated November 2025 revealed a baseline plan of care to meet the resident's immediate needs should be developed for each resident within 48 hours of admission. The interdisciplinary team (IDT) would review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs. The baseline care plan would be used until the staff could conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. The resident and their representative would be provided a summary of the baseline care plan. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review and staff interview, the facility failed to ensure comprehensive care plans addressed bladder and bowel incontinence and toileting assistance for Resident #27, #82 and #89. This affected three (Resident #27, #82, and #89) of three residents reviewed for care plans. The facility census was 87. Findings include:1. Review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included congestive heart failure (CHF), chronic kidney disease- stage thee, hypertension, and edema. Review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. Resident #27 was dependent on staff for toileting hygiene and required substantial/ maximum assist with toilet transfers. Resident #27 was frequently incontinent of bladder and always continent of bowel. Review of Resident #27's care plans with a date initiated of 10/26/25 and last revised on 04/01/26, revealed no care plan in place to address urinary incontinence or assistance required with activities of daily living (ADL's) to include toileting assistance. 2. Review of Resident #82's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, adult-onset diabetes mellitus, COPD, and hypertension. Review of Resident #82's admission MDS assessment dated [DATE] revealed the resident had unclear speech and was usually able to make himself understood. Resident #82 had minimal difficulty hearing and was usually able to understand others. Cognition was moderately impaired. Resident #82 required substantial/ maximum assistance with toileting hygiene and toilet transfers and was always incontinent of bladder and bowel Review of Resident #82's active care plans with date initiated 02/26/26 and last revised 03/04/26, revealed no care plan in place to address incontinence. There were no interventions to address his toileting needs or his known incontinence. 3. Review of Resident #89's closed medical record revealed she was admitted to the facility on [DATE]. Diagnoses included COPD, acute on chronic respiratory failure, malignant neoplasm (cancerous tumor) of an unspecified part of an unspecified bronchus or lung, heart failure, dependence on supplemental oxygen, chronic kidney disease- stage three, muscle weakness, syncope and collapse, and an unspecified fall. Resident #89 discharged from the facility on 04/11/26. Review of Resident #89's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. Resident #89 was dependent on staff for toileting hygiene and required a substantial/ maximum assist with toileting transfers and was frequently incontinent of bladder and always continent of her bowel. Review of Resident #89's care plans with a date initiated of 03/10/26 revealed no care plan in place to address urinary incontinence or needing assistance with toileting needs through date of discharge of 04/11/26. On 04/21/26 at 8:50 A.M., an interview with the DON verified the findings for Resident #27, #82 and #89. The DON stated when she first started working as the facility's DON in March 2026, she noted the residents did not have basic care plans in place to address ADL's needs and toileting/ incontinence needs. She stated since she had been there, they started to audit the residents' records and have since added those care plans when appropriate. She did not update Resident #89's care plans, since she had already been discharged from the facility, but some of the other residents had been addressed. She acknowledged Resident #27 and #82 remained in the facility and were known to have incontinence. The DON stated neither residents' care plans had been updated to ensure they addressed their ADL needs to include toileting assistance or to address their known incontinence status. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, interview and review of facility policy, the facility failed to ensure contracted pharmacy services were provided to assure Resident #89's medications were delivered timely and administered as ordered. This affected one (Resident #89) of three residents reviewed for pharmacy services. The facility census was 87. Findings include: Review of the closed medical record for Resident #89 revealed an admission date of 03/09/26 with diagnoses including chronic obstructive pulmonary disease (COPD), acute on chronic respiratory failure with hypoxia, malignant neoplasm (cancer) of an unspecified part of an unspecified bronchus/ lung, dependence on supplemental oxygen, heart failure, syncope (dizziness) and collapse, sepsis, and shock. Review of Resident #89's progress notes revealed a nurse's note dated 03/21/26 at 10:20 A.M. that stated the resident had an unwitnessed fall in her room that resulted in complaints of left hip pain. A stat x-ray was ordered for the left hip with directions to send to the emergency room if the x-ray could not be obtained within two hours. The facility's nursing staff was unable to reach the mobile x-ray unit, and the resident was sent to the hospital where she was found to have a fractured left hip. She remained in the hospital until she was transferred back to the facility on [DATE], at approximately 11:57 A.M. Review of Resident #89's Discharge Summary from the hospital with a discharge date of 03/31/26 at the time of 10:58 A.M. revealed the resident was returning to the facility with an order for Midodrine (medication used to treat symptomatic orthostatic hypotension) 10 milligrams (mg) three times a day before meals. Her hospital records indicated the resident was given Midodrine 10 mg by mouth (po) as ordered three times a day, with last dose administered on 03/31/26 at 10:22 A.M. Her next scheduled dose would have been due at 5:00 P.M. Review of Resident #89's physician's orders revealed the resident's initial order for the Midodrine written on 03/31/26 was for the resident to receive 10 mg po three times a day (TID) for her blood pressure. A subsequent order for Midodrine was given on 04/01/26 to include parameters to hold the medication if her systolic blood pressure (top number of a blood pressure reading) was above 120 millimeters of mercury (mmHg). Review of Resident #89's medication administration record (MAR) for March 2026 revealed the facility set up the administration times for the Midodrine 10 mg three times a day as AM, Mid, and HS. On 03/31/26 the Mid dose was not administered and a code 9 was marked in the box. The legend at the end of the MAR identified the code 9 meant other/ see progress notes. Review of Resident #89's nurses' progress notes revealed a nurse's note dated 03/31/26 at 5:10 P.M. that indicated the scheduled dose of Midodrine 10 mg due at that time was not able to be administered as ordered due to the facility waiting on the pharmacy to deliver that medication. Further review of Resident #89's nurses' progress notes revealed a nurse's note dated 03/31/26 at 10:25 P.M. that indicated the resident was off the unit at that time and in route to the local emergency department via Emergency Medical Services (EMS) for an evaluation. The resident was indicated to be having complaints of shortness of breath and oxygen saturation levels at around 78-80 % (above 92% within normal limits). A nurse's progress note by the same nurse on 04/01/26 at 12:55 A.M. indicated the resident did not receive her dose of Midodrine that was scheduled to be given at HS, due to her being sent out to the emergency department (ED), Her nurses' progress notes revealed she returned to the facility on [DATE] at 7:15 A.M.Review of Resident #89's ED notes for her visit on 03/31/26 revealed the resident was given a dose of Midodrine 10 mg po, while at the hospital on [DATE] at 12:40 A.M. The ED note further indicated that the resident was hemodynamically stable upon her presentation to the ED with her blood pressure being similar to when she was discharged from her previous hospitalization on Midodrine. Her blood pressure did begin to decrease at the hospital, but once she received her dose of Midodrine she went back to her baseline. She was sent back to the facility with the diagnosis of shortness of breath in stable condition. Review of Resident #89's MAR for April 2026 revealed the resident was not documented to have received her scheduled doses of Midodrine for either the AM dose or the mid-day dose on 04/01/26. The first documented dose of Midodrine given to the resident was on 04/01/26 for her scheduled HS dose. Further review of Resident #89's progress notes revealed a nurse's note dated 04/01/26 at 8:13 A.M. that indicated the resident's Midodrine 10 mg was not administered as ordered for her blood pressure as the medication had been ordered and not available for administration. Review of the facility's medication administration times revealed the scheduled times included rising, mid-day, evening, and HS. Rising was between 7:00 A.M. and 10:00 A.M., mid-day was between 11:00 A.M. and 1:00 P.M., evening was between 4:00 P.M. and 6:00 P.M., and HS was between 7:00 P.M. and 11:00 P.M. Review of the facility's medication inventory from their Omnicell (contingent medication dispensing system) Inventory list revealed there were a total of 116 different medications available for use when needed from their emergency contingency supply. Midodrine was not one of the medications readily available at any dose. Review of a posting of an Ohio Pharmacy Information sheet from the facility's contracted pharmacy revealed the pharmacy delivered to the facility Monday through Friday for new orders and refills. Cut off times on those days were 12:00 P.M. and 12:00 A.M. Saturdays, Sundays, and Holidays. New orders and refills had a cut off time at 12:00 P.M. and 5:30 P.M. A message under New Orders and Refill Requests at the bottom of the page revealed new orders/ refill requests received before 12:00 P.M. would arrive with the first scheduled delivery. New orders and refill requests received after 12:00 A.M. (Monday to Friday) and after 5:30 P.M. (Saturday, Sunday, and Holidays) would arrive on the first scheduled delivery the following day. New orders and refill requests received after the cut-off would arrive on the next scheduled delivery. On 04/20/26 at 3:05 P.M., an interview with the DON revealed the facility's pharmacy did make deliveries twice a day (once in the morning and once again in the evening). The DON stated she was not sure of the approximate times other than what she had been told by their pharmacist, which was morning and evening. The DON stated she and the Administrator were just discussing pharmacy issues they had been having at the facility. The DON did not elaborate on what those issues were. On 04/20/26 at 3:50 P.M., a follow up interview with the DON revealed she had been the facility's DON since March 2026. The DON stated she felt there was a definite issue with the pharmacy the facility was using. The DON stated there should not have been a reason Resident #89's Midodrine was not available for administration until the HS dose on 04/01/26. She felt maybe the first dose would not have been available, but the nurses definitely should have had the Midodrine available to administer for the morning and mid-day doses that were scheduled for 04/01/26. The DON confirmed the hospital had given the resident a dose of Midodrine 10 mg, while the resident was in the ED on 03/31/26. The DON stated she was still getting to know the ins and outs of the pharmacy they used. The DON stated she was not sure if they had a local pharmacy that could be used as a backup when medications needed to be drop shipped and received timelier than what their contracted pharmacy could do when it was necessary. On 04/21/26 at 9:43 A.M., an interview with Registered Nurse (RN) #200 revealed she remembered Resident #89 having an order to receive Midodrine while there but did not recall if it was ordered before or after her hospitalization. She denied she had any concerns with Midodrine not being available during the times she worked. She reported the pharmacy the facility used was a struggle sometimes. If they stayed on them (pharmacy), they would get the medication to them (facility). The pharmacy made two deliveries a day, once in the early morning (before 7:00 A.M.), and the other in the afternoon between 4:30 P.M. and 5:00 P.M. She reported they would have to send in requests for routine medication by 8:00 A.M. that day to get them delivered that evening. Any new medication orders would have to be submitted by noon, if it was to be delivered with the evening delivery. If they needed something right away, they would have to put the medication in as a stat order and then would receive it within four hours. She did not feel there was any reason Resident #89 could not have had her Midodrine delivered before the evening delivery on 04/01/26, if the order was received and placed at the time of the resident's re-admission on [DATE] at 11:57 A.M. RN #200 stated the nurse receiving the re-admission orders could have put the Midodrine in as a stat order and it would have been received within four hours. RN #200 denied the facility used a local pharmacy as a backup, and if that was needed, that would have been something the pharmacy set up on their end. Review of the facility's policy on Pharmacy Hours and Delivery Schedule revised August 2020 revealed a schedule of pharmacy hours and delivery times was established and posted in a visible area in the facility. It did not specify when the deliveries would occur only that the Administrator, Director of Nursing (DON), and provider pharmacy would establish a daily delivery and pick up schedule for medication orders.This deficiency represents non-compliance investigated under Complaint Number 2976676.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident's medical record was complete and included all documentation required as part of the resident's admission into the facility. This affected one (Resident #89) of three resident records reviewed. The facility census was 87. Findings include:Review of the closed medical record for Resident #89 revealed an admission date of 03/09/26. Resident #89 was hospitalized on [DATE] then re-admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), acute on chronic respiratory failure with hypoxia, pneumonia, malignant neoplasm of an unspecified part of unspecified bronchus/ lung, dependence on supplemental oxygen, heart failure, sepsis, shock, unspecified fall (03/09/26), fractured nasal bones (03/09/26), syncope and collapse, muscle weakness, and unspecified protein-calorie malnutrition. Diagnoses were updated on 03/31/26 to include an unspecified fracture of the left pubis, fracture of the superior rim of the left pubis, and fracture of the left pubis. Review of Resident #89's admission Observation assessment (nursing admission assessment) dated 03/09/26 revealed the admission observation assessment was blank and did not include any information on it that was collected as part of the resident's initial admission into the facility on that date. The only information documented on the assessment was that the resident's allergies were to be determined. All other sections on the assessment that were to include an assessment of the resident's vitals signs and review of her body systems were left blank. Review of Resident #89's progress notes revealed a nurse's note dated 03/21/26 at 10:20 A.M. that revealed the resident was found on the floor beside her closet. The resident was attempting to get her clothes when she fell. She complained of left hip pain and a new order was received to obtain a stat x-ray of her left hip. The order indicated if the stat x-ray of the left hip could not be obtained within two hours then the resident was to be sent to the emergency department (ED) for an evaluation. The facility was unable to reach the mobile x-ray unit and the resident was transferred to the ED to be evaluated. She was admitted to the hospital with a fractured left hip and did not return to the facility until 03/31/26. Review of Resident #89's admission Observation assessment for her re-admission into the facility on [DATE] at 11:57 A.M. revealed it was not completed in its entirety. It included more information that what was collected during her initial admission but was still missing the majority of her assessment and review of her body systems. Her vital signs were recorded, as well as her known allergies, and some other parts of the assessment were documented, but the majority of the assessment was left blank. On 04/20/26 at 11:35 A.M., an interview with the Director of Nursing (DON) revealed she was not able to find evidence of a completed admission Observation assessment for the resident's initial admission into the facility on [DATE]. She stated it looked like it was completed in the electronic medical record, but when she pulled it up it was blank. She acknowledged the admission observation assessments was a means to assess the resident's condition upon entry into the facility and to identify/ address any resident specific care needs. She further acknowledged the admission Observation assessment completed upon the resident's readmission to the facility on [DATE] was also missing assessment data. She reported the nurse admitting the resident should be the one who completed the admission Observation assessment, but it was not consistently being done. Review of the facility's policy on admission Assessments dated November 2025 revealed the purpose of the procedure was to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the Minimum Data Set (MDS) assessment. The steps in the procedure directed them on how to conduct the admission assessment, a physical assessment, and any supplemental assessments. They were also to determine if a resident had existing advanced directives. If so, they were to initiate the process of obtaining a copy for the medical record. If not, provide the resident with information on his/ her rights to have advanced directives and initiate the process of establishing them. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, interview and facility policy review, the facility failed to ensure physician's orders were followed for three (Residents #27, #89, and #91) of seven residents reviewed for physician's orders. The facility census was 88.Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including left foot amputation, sepsis, type II diabetes mellitus, chronic ulcer of the left foot, end stage renal disease, dialysis dependent, heart disease, and hypertension. Review of the quarterly Minimum Data set (MDS) assessment completed 11/06/25 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact.Review of resident #27's medical record revealed an order dated 11/06/25 for a daily weight once a day for Resident #27.Review of Resident #27's medical record revealed no documentation of weights being obtained on 11/13/25, 11/17/25, and 11/29/25.Review of Resident #27 orders dated 11/29/25 revealed an order for insulin aspart 100 units/milliliter (ml) flex pen, inject 18 units subcutaneously before meals for type two diabetes mellitus.Review of Resident #27 orders revealed an order dated 12/10/25 for NovoLog 100 units/ml flex inject as per sliding scale: if 121-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; and 301-350 give 8 units; 351-400 give 10 units subcutaneously before meals and at bedtime for type two diabetes mellitus. If blood sugar is greater than 400 notify medical director immediately.Record review including progress notes, Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November and December 2025 revealed no documented evidence that Resident #27 receiving insulin aspart on 11/15/25 and 11/28/25 and no documented evidence Resident #27 received NovoLog 11/15/25, 12/08/25, and 12/09/25. In addition, there was no documented evidence Resident #27 had a blood sugar check as ordered by the physician on 12/08/25 after 8:36 A.M. and on 12/09/25 after 5:43 P.M.2. Record review revealed Resident #89 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia, gastro-esophageal reflux disease, anxiety, hyperlipidemia, and benign prostatic hyperplasiaReview of Resident #89 MDS assessment completed on 08/21/25 revealed a BIMS score of 9 of 15, indicating moderate cognitive impairment.Review of Resident #89's physician's orders revealed an order dated 09/18/25 for buspirone oral tablet 10 milligram (mg) give one tablet by mouth once daily for anxiety, and order dated 09/19/25 for amlodipine tablet 5 mg give one tablet by mouth one time a day related to hypertension, and an order dated 09/19/25 for aspirin tablet chewable 81 mg give one tablet by mouth one tine a day related to atherosclerotic heart disease of native coronary artery without angina pectoris.Review of Resident #89 October 2025 MAR revealed no documented evidence of aspirin 81 mg, amlodipine 5 mg, and Buspirone 10 mg being administered to Resident #89 on 10/04/25, 10/11/25, 10/12/25, 10/14/25, and 10/15/25.3. Review of the closed medical record revealed Resident #91 was admitted to the facility on [DATE] with diagnoses including heart disease, pancytopenia, anemia, bradycardia, hypertension, peripheral vascular disease, hyperlipidemia, anxiety, and hypokalemia,Review of Resident #91's physician's orders revealed an order dated 11/14/25 for levothyroxine 75 micrograms (mcg) give one tablet by mouth one time a day for hypothyroidism.Review of Resident #91's October 2025 MAR revealed no documented evidence levothyroxine was administered to the resident on 10/09/25, 10/24/25, 10/29/25, and 10/30/25. Interview on 12/15/25 at 3:00 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence Resident #27, Resident #89, and Resident #91 received their medications on the above specified dates, and no documented evidence daily weights were obtained for Resident #27 on 11/13/25, 11/17/25, and 11/29/25 as ordered by the physician.Review of the undated facility policy titled Medication Administration revealed medication must be administered as ordered in accordance with manufacturer specifications. The MAR will be signed after medications are administered. For those medications requiring vital signs, record the vital signs onto the medication administration record. Physicians will be notified timely of medication omissions.This deficiency represents noncompliance investigated under Complaint Number 2612904.

Based on record review, observation, interview and review of the facility policy, the facility failed to assess, observe, and document care of a left arm fistula site and an external central venous catheter (CVC) dialysis access site for Resident #27. This affected one (Resident #27) of one resident reviewed for dialysis care and services. The facility census was 88.Findings include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including left foot amputation, sepsis, type II diabetes mellitus, chronic ulcer of the left foot, end stage renal disease, dialysis dependent, heart disease, and hypertension. Review of the quarterly Minimum Data set (MDS) assessment completed 11/06/25 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. Resident #27 received dialysis and had a diagnosis of end stage renal disease. Review of the physician's orders for Resident #27 revealed an order dated 11/17/25 for dialysis every Monday, Wednesday, and Friday.Review of Resident #27 orders, medication administration record (MAR), treatment administration record (TAR), progress notes, and care plan revealed no documented evidence Resident #27's CVC and/or fistula were assessed by facility staff.Interview on 12/11/25 at 8:33 A.M. with Resident #27 revealed she attended dialysis every Monday, Wednesday and Friday. Resident #27 stated she has been going to dialysis for about a year and had been a resident at the facility for approximately two years. Resident #27 stated she had a dialysis access point, two of them, one in her left upper chest accessible by a CVC, and the other a fistula in her left arm. Resident #27 stated, if she is remembering correctly, her fistula was placed about six months ago, and the CVC was placed a year ago.Observation on 12/11/25 at 8:33 A.M. revealed a fistula present on Resident #27 left extremity, near the radial artery. Observation revealed an external dialysis catheter Dura Flow CVC in Resident #27's left upper chest with two lumens, one red and one black, with gauze and Tegaderm present.Interview on 12/15/25 at 2:53 P.M. with Director of Nursing (DON) confirmed Resident #27's medical record does not reflect assessment or monitoring of Resident #27's dialysis access cites.Review of the undated facility policy titled Dialysis - [NAME] Oaks revealed ongoing assessment and oversight of the resident before, during, and after dialysis treatments including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions and using appropriate infection control practices. The facility will ensure that the physicians order for dialysis include the type of access for dialysis (e.g. graft, arteriovenous shunt, external dialysis catheter) and location.This deficiency represents non-compliance investigated under Complaint Number 2612904.

Based on record review, interview and facility policy review, the facility failed to obtain a urinalysis for Resident #23 when ordered by the nurse practitioner. This affected one (Resident #23) of five residents reviewed for incontinence. The facility census was 88.Findings include:Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury with loss of consciousness, hemiplegia, hypokalemia, chronic pain, chronic kidney disease stage three, stress incontinence, and irritable bowel syndrome.Review of the quarterly Minimum Data Set (MDS) assessment completed 09/15/25 revealed Resident #23 was cognitively intact, displayed no behaviors, and was always incontinent of urine.Review of Resident #23's orders revealed an order placed on 11/21/25 for a urinalysis and culture and sensitivity one time for dysuria.Review of Resident #23's progress notes revealed a note authored by the Director of Nursing (DON) on 11/21/25 at 1:14 P.M. stating resident complains of (c/o) burning with urination; notified nurse practitioner (NP) at this time. A new order was received for urine culture and sensitivity (C&S). Resident #23 aware and in agreement at this time.Review of Resident #23's Medication Administration Record (MAR) revealed on 11/22/25 at 8:37 A.M. the resident's urinalysis was collected.Review of Resident #23's medical record including lab results, progress notes, physician notes, and physician's order as well as the facility infection control log for November 2025 revealed no results for Resident #23's urinalysis and no notification to the ordering provider regarding lack of lab results.Interview on 12/10/25 at 2:20 P.M. with Licensed Practical Nurse (LPN) #605 confirmed Resident #23 urinalysis does not appear to have been resulted, and she was unsure if it was collected. LPN #605 stated she would check with the lab. Interview on 12/10/25 at 2:59 P.M. with LPN #605 confirmed that the lab did not receive a urine specimen for Resident #23, and no provider was contacted. Review of the policy titled Lab Notification, effective 11/01/25, revealed it is the policy of the facility to timely notify the resident physicians or other providers of lab results. This deficiency represents non-compliance investigated under Complaint Number 2612904.

Based on observation, record review, review of the facility Abuse and Neglect policy and procedure, and interviews, the facility failed to provide adequate and necessary supervision and intervention to protect Resident #27's right to be free from sexual abuse by Resident #21. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 11/16/24 when Certified Nursing Assistant (CNA) #300 observed Resident #21, who was positive for Hepatitis C engaging in non-consensual sexual intercourse with Resident #27, a cognitively impaired and non-interviewable male resident who lacked the cognition to consent to the interaction. CNA #300 reported the incident to CNA #203 and Registered Nurse (RN) #188 but no investigation was completed, and no interventions were initiated to prevent potential recurrence. On 11/21/24 staff again observed Resident #21 in Resident #27's room with her shirt lifted up in front of the resident. This affected one resident (#27) of two residents reviewed for abuse. The facility census was 85. On 01/15/25 at 4:00 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/16/24 when the facility failed to protect Resident #27's right to be free from sexual abuse by Resident #21. In addition to failing to prevent the incident from occurring, following the incident, the facility failed to timely intervene, thoroughly investigate and implement measures to prevent additional incidents of sexual abuse from occurring. The Immediate Jeopardy was removed on 01/16/25 when the facility implemented the following corrective actions: On 01/15/25 at 4:00 P.M. the facility initiated an investigation related to the incident of sexual abuse involving Resident #27. The investigation process included speaking to Resident #21 and Resident #27 regarding the alleged incident, interviewing all residents, or assessing residents if they were not cognitively intact including skin assessments, pain assessments. The investigation process also included interviewing staff who worked on 11/16/24 for potential knowledge of any abuse incidents, as well as educating all staff on the abuse policy and procedure, notifying family and physician. On 01/15/25 at 4:35 P.M. Resident #21 was placed on one-on-one supervision. Resident #21 would remain on one-on-one services until seen by psychiatric services. Facility staff would complete the one-on-one supervision which would be tracked through documentation. On 01/15/25 at 5:15 P.M. Resident #21 and Resident #27's guardians were notified of the sexual abuse incident by the DON/Designee. On 01/15/25 at 5:30 P.M. a Quality Assurance Assessment (QAA) meeting was held which included the Administrator/Executive Director, DON, two unit managers, social worker, regional nurse consultant, and medical director. The team discussed a plan to mitigate the sexual abuse concern identified including an immediate intervention to keep all residents safe, the investigation including all education needed, interviews, assessments, discussions with all physicians, any medications that needed ordered or clarified, notifying family and the next steps including notifying the police department and filing a self-reported incident (SRI). On 01/15/25 at 5:30 P.M. Resident #21 and Resident #27's physician was notified of the sexual abuse incident by the Administrator/Designee. On 01/15/25 at 5:30 P.M. the DON/Designee assessed Resident #21 with no negative findings. On 01/15/25 at 5:58 P.M. the Administrator/Designee notified the police department of Resident #21 and Resident #27 allegedly having sexual intercourse in November 2024 and that the facility had started an internal investigation. On 01/15/25 at 5:58 P.M. the Administrator/Designee reported the allegation of sexual abuse involving Resident #27 to the State Agency and began a thorough investigation. On 1/15/25 at 6:00 P.M. the DON/Designee assessed 23 of 23 non-interviewable residents on the memory care unit to ensure no signs or symptoms of sexual abuse were identified. On 01/15/25 at 6:10 P.M. the DON/Designee assessed Resident #27. On 01/15/25 at 6:10 P.M. Social Service Designee (SSD)/Designee #190 assessed Resident #21 for psychosocial well-being. On 01/15/25 at 6:13 P.M. a local Police Department (PD) Officer arrived at the facility to take a report. The DON informed the officer there was an allegation of (sexual) intercourse between two memory impaired residents (#27 and #21) and that the facility was investigating the allegation. On 01/15/25 at 6:15 P.M. SSD #190 spoke with Resident #21's guardian. As a result of the conversation, the guardian agreed to transfer Resident #21 to another facility that could accommodate her sexual behaviors. Discharge planning was started. Resident #21 would remain on increased supervision as recommended by psychiatric services. Supervision was changed to every 15 minutes checks on 01/16/25 at 12:30 P.M. On 01/15/25 at 6:20 P.M. SSD #190/Designee assessed Resident #27 for psychosocial well-being. On 01/15/25 at 6:30 P.M. SSD #190/Designee interviewed or assessed 89 of 89 current residents and interviewed 123 of 123 staff members with no additional allegations of sexual abuse identified. On 01/15/25 at 7:00 P.M. SSD #190/Designee assessed 23 of 23 residents on the memory care unit for psychosocial well-being. On 01/15/25 at 7:15 P.M. the DON/Designee reviewed the orders and care plans for 23 of 23 residents on the memory care unit to ensure interventions for sexually inappropriate behaviors were in place. 01/15/25 at 9:00 P.M. the Administrator/Designee educated 123 of 123 staff members on the Abuse policy including Sexual abuse and reporting and investigating abuse. On 01/16/25 at 1:30 P.M. bloodwork was drawn for a Hepatitis panel for Resident #27. On 01/16/25 at 8:15 A.M. the DON/Designee spoke with the Nurse Practitioner regarding Resident #21. Orders were obtained for birth control pills. The resident had been started on the medication, Tagamet (a medication used to decrease libido) on 12/26/24. The resident's guardian was notified of these orders on 01/16/25. On 01/17/25 at 11:00 A.M. Resident #21's plan of care was updated to include the following non-pharmacological interventions to deter potentially sexually inappropriate behaviors: activities of choice, offer other activities to participate in with the activities department, leave the unit with supervision to participate in other activities and socialize, going on outings when able, family trips when able and counseling with Psychiatric Nurse Practitioner. Beginning on 01/16/25 the facility implemented audits for the Administrator/Designee to interview three staff members weekly times four weeks to ensure no concerns of sexual abuse were identified, then as determined by the QAA Committee. Beginning on 01/16/25 the facility implemented audits for the DON/Designee to assess three non-interviewable residents weekly times four weeks to ensure no signs or symptoms of sexual abuse were identified, then as determined by the QAA Committee. Although the Immediate Jeopardy was removed on 01/16/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Record review revealed Resident #27 admitted to the facility on [DATE] with diagnoses including dementia, hypertension, angina pectoris, attention and concentration deficit following cerebral infarction, and personal history of a traumatic brain injury. Record review revealed Resident #27 had a court appointed legal guardian of person and estate as of 05/14/24 related to being deemed an incompetent adult in the probate court. Resident #27 resided on the facility secured memory care unit. Review of a care plan dated 07/22/24 revealed Resident #27 may demonstrate inappropriate behaviors including agitation. The care plan was not specific to what the inappropriate behaviors were and did not include evidence of sexually inappropriate behaviors for the resident. In addition, there was no evidence in the medical record or plan of care that the resident was sexually active with other residents in the facility. Review of Resident #27's Minimum Data Set (MDS) assessment dated [DATE] revealed the cognitive assessment was incomplete. The assessment revealed Resident #27 refused care one to three days of the seven-day assessment reference period. Review of a psychiatric consult note documented in Resident #21's medical record, dated 11/21/24 at 1:40 P.M. revealed Resident #21 was caught on 11/16/24 having sexual relations with a gentleman (identified to be Resident #27) on the unit. The note indicated staff were being diligent at trying to keep them apart. Record review revealed no documentation of this incident was included in Resident #27's medical record. Following the incident, there was no evidence Resident #27 was assessed for injury, assessed related to his ability to consent to a sexual relationship with another resident/resident #21 or evidence the resident's legal guardian was notified. Review of a nursing note dated 11/21/24 at 1:27 P.M. by RN #188 revealed Resident #27 was found with Resident #21 in his room with her shirt pulled slightly up and the female resident was redirected out of Resident #27's room. There was no evidence that the provider or legal guardian were notified of the incident. Review of a handwritten, unsigned note dated 11/21/24 revealed Resident #27's guardian was alerted of a relationship with a resident, and noted the resident does not like to be told to stay out of the female resident's room. Staff were educated to assist with socializing in the common area. Record review revealed there was no evidence Resident #27 was assessed related to his ability to consent to a sexual relationship with another resident/Resident #21 at this time. Record review revealed Resident #21 admitted to the facility on [DATE] with diagnoses including anoxic brain damage, unspecified dementia, opioid use with opioid-induced psychotic disorder, bipolar disorder, major depression, chronic viral Hepatitis C, [NAME] (an eating disorder in which a person eats things not usually considered food), and acute Hepatitis C without hepatic coma. Record review revealed Resident #21 had a court appointed legal guardian of person and estate as of 05/02/22 related to being deemed an incompetent adult in probate court. Resident #21 resided on the facility secured memory care unit. Review of a care plan dated 04/15/24 revealed Resident #21 demonstrated inappropriate behaviors including making false accusations about peers and staff. There was no evidence of a care plan related to sexually inappropriate behaviors or that the resident was sexually active with other residents in the facility. Review of a MDS assessment completed on 11/15/24 revealed Resident #21 had severe cognitive impairment. The MDS revealed the resident had no behaviors. Review of a nursing note dated 11/21/24 at 1:17 P.M. by RN #188 revealed Resident #21 was found in Resident #27's room with her shirt up. Resident #21 was redirected out of the male resident's room. There was no evidence Resident #21's physician or legal guardian were notified of the incident. In addition, there was no evidence the facility implemented additional interventions to prevent continued sexual behaviors from occurring. Review of a psychiatric consult note documented in Resident #21's medical record, dated 11/21/24 at 1:40 P.M. revealed Resident #21 was caught on 11/16/24 having sexual relations with a gentleman (identified to be Resident #27) on the unit. The note indicated staff were being diligent at trying to keep them apart. The note indicated Resident #21 was not on birth control and a pregnancy test was ordered. Review of orders revealed Resident #21 had an order entered by LPN #165 dated 11/21/24 for a pregnancy test to be completed on 12/02/24. Review of a handwritten, unsigned note dated 11/21/24 revealed Resident #21's guardian was notified of sexual behaviors and stated, that's how she is. The note indicated Resident #21 was spoken to about appropriate and inappropriate behaviors. However, there was no evidence the facility implemented additional interventions to prevent continued sexual behaviors at this time. Review of the medical record revealed a progress note dated 12/22/24 at 10:46 A.M. by RN #212 that included Resident #21 wanders ad lib and is very friendly with male resident (Resident #27). Review of an addendum to a psychiatric consult note dated 12/26/24 at 1:37 P.M. revealed after speaking with staff, a pattern of Resident #21's behavior was that she tended to be more sexual with any new male resident. A recommendation for Tagamet 400 milligrams (mg) twice daily was provided in addition to a recommendation Resident #21 be placed on birth control if appropriate clinically. Record review revealed no evidence the facility implemented any additional non-pharmacological interventions and/or supervision to timely identify and/or prevent continued sexual behaviors by Resident #21 at this time. Review of orders revealed Resident #21 received an order dated 12/26/24 for Tagamet 200 mg two tablets twice daily by mouth. Interview on 01/14/25 at 10:28 A.M. with SSD #190 revealed she was involved on the memory care unit, but stated not as much as she would like to be. She stated Resident #21 had a boyfriend (Resident #27), the staff tried to keep them apart and staff were attempting interventions. However, SSD #190 did not specify what type of interventions and stated she does not document in care plans because the MDS nurse entered care plans for behaviors. She stated Resident #21 and Resident #27's families were aware of their interest in each other, and the SSD revealed she did not think they were concerned. Interview on 01/14/25 at 2:36 P.M. with RN #188 revealed there had been an incident where Resident #21 was in a room with a male resident (Resident #27) and pulled her shirt up, but the resident stated she only showed the male resident her belly button. Resident #21 was then started on Tagamet to lessen behaviors and sex drive, which the RN stated she believed were working. The RN also indicated staff were to ensure Resident #21 and Resident #27 were not alone in the same room together. Interview on 01/15/25 at 8:26 with CNA #153 revealed she believed Resident #21 and Resident #27 were boyfriend and girlfriend and stated they had been caught a few times together behind closed doors. She stated the residents were caught lying in bed together, but one time it was more than that, although the CNA stated she was not working at the time of this incident. The CNA revealed staff were to make sure the residents were not alone behind closed doors. Interview on 01/15/25 at 8:50 A.M. with CNA #202 revealed she had seen Resident #21 holding hands with and kissing Resident #27 more on the evening shift. The CNA stated she tried to redirect and separate the residents when this occurred. Interview on 01/15/25 at 8:55 A.M. with LPN #165 revealed she had observed Resident #21 holding hands with Resident #27 but denied knowledge of any type of sexually inappropriate behaviors being reported to her. An additional interview on 01/15/25 at 9:02 A.M. with LPN #165 revealed (in November 2024) Resident #21 told Psychiatrist #305 that she needed a pregnancy test, and Psychiatrist #305 ordered the test. LPN #165 stated she just entered the test in the computer but did not inquire why it was necessary. Interview on 01/15/25 at 9:03 A.M. with Psychiatrist #305 revealed he was informed by staff (unable to state which staff) Resident #21 had sexual relations with a male resident on the unit. He stated Resident #21 still menstruated, so after being made aware of the sexual activity, a pregnancy test was ordered (the test was negative). Psychiatrist #305 revealed if the resident continued to have sex, she should be started on birth control. During the interview, Psychiatrist #305 revealed he confirmed with Resident #21 she had sex with another resident, and stated the resident was quite proud. However, there was no evidence the psychiatrist discussed with staff the other resident involved in the sexual activity to ensure the resident was able to and had consented to the sexual activity. Interview on 01/15/25 at 10:16 A.M. with Licensed Social Worker (LSW) #313 revealed she worked with Psychiatrist #305 for any consults in the facility. She stated she was contacted (unable to recall by which facility staff member) because Resident #21 had allegedly been having sex with a male resident (Resident #27). The LSW revealed since the resident still had menses, there was a possibility of her becoming pregnant, so Psychiatrist #305 ordered a pregnancy test, then eventually started her on Tagamet. However, there was no evidence the LSW discussed with staff the other resident involved in the sexual activity to ensure the resident was able to and had consented to the sexual activity. Interview on 01/15/25 at 10:26 A.M. with MDS Nurse #139 revealed social service staff were expected to develop and document care plans related to resident behaviors. Interview on 01/15/25 at 10:35 A.M. with Resident #21 revealed she had a boyfriend and identified him as Resident #27. Resident #21 stated they had already had sex (including penetration) without protection, and they got in trouble because she could still get pregnant. Resident #21 stated she sees Resident #27 every day. During the interview Resident #21 stated all the staff know about her sex life. Resident #21 stated I have tried to hide myself, but I'm not hideable due to having a loud voice and Resident #27 is able to find her. Interview on 01/15/25 at 10:39 A.M. with RN #188 revealed she had heard CNA #300 allegedly witnessed Resident #21 and Resident #27 having sex. During the interview, Resident #21 approached RN #188 and stated she needed condoms so she could have safe sex. Interview on 01/15/25 at 11:42 A.M. with SSD #190 revealed she had spoken with Resident #21 about her interactions with Resident #27 as she felt Resident #21 was able to remember a little more than Resident #27 could. SSD #190 revealed she cautioned Resident #21 about the relationship because of the age difference between the two residents and the resident's memory impairment. During the interview, she confirmed Resident #21 had a diagnosis of Hepatis C and having unprotected sex with another person would not be safe. Interview on 01/15/25 at 1:12 P.M. with CNA #300 revealed (on 11/16/24) she was about to provide incontinence care to another resident, but there were no gloves in the room, so she went to Resident #27's room because she recalled seeing gloves in there. She stated upon entering the room, she observed Resident #21 lying with her back on the bed with her buttocks towards the edge and her legs spread while Resident #27 was standing in front of her penetrating her. Both residents were completely naked. She stated she was new to the facility and did not know what to do, and she noticed the residents became nervous with her presence as well. She stated she closed the door and walked to the nurse's station to ask what to do. She was informed by CNA #203 the residents needed to be separated, and a statement needed to be written. CNA #300 stated CNA#203 took her statement. Interview on 01/15/25 at 1:53 P.M. with Resident #21's guardian revealed the resident was very forward and talked about sex often. The resident's guardian stated the facility had not contacted her or made her aware of any type of relationship between Resident #21 and Resident #27. The guardian stated it was her preference that the resident does not have sexual interactions. She stated she wanted Resident #21 to be safe, and she did not feel Resident #21 should be sexually active due to cognition and hygiene concerns. Interview on 01/15/25 at 2:40 P.M. with Resident #27's guardian revealed at the last care conference she had with the facility she was made aware Resident #27 was having sexualized types of behaviors. However, she was not aware of actual sexual activity, the extent of the sexualized behaviors or that the resident was involved in any type of relationship with another resident. During the interview, the guardian revealed Resident #27 was not able to provide consent (to sexual activity) due to his cognitive impairment. The guardian revealed she had not been notified that the sexual activity that had occurred had placed Resident #27 at risk for contracting Hepatitis C (as the sexual intercourse was unprotected). She stated the last phone call she received from the facility was on 11/14/24. Interview on 01/15/25 at 3:09 P.M. with the DON revealed she was aware Resident #21 and Resident #27 would hold hands, and she was aware there was human contact where some upper body contact was attempted or did happen. However, she stated she was not aware of any invasive contact (eluding to sexual intercourse). The DON verified Resident #27, due to cognitive impairment would not be able to consent to sexual activity. The DON revealed she was unaware of pregnancy testing for Resident #21 until 01/13/25. The DON revealed she was aware Tagamet had been ordered for Resident #21 to decrease her libido and deter potential attempts at sex. The DON indicated it was her expectation if two residents were observed having sex that the staff would call her and the Administrator, not leave until they were interviewed, and an investigation and self-reported incident (SRI) would be completed immediately. During the interview, the DON indicated she was unaware of this incident involving Resident #27 in 11/2024 until interview with the State agency surveyor. Interview on 01/15/25 at 4:17 P.M. with CNA #108 revealed she had previously observed Resident #21 kissing Resident #27 and had observed the resident's holding hands. While the CNA did not report witnessing Resident #21 having sexual activity with Resident #27, she stated she had heard from a lot of staff that had witnessed Resident #21 having sex with Resident #27. Interview on 01/15/25 at 4:34 P.M. with CNA #300 revealed additional staff present during the incident (on 11/16/24) included the scheduler, CNA #203, and a higher up lady. CNA #300 stated it was her second week at work, and following the incident, she placed a written statement in a folder next to the computer. She stated the incident had occurred after lunch but before 2:00 P.M. She stated, the higher up lady who shared the same name as the DON, stated there was nothing that could be done about it. Interview on 01/15/25 at 4:41 P.M. with CNA #201 revealed Resident #21 believed she was in a relationship with Resident #27 and staff had to remind them of their age gap. Interview on 01/16/25 at 8:16 A.M. with RN #188 revealed she could not recall working at the time Resident #21 and Resident #27 were observed having sex, despite being on the schedule to work on this date (11/16/24). During the interview, the RN was unable to recall information from this time period. During the interview, RN #188 revealed she was also unaware Resident #21 had Hepatitis C and the potential for spreading it during sex. Interview on 01/16/25 at 8:18 A.M. with CNA #203 revealed she was working at the facility (on 11/16/24) when CNA #300 informed her Resident #21 and Resident #27 were in Resident #27's room having sex and she was unsure what to do. CNA #203 stated she told CNA #300 the resident's needed separated, so she went to split them up, but they had already separated themselves and were getting their clothes back on. Both residents were naked at that time. CNA #203 stated she told RN #188 about the incident, but she was passing medications, so she told CNA #300 to write a witness statement and place it on the medication cart. Interview on 01/16/25 at 8:23 A.M. with SSD #190 revealed she was not clinical, so she did not think to inquire why Resident #21 needed a pregnancy test ordered. SSD #190 revealed she did not know Resident #21 had Hepatitis C and could potentially transmit it sexually. During the interview, SSD #190 provided no evidence the sexual activity between Resident #21 and Resident #27 was consensual, that Resident #27 had the ability to consent to the interaction or that the incident had been investigated as possible sexual abuse with Resident #27 being the victim. Interview on 01/16/25 at 8:34 A.M. with the DON revealed no one inquired why the pregnancy test was ordered for Resident #21 in November 2024. The DON verified the lack of written documentation of the sexual intercourse incident in the resident's medical records at the time of the incident, lack of responsible party/guardian notification and physician notification. The DON verified the incident was not reported to the State agency and/or investigated as an incident of sexual abuse. The DON also verified the lack of comprehensive assessments and care plans related to the ability to consent to sexual activity for Resident #27. During the interview, the DON denied knowledge of CNA #300 writing a statement following the observed incident on 11/16/24. Attempts to interview Resident #27 throughout the survey were unsuccessful due to the resident's impaired cognitive status. During the survey, the resident was observed on the secured memory care unit often times sweeping the carpet and participating in activities. On 01/16/25 the facility provided a root cause analysis indicating the incidents of sexual abuse had occurred due to Resident #21's age and being very impulsive due to medical diagnoses including memory impairment, anoxic brain damage, unspecified dementia, history of opioid use, bipolar disorder and not recognizing socially appropriate boundaries. The root cause analysis revealed a nursing home had been determined to not be the least restrictive environment for Resident #21 and that Resident #21 would likely be served in a group home setting or all female facility/unit. However, there was no evidence the facility had identified this or addressed this for the resident prior to the State agency being onsite for the annual survey. Upon further questioning of the root cause analysis, the facility updated the analysis to only note the incidents of sexual abuse had occurred due to Resident #21's age and being very impulsive due to medical diagnoses including memory impairment, anoxic brain damage, unspecified dementia, history of opioid use, bipolar disorder and not recognizing socially appropriate boundaries. During the onsite survey, staff reported their belief was that Resident #21 and Resident #27 were boyfriend and girlfriend and were aware physical contact (i.e. hand holding and kissing) between the residents had and was occurring (as noted in the staff interviews above). However, the facility failed to identify these behaviors as potentially inappropriate, failed to ensure an interdisciplinary comprehensive assessment of each resident's ability to consent to the relationship or sexual activity, or provide adequate supervision and intervention (staff reported simply re-directing when the residents were observed together) to prevent Resident #21 from engaging in unprotected sexual intercourse with Resident #27 on 11/16/24 placing Resident #27 at risk for contracting Hepatitis C and placing Resident #21 at risk for becoming pregnant. Review of a policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2016, revealed sexual abuse was non-consensual contact of any type with a resident. When an issue was identified, the resident involved should be protected from reoccurrence, the incident should be reported to the state, and an investigation should be completed and be thorough. All residents and witnesses should be interviewed. In the case of a resident-to-resident incident, the interdisciplinary team will determine appropriate interventions.

Based on observations, record reviews, and interviews, the facility failed to monitor and administer Resident #31's vancomycin per standards of care, failed to address edema and obtain Doppler testing timely for Residents #59, #85, and #191, failed to communicate orders and care plan with hospice for continuity of care for Resident #54, and failed to address a change in condition for Resident #41 following a fall. This affected six sampled residents (#31, #41, #54, #59, #85, #191) of 20 residents reviewed for quality of care. The facility census was 85. Actual Harm occurred to Resident #41 beginning on 12/20/24 when Registered Nurse (RN) #213 documented the resident had inflammation of left foot and toes after a fall on 12/19/24, with no evidence the resident's medical provider was notified of the resident's change in condition delaying any orders for treatment of the resident's change in condition. On 12/21/24, Resident #41's left foot continued to be edematous and red, with the resident exhibiting facial grimacing with repositioning and generalized discomfort; the resident's wife verbalized he had been sleepier and had a poor appetite since his fall on 12/19/24. An order was received on 12/21/24 at 11:42 A.M. for an x-ray of the left foot and hip, and a venous Doppler to right foot. Resident #41 continued to show signs of discomfort including facial grimacing and moaning aloud with care, and as needed pain medication was administered. The left foot and hip x-rays were delayed and not completed until the following day (12/22/24) at 2:00 P.M., the x-ray results were received, the resident was transferred to the hospital for additional testing that identified the resident had an acute mildly impacted subcapital right femoral neck fracture. Findings include: 1. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease without angina pectoris, hypo-osmolality and hyponatremia, anemia, hypertension, and heart failure. Resident #41 was recently readmitted to the facility on [DATE] after a brief stay in the hospital. Review of a nursing note dated 12/19/24 at 2:30 P.M. by RN #188 revealed Resident #41 was noted to have fallen from his wheelchair on his right side in the dining room attempting to throw away an apple core. Resident #41 was assessed with no injuries noted, he did not complain of pain or discomfort, but stated this floor is hard. Resident #41 was assisted into his wheelchair without difficulty. The resident's responsible party was notified. Review of a nursing note dated 12/20/24 at 8:00 P.M. by RN #213 revealed Resident #41 had inflammation noted to his left foot and toes. There was no evidence the resident's medical provider was notified of the resident's change in condition after his fall on 12/19/24. Review of a nursing note dated 12/21/24 at 11:42 A.M. by RN #202 revealed Resident #41's left foot was noted to be slightly edematous and red, with pedal pulses palpable and no increased warmth. Resident #41 had grimacing with positioning and generalized discomfort, and as needed Tylenol was administered. Resident's wife was present and stated he had a poor appetite and was sleepier since his fall on 12/19/24. A new order was received for an x-ray to the left hip and foot due to pain, and a venous Doppler to the right foot. Wife present and agreeable. Review of a nursing note dated 12/21/24 at 9:41 P.M. by RN #216 revealed the mobile imaging company called and stated the x-ray would not be able to come in as scheduled but would come sometime tomorrow. Review of a nursing note on 12/22/24 at 11:22 A.M. by RN #202 revealed Resident #41 continued to show signs of discomfort, facial grimacing and moaning aloud with care, and as needed Tylenol was administered as ordered. Review of a nursing note dated 12/22/24 at 2:00 P.M. by RN #202 revealed the mobile imaging company was in-house for exam of Resident #41. Review of a medication administration record for December 2024 revealed on 12/22/24 Resident #41 received an x-ray of his left foot and hip. Review of a nursing note dated 12/22/24 at 2:10 P.M. by RN #202 revealed x-ray results were received, and the on-call provider was notified and gave new orders to send to the emergency department for further evaluation. A squad was notified of need for transfer and family notified. Review of a nursing note dated 12/22/24 at 3:59 P.M. by RN #202 revealed Resident #41 was transported to the hospital. Review of a hospital note dated 12/23/24 revealed Resident #41 presented to the emergency department (ED) following a fall at a facility. Upon presentation, Resident #41's blood pressure was 190/71 and other vitals were within normal limits. An x-ray of the pelvis showed a previous internal fixation of the left femoral neck and due to a nondisplaced fracture of the right femoral neck, and fecal impaction. A CT scan of the pelvis showed an acute mildly impacted subcapital right femoral neck fracture. Interview on 01/16/25 at 2:43 P.M. with Director of Nursing (DON) revealed there have been concerns with the mobile imaging company not showing up to complete STAT imaging. The DON confirmed Resident #41 began to complain of pain on 12/20/24, with no new intervention in place until the imaging services were ordered on 12/21/24, which were not completed until 12/22/24. The DON stated if the company does not show up within four hours, a resident should be sent to the hospital. 2. Record review revealed Resident #59 admitted to the facility on [DATE] with diagnoses including dementia, metabolic encephalopathy, type II diabetes, and hypertension. Review of a minimum data set (MDS) completed on 10/09/24 revealed Resident #59 had impaired cognition and no behaviors. Review of a nursing note dated 11/30/24 by RN #188 revealed Resident #59 complained of discoloration to her left foot. Her foot was noted to be dark purple/black, and swelling was noted with capillary refill of less than three seconds. Resident #59 denied pain, the medical provider was notified, and new orders were received for an x-ray and a venous Doppler. The mobile imaging company stated they would not be able to complete the Doppler until next week. Review of a progress note dated 12/02/24 by Nurse Practitioner (NP) #315 revealed she was asked to see Resident #59 due to discoloration of the left foot. An x-ray was completed and negative and the venous duplex was not yet completed. There was one-two pitting edema to the left foot with purple discoloration to the left foot dorsal aspect, non-tender palpation and 2+ DPPT pulse. No new orders were given. Review of a note dated 12/10/24 at 2:20 P.M. revealed the mobile imaging company was in-house to complete Resident #59's ultrasound (Doppler). Results were negative. Review of a Doppler report dated 12/10/24 revealed there was no evidence of left lower extremity deep venous thrombosis. Interview on 01/16/25 at 1:47 P.M. with RN #188 revealed she entered Resident #59's order for a stat venous Doppler and she faxed the information six times before the mobile imaging completed the ultrasound. RN #188 stated she notified the NP (#315) of the situation but the Medical Director (MD) #340 came in and evaluated the resident and was not worried. Her family did not want her sent out for evaluation and were okay with waiting until the scan could be done in house. Interview on 01/16/25 at 10:56 A.M., with the Nurse Practitioner (NP) #315 confirmed her expectations would be the venous Doppler be done within 24 hours from when it was ordered. Interview on 01/16/25 at 2:43 P.M. with Director of Nursing (DON) revealed there have been concerns with the mobile imaging company not showing up to complete STAT imaging. The DON confirmed Resident #59 waited from 11/30/24 to 12/10/24 to receive the venous Doppler. The DON stated if the company does not show up within four hours, a resident should be sent to the hospital. 3. Record review revealed Resident #85 admitted to the facility on [DATE] with diagnoses including vascular dementia, post-traumatic stress disorder, and idiopathic gout. Review of a MDS completed on 11/29/24 revealed Resident #85 had moderately impaired cognition and wandered daily. Review of orders revealed Resident #85 had an order in place to receive a venous duplex (Doppler) to his left lower extremity due to pain and swelling dated 01/02/25. The order was discontinued on 01/02/25. Review of a nursing note dated 01/02/25 at 9:54 A.M. by Licensed Practical Nurse (LPN) #177 revealed new orders were received for Resident #85 for a CBC, Chem 8, ESR, CRP, and uric acid level, obtain an x-ray of left knee due to pain and swelling, and a venous duplex of the left lower extremity. Review of a nursing note dated 01/05/25 at 10:03 A.M. by LPN #211 revealed Resident #85 had +1 putting edema to the right foot with minimal movement and grimacing when attempting to move. The resident's medical provider was notified and new order was received for right lower extremity venous duplex. Review of a nursing note dated 01/05/25 at 6:40 P.M. for late entry from 9:28 A.M. by LPN #211 revealed she called the mobile imaging company to schedule a Doppler for Resident #85 and was told a face sheet and order needed sent prior to scheduling. Information was sent. Review of orders revealed Resident #85 had an order in place for a venous duplex of right lower extremity dated 01/05/25. The order was discontinued on 01/08/25. Review of a nursing note dated 01/08/25 at 9:29 A.M. by LPN #211 revealed she called the mobile imaging company to ask if the venous Doppler had been completed and the scheduler requested a new order with updated symptoms. Review of orders revealed Resident #85 had an order in place dated 01/08/25 for a venous duplex of right lower extremity due to pain and edema. The order was discontinued on 01/16/25. Review of a nursing note dated 01/10/25 at 10:44 A.M. by LPN #165 revealed a face sheet and orders were faxed to the mobile imaging company for a venous duplex of the right lower extremity due to pain and swelling and will call back to schedule exam. Review of a patient report (for Resident #85) for venous Doppler dated 01/15/25 revealed there was no deep venous thrombosis evident on the right lower extremity. Interview on 01/16/25 at 10:56 A.M., with the Nurse Practitioner (NP) #315 confirmed her expectations would be the venous Doppler be done within 24 hours from when it was ordered. Interview on 01/16/25 at 2:43 P.M. with the DON revealed there have been concerns with the mobile imaging company not showing up to complete STAT imaging. The DON confirmed Resident #85 received an initial order on 01/02/25 and waited until 01/15/25 to have a venous Doppler completed. The DON stated if the company does not show up within four hours, a resident should be sent to the hospital. 32801 4. Medical record review revealed Resident #31 was admitted to the facility on [DATE] at 5:05 P.M., with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia, deformity of the head, atrial fibrillation, chronic pain, and iron deficiency anemia. Review of Resident #31's hospital records dated 12/04/24 to 12/18/24 revealed the resident was admitted for a cranial wound dehiscence and purulence. The resident had a craniectomy in 2019 complicated by chronic draining scalp wound and was treated with long term antibiotics. The resident had been having ongoing purulent drainage and exposed hardware. She was taken to neurosurgery and plastics on 12/04/24 for excision of skull bone infection with craniectomy, removal of prior cranial hardware, debridement of bone and scalp and dermal tissue, and implantation of dura matrix. The infection disease was consulted to assist with intravenous antibiotics. Their recommendation at discharge included intravenous meropenem two grams every eight hours for six weeks and vancomycin (pharmacy to dose) for six weeks. The stop date would be 01/16/25. A left tunneled internal jugular central line was placed on 12/12/24. The resident will need oral antibiotics therapy at the end of the parenteral therapy based on the follow up MRI. Review of Resident #31's hospital discharge orders dated 12/18/24 revealed to obtain Vancomycin tough and a basic metabolic profile (BMP) 30-60 minutes before the scheduled dose on Monday and Thursday for two weeks and then weekly on Mondays. Obtain a complete blood count (CBC) and hepatic function panel weekly on Monday. The resident's vancomycin trough range goal was 15-20 micrograms (mcg) per milliliter (ml). Fax laboratory results to the infection disease physician (name and fax number was provided on discharge paperwork). Further review revealed to administer meropenem two grams intravenously every eight hours (last dose was administered on 12/18/24 at 10:56 A.M.) and vancomycin 750 milligrams (mg) every 12 hours intravenously (last dose was administered on 12/18/24 at 5:42 A.M.). A. Review of Resident #31's current orders dated 01/2025 revealed meropenem two grams intravenous every eight hours (6:00 A.M., 2:00 P.M., and 10:00 P.M.) and vancomycin 750 mg intravenous every 12 hours (goal trough range 15-20 mcg/ml) at 8:00 A.M. and 8:00 P.M. Review of Resident #31's medication administration records (MAR) dated 12/18/24 to 01/15/25 revealed the resident didn't receive meropenem on 12/18/24 10:00 P.M., 12/19/24 at 6:00 A.M., 12/29/24 at 2:00 P.M. due to the medication was not available. The vancomycin was not administered on 12/18/24 8:00 P.M., 12/19/24 at 8:00 A.M., 12/23/24 at 8:00 A.M., 12/29/24 at 8:00 P.M., 12/30/24 at 8:00 A.M. and 8:00 P.M. and 12/31/24 at 8:00 A.M., due to the medication was not available. The physician was notified on 12/31/24 that the vancomycin was not available. The medication was on hold on 01/09/25 for the 8:00 A.M. and 8:00 P.M. awaiting trough to be drawn, however the trough (blood work to check medication level) was never collected on 01/09/25. B. Review of Resident #31's orders revealed vancomycin trough was ordered on 12/19/24 on Tuesday and Thursday for two weeks (discontinued on 12/31/24). On 12/27/24 and 01/06/25 vancomycin trough was ordered every Monday and was discontinued on 01/19/25 and 01/09/25 a vancomycin trough was ordered and discontinued the same day. Further review revealed on 12/27/24 a BMP, CBC, CMP, and hepatic function was ordered every Monday and discontinued on 01/19/25. Review of Resident #31's laboratory results revealed the only laboratory results in the medical record were dated 01/10/25. Review of Resident #31's medical record revealed no evidence the laboratory test was faxed to the infectious disease physician per the hospital discharge orders. Review of the laboratory results dated [DATE] to 1/20/25 revealed: -12/19/24 (Thursday) only the vancomycin trough was completed. There was no evidence the BMP was collected per the hospital discharge orders. The vancomycin trough was collected at 10:22 A.M. Per the MAR the resident had missed the 8:00 P.M. dose on the 12/18/24 and the 8:00 A.M., dose on 12/19/24. The trough level was 10.7 microgram (mcg)/ milliliter and the resident's goal were 15-20. -12/23/24 and 12/26/24 (Monday and Thursday) There was no evidence laboratory results were obtained. -12/30/24 (Monday) the blood was collected at 1:45 P.M. (Vancomycin was not administered on 12/29/24 at 8:00 P.M., or on 12/30/24 at 8:00 A.M., due it was not available). The trough level was 5.5 mcg/ml. The BMP, hepatic, and CBC was collected. -01/06/25 (Monday) There was no evidence lab testing was collected. -01/07/25 (Tuesday) The trough level was 26.3 mcg/ml. The BMP, hepatic, and CBC was collected. The trough level was collected at 11:36 A.M., which would have been after the administration of the vancomycin (order was to collect 30-60 minutes prior to administration of vancomycin). New orders were to hold to hold morning dose on 01/09/25 and recollect vancomycin's trough due to the 01/07/25 bloodwork was not collected properly. -01/09/25 there was no evidence the vancomycin trough was collected; however, the resident did not receive either dose of vancomycin on 01/09/25. -01/10/25 the vancomycin trough was collected at 1:44 P.M. and the trough was 4.0 mcg/ml. The MAR indicated the 8:00 A.M., dose was held until the lab was drawn. -01/13/25 (Monday) the vancomycin trough was 13.0 mcg/ml and was collected at 1:47 P.M. The MAR indicated the vancomycin was held until the trough was collected. The other labs were obtained per orders. Review of Resident #31's progress notes dated 01/08/25 revealed the vancomycin trough was reported to pharmacy. The results were 26.3. The dose of vancomycin was administered before the labs were drawn on 01/07/25 so the trough was not a true draw. Recommendation received to redraw trough tomorrow 01/09/25 and hold the 8:00 A.M., dose of Vancomycin until after labs have been drawn. Interview on 01/21/25 at 10:53 A.M., with Licensed Practical Nurse (LPN)/Unit Manger #177 confirmed Resident #31's laboratory results were not in the resident medical record except for the laboratory testing that was completed on 01/10/25. The LPN verified she called and had the hospital fax over all the laboratory results today (01/21/25) from admission to present. The laboratory person comes to the facility on Monday and Thursday to collect labs. LPN #177 reported she called the infection disease physician office today, and they confirmed they had received the laboratory results. The LPN confirmed the troughs should have been drawn 30-60 minutes prior to administering the vancomycin, however the vancomycin troughs on 12/26/24, 12/30/24, and 01/07/25 were collected after the administration of the vancomycin. The LPN confirmed the resident had missed seven doses of the vancomycin and three doses of the meropenem because they were not available to administer from pharmacy, which has been an issue for the facility. LPN #177 confirmed the BMP was not collected on 12/19/24 nor was the trough or BMP collected on 12/23/24, or 12/26/24 per the hospital discharge orders. The laboratory staff did not come on 01/06/25 due to weather but came on 01/07/25. LPN #177 confirmed the resident lab work should have been collected via the central line by the facility's nursing staff; however, it was not collected because the facility depends on the lab to transport specimens. The labs were not done on 01/09/25 and staff should have (but did not) contacted the physician and not held the two doses. 5. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of liver, type two diabetes, urinary tract infection, anemia, paroxysmal atrial fibrillation, congestive heart failure, cardiomegaly, hyperlipidemia, anxiety, history of acute kidney, ileus, acute pulmonary edema, conjunctival hemorrhage, severe sepsis with septic shock, sepsis, encephalopathy, bacteriuria, liver disease, diarrhea, gastroenteritis and colitis, muscle weakness, difficulty walking, need for assistance with personal care. Review of Resident #54's face sheet revealed the resident primary payer was hospice Medicaid. Review of Resident #54' Minimum Data Set (MDS) dated [DATE] revealed the resident was receiving hospice services. A. Review of Resident #54's current and discontinued orders dated 12/19/24 to 01/15/25 revealed no evidence of orders for hospice. Review of Resident #54's medical record revealed no evidence of hospice notes. Review of Resident #54's care plans revealed no evidence of a plan of care for hospice. B. Review of Resident #54's orders dated 12/16/24 to 01/15/25 revealed to check the resident's blood glucose twice a day and notify hospice if greater than 450 mg/dL. Review of Resident #54's MAR dated 12/2024 revealed the resident's blood glucose on 12/18/24 was 509. Review of Resident #54's medical record revealed no evidence hospice was notified of the blood glucose of 509 mg/dL on 12/28/24. C. Review of Resident #54's hospice orders dated 12/10/24 and 01/22/25 revealed the resident was ordered Humalog insulin 10 units prior to meals. Review of Resident #54's facility orders dated 12/11/24 to 01/16/25 revealed the resident was ordered Humalog 15 units three times a daily. Review of Resident #54's MAR dated 12/16/24 to 01/15/25 revealed the resident was receiving 15 units of Humalog three times daily. Interview on 01/22/25 at 9:45 A.M., with RN #139 confirmed Resident #54 did not have a plan of care for hospice. Interview on 01/22/25 at 10:59 A.M. and 2:20 P.M. with LPN #177 confirmed she had called hospice and reviewed Resident #54's medical record and there was no evidence hospice was notified of the blood sugar of 509 mg/dL on 12/18/24. LPN #177 confirmed the facility's physician had increased the resident's Humalog to 15 units on 12/10/24, however hospice was not updated. Originally LPN #177 confirmed the facility had to call hospice to obtain notes, however later reported the facility staff was not aware, however hospice confirmed there was a binder they have been leaving notes in for the staff. Interview on 01/22/25 2:16 P.M. with Hospice RN #340 revealed there has been communication issues with the facility not notifying hospice of changes in resident conditions/orders. The night shift nurses were worse than day shift. For example, Resident #54 has been yelling out at night. No one had called and updated hospice. Hospice RN #340 stated she usually gets information from the chart during her visits, the resident, and sometimes she gets information from other residents. Resident #54 had had an as needed order for Ativan and the facility was not utilizing the as needed medication or notifying hospice. There has been concerns with medication not being administered timely as well. If medications are ordered from the facility, it may take 2-3 days before the medications are started. Hospice RN#340 reported she brings notes in every two weeks and places in the binders for staff. Review of the facility's policy titled Hospice (dated 06/2022) revealed the facility policy was to coordinate end-of-life care with hospice agency of a resident/resident representative choice. The facility would coordinate care with the hospice agency. Facility would notify hospice agency upon resident/resident representative request, or a change in resident condition. Facility would document the coordination of care and treatment that was given to the resident. 6. Medical record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. Review of Resident #191's progress note dated 01/13/25 at 9:41 A.M., revealed the resident had noted with swelling and bruising to right arm. Area noted to be warm and tender to touch. New orders received to obtain a venous duplex and laboratory testing. Review of Resident #191's progress note dated 01/14/25 revealed no evidence the venous duplex was completed. Review of Resident #191's progress note dated 01/15/25 at 11:54 A.M., revealed the resident had a Doppler completed to the right upper extremity per orders. Review of Resident #191's Doppler results dated 01/15/25 revealed the reason for the right upper extremity Doppler was for pain and swelling to the right arm. The impression included no findings of the right upper extremity deep vein thrombosis. Review of the facility's imaging services agreement (dated 10/01/22) revealed the imaging service was to respond within a reasonable timeframe to request for services, usually within a few hours. Doppler exams are scheduled services, although every effort is made to prioritize emergent venous Doppler studies to be performed within 24 hours. Interview and observation on 01/13/25 at 10:19 A.M., with Resident #191 revealed she had had swelling in her right arm/hand since admission and had not been able to move it. The resident reported she had voiced concerns to the facility staff and wanted an x-ray, but no one had gotten back to her, and she didn't know what the holdup was. At 10:28 A.M., during the interview with the resident an unknown staff member had walked into the resident's room and reported she had spoken to the Nurse Practitioner, and she had ordered a venous Doppler and blood work. Interview on 01/15/25 at 10:16 A.M., with Resident #191 revealed the venous Doppler still had not been completed and she still had the swelling in her right arm and hand. Interview on 01/15/25 at 10:20 A.M., with Licensed Practical Nurse (LPN)/Unit Manger #177 confirmed the resident had not had the venous Doppler at this time. Interview on 01/15/25 at 10:33 A.M., with the Director of Nursing (DON) revealed she was not aware the Doppler was not done and her expectation would be the Doppler would have been done within 24 hours of the order, if not, the facility would transport the resident to the hospital to have the test completed. Interview on 01/16/25 at 10:56 A.M., with the Nurse Practitioner (NP) #315 confirmed her expectations would be the venous Doppler be done within 24 hours from when it was ordered. The NP confirmed staff did not update her that the Doppler was not completed within the 24 hours. Interview on 01/16/25 at 11:06 A.M., with LPN #177 revealed it was the facility's expectation to have a venous Doppler completed within 24 hours from the order. The LPN reported she thought the contracted company was having staff issues.

Based on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure skin assessments/skin checks were completed and to ensure skin integrity issues were reported to the medical provider. In addition, the facility failed to provide treatment to newly developed pressure ulcers for Resident #41 and failed to implement skin interventions for Resident #1 per the resident's plan of care. This affected two residents (#1 and #41) of two residents reviewed for pressure ulcers. The facility census was 85. Actual Harm occurred beginning on 01/01/25 when Resident #41, who was assessed to be at high risk for the development of pressure ulcers, was readmitted to the facility from the hospital with mushy heels and the facility failed to comprehensively assess or implement interventions to prevent pressure ulcer development. On 01/09/25 prevlon boots were ordered to both feet without documentation regarding the reason the boots were ordered. On 01/12/25 an initial assessment revealed had a pressure ulcer to his left heel that measured 4.5 (did not specify inches or centimeters) in diameter and was brown in color (with no staging included). The facility failed to implement new pressure ulcer interventions at this time resulting in a decline and identification of bilateral heel pressure ulcers that were Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss due to the eschar and coloring of the wound) pressure ulcers. Findings include: 1. Record review revealed Resident #41 admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease without angina pectoris, hypo-osmolality and hyponatremia, anemia, hypertension, and heart failure. Resident #41 recently readmitted to the facility on [DATE] after a brief stay in the hospital. Review of a care plan initiated 12/26/23 revealed Resident #41 was at risk for skin breakdown related to decreased mobility and incontinence. Interventions (all dated 06/28/24) included avoiding shearing skin during positioning, turning and transferring; conduct a weekly skin assessment and pay particular attention to bony prominences; encourage and assist to turn and reposition for comfort and as needed; floats heels as needed; keep linens clean and dry as possible, minimize skin exposure to moisture; pressure reducing cushion to chair; pressure reducing mattress to bed; use lifting device as needed for bed mobility; and use moisture barrier product to perineal area as needed. The care plan was last reviewed on 01/02/25 with no new interventions. Record review revealed no documented evidence care planned interventions, including turning and repositioning and floating the resident's heels, were implemented and completed. Review of a hospital wound care note dated 12/24/24 revealed Resident #41 had a traumatic wound to the second toe of his right foot. There were no additional wounds listed. Review of a nursing note dated 01/01/25 at 3:42 P.M. by Licensed Practical Nurse (LPN) #211 revealed Resident #41 was readmitted to the facility, with pain noted to hip, scattered bruising to bilateral arms and right leg was yellow and purple in color. There was an incision to his right hip measuring 10 centimeters (cm) in length by 0.01 cm in width and 0 cm in depth. Review of an Admission Observation and Data Collection assessment dated [DATE] revealed Resident #41's skin color was normal, warm in temperature, normal turgor, and skin impairment was identified and to be assessed on a Wound Event Assessment. Resident #41 was determined to be at high risk for developing pressure ulcers. Review of a progress note dated 01/02/25 by Nurse Practitioner (NP) #315 revealed Resident #41's skin was warm, dry, and the dressing to the right hip was dry and intact with surrounding ecchymosis. Review of an order dated 01/09/25 revealed Resident #41 was to have prevlon boots on when in bed. Review of a nursing note dated 01/12/25 at 9:23 A.M. by Registered Nurse (RN) #213 revealed wound on Resident #41's left heel was now approximately 4.5 (did not specify inches or centimeters) in diameter and had become brown in color. There was no staging including in the note. No drainage was noted, and soft boots were in place to elevate foot and heel off the bed. Review of a nursing note dated 01/16/25 at 7:20 P.M. by RN #213 revealed the heel of Resident #41's left foot had approximately 4 centimeter (cm) area of light brown coloration, was soft to touch, and soft booties were in place to both feet. Review of a nursing note dated 01/20/25 at 11:05 A.M. by RN #213 revealed Resident #41 had a Stage I (intact skin with a localized area of non-blanchable erythema) pressure ulcer to his left heel, which was darker brown than previously noted and padded boots were in place to each foot. Review of an order dated 01/22/25 revealed Resident #41's heels should be monitored and notify nurse practitioner of any changes due to deep tissue injury. Measurements provided to the surveyor on 01/22/25 of bilateral heel pressure ulcers revealed an ulcer to the left heel was five centimeters by three centimeters and an ulcer to the right heel was three centimeters by 1.5 centimeters. Eschar noted to be present was not measured. Interview on 01/21/25 at 10:21 A.M. with Registered Nurse (RN) #188 revealed Resident #41 had a wound to his right second toe, which the resident was admitted with from the hospital, and a wound to the left and right heels. RN #188 stated the bilateral heels were hard and brown. Interview on 01/21/25 at 2:25 P.M. with Licensed Practical Nurse (LPN) #165 revealed she completes wound rounds with the NP, NP #315 when she comes in. LPN #165 stated they had not looked at Resident #41's heels during the wound rounds on 01/20/25 because the last they heard, the heels were just soft and prevlon boots had been added as a preventative measure. LPN #165 confirmed there was no documentation in the medical record regarding where the wounds to Resident #41's heels came from or information about the right heel at all. Interview and observation on 01/21/25 at 2:40 P.M. with Director of Nursing (DON) revealed the wound to Resident #41's left heel was approximately the size of a fifty-cent piece, was purple and brown in color, with approximately 25% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like). The wound to the right heel was approximately the size of a nickel, brown in color and had about 5% eschar. Resident #41's wife was present at the time of the observation and stated the resident's heels were soft upon return to the facility from the hospital (on 01/01/25). Observation on 01/22/25 at 10:36 A.M. of Resident #41's heels revealed the right heel was a healing blister the size of a nickel with blanchable skin and the skin was intact and wound edges approximate. The left heel had 30% eschar in the corner of the wound and was dry. Fascia, muscle, tendon, ligament, cartilage and/or bone were not exposed indicating a potential Stage 3 pressure injury. Interview on 01/22/25 at 11:18 A.M. with LPN #165 revealed she was unable to locate any documented evidence Resident #41 had mushy heels upon readmission to the facility on [DATE], however, LPN #165 stated the floor nurse knew but failed to document it. LPN #165 confirmed there was nothing regarding pressure ulcers/wounds to Resident #41's heels in the care plan, nursing notes, or hospital documentation to indicate the resident's heels had started to have wounds in the hospital. Interview on 01/22/25 at 11:40 A.M. with Medical Director (MD) #340 revealed he does not specialize in wound care and was not comfortable with staging the wounds to Resident #41's heels. MD #340 stated the NP took care of wounds for the facility. MD #340 stated the wounds looked like a blister, but he was not sure. He stated if new wounds arise, staff should contact the NP to let her know so she can assess and give interventions as soon as the wound is noticed. Interview on 01/22/25 at 12:53 P.M. with the DON revealed nursing notes, hospital notes, the NP note, assessments, and orders did not address potential deep tissue injuries or pressure ulcers to Resident #41's heels until 01/09/25 for the prevlon boots. The DON stated she assessed Resident #41's heels upon his return to the facility (01/01/25) but failed to document. After observing wounds on 01/21/25 (at 2:40 P.M. with the surveyor), the DON did not contact a medical provider, complete an assessment, or measure the wounds to Resident #41's bilateral heels. The DON acknowledged eschar was present in both wounds. Interview on 01/22/25 at 3:16 P.M. with RN #213 revealed she had assessed Resident #41's left heel the other day and it was about a Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister), and she reported to the unit manager, LPN #165, to have the NP look at Resident #41's heels. RN #213 went to observe Resident 41's heels with surveyor present and stated the wound to Resident #41's left heel appeared to be a Stage Three (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss due to the eschar and coloring of the wound). Review of the National Pressure Ulcer Advisory Panel Pressure Injury Stages (dated 2018) revealed a deep tissue injury in intact or non-intact skin with localized area of persistent, non-blanchable deep red, maroon, purple discoloration or epidermal separation revealed a dark wound bed or blood filled [NAME]. If necrotic tissue (eschar), subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, stage 3 or 4). A stage 3 pressure injury is full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and eschar may be visible. If slough or eschar obscure the extent of tissue loss, it is an unstageable pressure injury. An unstageable pressure injury is when the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar. If slough or eschar are removed, stage 3 or 4 will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heels should not be removed. Review of a Pressure Ulcer/Injury Risk Assessment policy (last revised in 2017) revealed the following information should be documented in the medical record: - The type of assessment - The date, time, and type of skin care provided - The name and title (or initials) of the person completing the assessment - Any change in the resident's condition if identified - The condition of the resident's skin - How the resident tolerated to procedure - Any problems or complaints made by the residents - If treatment/assessment were refused - Initiation of a form related to the type of alteration if a new skin alteration is noted - Addressing the MD notification if new alteration is noted - And notification to responsible party. 28923 2. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included paraplegia, neurogenic bowel, colostomy status, neuromuscular dysfunction of the bladder, supra-pubic catheter status, peripheral vascular disease, chronic pain syndrome, muscle weakness, and a stage IV pressure ulcer (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) on her buttocks. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was known to display verbal behaviors directed at others during the seven day assessment period, but was not known to reject care. She had a functional limitation in her range of motion of her bilateral lower extremities. She was dependent on staff for bed mobility and transfers and used a motorized wheelchair for mobility. She was identified as being at risk for pressure ulcers and had two unhealed pressure ulcers that were stage IV pressure ulcers that were present upon admission. Pressure reduction for her bed and chair, turning and repositioning, pressure ulcer care, application of medications/ ointments/ and dressings were all indicated to have been used for skin/ ulcer treatment. Review of Resident #1's active care plans revealed she had a care plan in place for having pressure ulcers on her her buttocks. The care plan was initiated on 02/24/23. The goal was for the resident's pressure ulcers to heal without complications. The interventions included the use of a pressure reducing mattress and to provide treatment per the physician's orders. Further review of Resident #1's active care plans revealed she also had a care plan in place for being at risk for skin breakdown related to paraplegia, existing pressure ulcers, bowel incontinence, and decreased mobility. That care plan was initiated on 02/24/23. The goal was for the resident's skin to remain intact. Interventions included avoiding shearing of the skin during positioning/ turning/ transferring, encourage and assist the resident with turning and repositioning for comfort and as needed, float heels as needed, and pressure reducing mattress to bed. Review of Resident #1's physician's orders revealed she had a treatment in place to cleanse her wounds daily with normal saline, pat dry, lightly pack the wound with 1/4 inch Iodoform packing gauze, cover with a Mepilex border dressing or an equivalent, and they could continue to use an ABD pad and tape to cover. The physician's orders also included the use of an low air loss alternating mattress with directions to check the function every shift, encourage the resident to float heels when in bed, and a trapeze bar to her bed to assist the resident with bed mobility. On 01/14/25 at 10:30 A.M., an observation of Resident #1 noted her to be lying in bed in a supine position. The low air loss (LAL) alternating mattress on her bed was under-inflated as the resident was sunk down into the mattress. The settings on the pump that was attached to the foot of her bed revealed it was set on the softest setting with only the first green light of eight illuminated. The more lights illuminated the firmer the mattress was. There were setting guidelines on a label stuck to the top of the pump that indicated what the bed setting should be set on based on the resident's weight. The resident reported she was around 150 pounds (163 pounds was her actual weight recorded in her EMR when last weighed in January 2025), which both weights indicated the softness/ firmness setting of her mattress should have been set between two and four. The resident was asked at the time of the observation who adjusted the settings on her LAL mattress. The resident reported the maintenance employee had changed the settings on her bed when she last complained that the bed was not comfortable. The maintenance employee stated he wanted to try that softer setting before he proceeded with having to replace her mattress. She was not observed to have a trapeze bar in place over her bed as ordered to assist her with bed mobility. The resident was asked if staff were providing her encouragement or assistance with turning and repositioning. She denied that they were regularly coming in to encourage or assist her with turning and repositioning, as per her orders and plan of care. She reported there had been times she had been asleep in her bed and she would wake up four or five hours later in the same position. On 01/14/25 at 2:20 P.M., an interview with Certified Nursing Assistant (CNA) #199 revealed Resident #1 was known to have two wounds to her buttocks area that had dressings on them. She reported the wounds had been there since her admission and the nurses took care of the wounds. They tried to keep the resident on her side. She liked to be on her side, unless she was eating or up in her wheelchair. She claimed the resident would let them know when she wanted to be turned. It was typically maybe twice a shift (eight hour shifts) that the resident would ask to be turned and repositioned. She denied that they offloaded the resident's heels when she was in bed. The resident had the use of an air mattress and she had heard the resident complain there were areas on her bed that were hard on her back. She denied that the aides messed with the settings on the resident's mattress. If the bed beeped, they called the bed company to come in and fix it. She denied the resident had a trapeze over her bed to assist with bed mobility. On 01/14/25 at 2:30 P.M., an interview with RN #162 revealed Resident #1 had pressure ulcers on her bilateral buttocks that had tunneling. She was aware they were pressure ulcers but was not sure what stages they were classified as. The resident was being followed by the local hospital's wound clinic and the facility's visiting nurse practitioner. She confirmed the pressure ulcers were present upon the resident's admission. Tunneling had decreased according to the report the resident gave them following her last wound clinic appointment. She verified the resident had the use of a LAL mattress. She claimed the resident was able to turn and reposition herself, but the aides would assist as needed. She denied the resident had the use of a trapeze to assist with bed mobility that she was aware of. On 01/14/25 at 3:10 P.M., observations made during a treatment observation of Resident #1's pressure ulcers revealed her LAL mattress remained on the softest setting and not according to her known weight. She also did not have a trapeze bar over her bed as ordered and per her plan of care. After the completion of her wound treatments, Resident #1 informed RN #162 that the surveyor had concerns with her LAL mattress not being properly inflated based on her known weight and what the settings called for based on that weight. LPN #165, who was in the room assisting RN #162 with the treatment, verified the resident's LAL mattress was set on the first setting (softest) and should have been set between two and four based on the resident's weight. She was observed to raise the setting to three and informed the resident that they would try that setting since it was in the middle of what was called for based on her weight. They would then adjust it between two and four as needed until the desired comfort was achieved. On 01/14/25 at 3:30 P.M., a follow up interview with RN #162, after she left Resident #1's room following the completion of her dressing changes. She acknowledged skin prevention interventions were not being followed for the resident as per her plan of care as a trapeze bar was not in place over the resident's bed to assist her with bed mobility and her heels were not being offloaded as ordered. She further acknowledged the LAL mattress should have been inflated to the proper setting based on the resident's known weight. She further acknowledged inconsistencies in the information provided by the nursing staff and the resident on how often the resident was to be encouraged and assisted with turning and repositioning. The aides reported they turned and repositioned the resident twice a shift and not every two hours as per her plan of care and the nurse had indicated the resident was able to turn and reposition herself when the resident denied being able to do so.

Based on observation, record review and interview, the facility failed to develop and implement comprehensive, individualized and effective interventions to prevent a fall and wandering behavior resulting in Resident #71 exiting the facility. Actual harm occurred on 07/31/24 when the facility failed to prevent Resident #71 from exiting the building to the patio after the resident reported he was aware he could exit after pushing on the door for 15 seconds to get out. Following this incident on this date, the facility failed to implement additional/new interventions for Resident #71's safety and five hours later, Resident #71 exited the building again, and sustained a fall. The resident complained of pain and was transported to the emergency department where he was diagnosed with a fracture of the shaft of the left femur. In addition, a concern not rising to the level of actual harm, was identified when the facility failed to ensure medications were stored properly on the memory care unit. This affected one resident (#71) of three residents reviewed for falls and had the potential to affect 18 residents (#5, #17, #21, #24, #27, #34, #37, #39, #58, #59, #62, #66 #71, #72, #76, #79, #83, and #85) of 85 resident's residing in the facility. Findings include: 1. Record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, memory deficit following cerebral infarction, and history of a transient ischemic attack. Review of the Minimum Data Set (MDS) assessment completed 06/27/24 revealed Resident #71 had moderately impaired cognition and wandered daily. Review of a nursing note dated 07/31/24 at 3:31 A.M. revealed Resident #71 was awake all night, asking repetitive questions of where the bathroom was and where to go. He had verbal agitation with redirection. Review of a nursing note dated 07/31/24 at 10:04 A.M. revealed Resident #71 got out of the facility into the courtyard area and stated he knew if he pushed on the door long enough it would open. Staff accompanied Resident #71 until he wanted to go back into the facility. No additional interventions were implemented to keep Resident #71 from exiting the building following this incident. Review of a nursing note dated 07/31/24 at 3:10 P.M. revealed Resident #71 went out the locked door, started to run, slipped on the sidewalk and hit his head on the white plastic fence and then hit the ground with his left hip. Resident #71 had a laceration to the left side of his head; he was complaining of hip pain in his right leg area. An emergency squad was called, and the resident left the facility at 3:56 P.M. (to go to the hospital). Review of a nursing note dated 07/31/24 at 5:24 P.M. recorded as a late entry for 3:25 P.M. revealed staff stated Resident #71 was pushing on the exit door and when staff tried to redirect him, he raised his fists to her so she stepped back, and the resident forced the door open falling forward to the pavement. Outward rotation of the left lower extremity was noted and Resident #71 complained of pain and was sent to the emergency department. Review of the fall investigation revealed no evidence of statements from staff were obtained as part of the investigation. Review of a care plan initiated on 08/14/24 revealed Resident #71 wanders without purpose. Interventions included assessing cognition quarterly; encourage resident to participate in brief periods of structured activity; encourage resident's family to visit on a schedule that meets the needs of the resident as appropriate; maintain routine in the resident's day including meal time, activity, family visits, etcetera; monitor cognitive function for significant fluctuations and refer to physician as needed; observed wandering patterns and escort away from other residents or other resident rooms as needed; and provide meaningful leisure activity as appropriate. Review of a care plan initiated on 08/14/24 revealed Resident #71 was at risk for falls related to dementia, impaired gait, and medication side effects. Interventions included to assure the floor is free of liquids and foreign objects; encourage and assist resident to assume a standing position slowly; keep call light in reach; keep personal items and frequently used items in reach; provide non-skid footwear; therapy evaluation and treatment as needed; and increase frequency of visual reminders. Interview on 01/15/25 with CNA #202 revealed she was not present when Resident #71 broke his hip. Interview on 01/15/25 at 2:30 P.M. with the Director of Nursing (DON) revealed Resident #71 had been exit seeking prior to his fall with fracture, but she was not aware of any additional interventions to stop him from continued exit seeking. The DON also confirmed two separate nursing notes had different descriptions of the event. Interview on 01/21/25 at 8:04 A.M. with the DON revealed a hand-written statement was completed the same day with a staff member who worked the day of Resident #71's fall. The DON stated a statement had been written at the time of the incident, but it could not be located. The DON stated the facility does utilize a 15-minute check form, but there was no evidence it was completed for the resident at the time of this incident. The DON stated she just found out today it was standard for the unit to use heightened checks but they do not enter orders for it. The DON stated the second note entered was the correct version of the incident. The DON stated in her mind, heightened checks means the resident is in line of sight, but not one-on-one. Review of a statement received at the time of the survey on 01/21/25 by Certified Nursing Assistant (CNA) #202 revealed Resident #71 was having increased behaviors and exit seeking. Heightened checks and frequent re-direction were initiated. 2. Observation on 01/13/25 at 8:55 A.M. on the memory care unit in the living room revealed two residents seated in the living room area with no staff supervision. A closet was unlocked and revealed multiple medications, a credit card, and a dull knife. The medications included: - a full bottle of probenecid - a full bottle of sodium bicarbonate, opened and unlabeled - a bottle of vitamin D - an open bottle of aspirin 325 milligrams (mg), unlabeled - two boxes of fluticasone propionate and salmeterol powder 250 micrograms (mcg)/50 mcg - a bottle of multi-vitamins opened on 12/12/24 - unopened box of anti-diarrheal 24 2 mg capsules - a pill organizer for Sunday-Saturday morning and evening medications; morning pills were in container for Wednesday through Saturday and Sunday through Saturday for evening medications. The organizer was not labeled with the medication information or who they belonged to. - ondansetron four 4 mg tablets - one 21 mg nicotine patch - half a bottle vitamin B6 50 mg opened on 03/17/24 - a bottle opened on 12/31/22 with an expiration date of 04/2024 of geri-kot 8.6 mg - megesterol - cyclosprorine 0.05% eye drops - albuterol sulfate one inhaler with the label ripped off - finestreride 5 mg tablets - escitalopram 20 mg tablets - memantine 10 mg 136 tablets - two bottles of calcium 250 mg - carboxymethylcellulose gel - mucus-ER 40 tablets unopened - sodium chloride half bottle - unopened, unlabeled box of Tagamet 200 mg 30 tablets - estradiol 0.1 mg vaginal cream - nyastatin 100,000 units/gram powder - tacrolimus ointment 0.1% - clobetasol 0.05% cream - silver sulfadiazine 1% cream - megestrol acetate 40 mg half a bottle Interview on 01/13/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #165 confirmed the medication findings and the door being unlocked. LPN #165 stated she noticed over the weekend the door would be locked but wasn't latching. LPN #165 confirmed the door handle was not locked at the time of the observation. A list provided by the Director of Nursing (DON) on 01/13/25 at approximately 10:45 A.M. revealed the memory care unit residents were all confused and 18 residents (#5, #17, #21, #24, #27, #34, #37, #39, #58, #59, #62, #66 #71, #72, #76, #79, #83, and #85) residing on the memory care unit wandered throughout the memory care unit independently.

Based on employee record review and staff interview, the facility failed to ensure Certified Nursing Assistants (CNA) performance reviews were completed as required at least every 12 months. This had the potential to affect all 85 residents residing in the facility. The facility census was 85. Findings Include: 1. Review of the employee file for CNA #106 revealed a hire date of 06/10/22. Further review of the employee file revealed no annual performance review for 2024. On 01/22/25 at 5:45 P.M., interview with Human Resource (HR) #187 and the Director of Nursing (DON) verified the employee performance review was not completed as required. 47985 2. Review of the employee file for CNA #182 revealed no evidence of annual training for the memory care unit and 12 hours of annual in-services. Interview on 01/22/25 at 5:42 P.M. with the DON confirmed she was not able to provide evidence of CNA #182's annual training for the memory care unit or 12 hours of annual in-services.

Based on observation and interview the facility failed to ensure the oven was in safe operational condition and failed to ensure the facility had adequate supply of plates and cups. This had the potential to affect all 85 residents residing in the facility. Findings included: 1. Observation of 400 hall lunch dining on 01/13/25 12:03 P.M., revealed disposable plates were used for the grilled cheese and desserts. Interview on 01/13/25 at 12:03 A.M. with Certified Nurse's Aide (CNA) #183 confirmed some lunch items were served on disposable plates. The CNA was unsure why the kitchen was using them unless the dishwasher was down. Interview on 01/14/25 at 10:27 A.M., with [NAME] #144 and the Dietary Manger (DM) #128 confirmed the facility had to use disposable plates yesterday for lunch due to the kitchen was short about 80 small plates. The DM reported he had put several requests in for more small plates but was denied. 2. Observation of lunch tray line on 01/14/25 at 11:15 A.M., revealed the mashed potatoes temperature measured 109 degrees Fahrenheit (F) when removed from the oven. [NAME] #144 placed the mashed potatoes back in the oven. At 11:22 A.M. [NAME] #144 removed the mashed potatoes to check the temperature and the potatoes remained at 109 degrees Fahrenheit. The [NAME] reported the oven was newer however there has been issues with the pilot light not staying lit. The [NAME] reported she must frequently remove the front panel and relight the pilot light with a lighter. The [NAME] reported you never know when the pilot light is going to go out. There was no warning. Last week she was cooking bacon, and the bacon was not getting done and she kept adding time and after 10 minutes she realized the pilot light had went out. The facility has not called anyone to come and look at the oven. Interview on 01/14/25 at 11:22 A.M., with the DM #128 confirmed he was aware of the issues with the pilot light; however, the facility had switched contract company, and he didn't have a number to contact the new contractor. 3. Observation on 01/14/25 at 12:11 P.M., of 500 lunch dining revealed the staff ran out plastic cups for drinks. Certified Nursing Assistants (CNA) #160 and #169 confirmed they had to stop serving lunch trays while another staff member went to find cups. The CNA's reported they frequently run out of plastic cups and coffee cups during dining. Interview on 01/14/25 at 12:46 P.M. with [NAME] #144 and Dietary Assistants #121 and #181 confirmed the kitchen was short on coffee cups and plastic drinking cups. The Dietary Aides reported they can usually get coffee cups back out quickly; however, the plastic cups have been an issue, and they have been replacing them with disposable cups. Interview on 01/14/25 at 12:40 P.M., with DM #128 revealed he had just ordered plates and had the maintenance director reach out to the contracting company to service the oven. He would have to order cups and he would do that now.

Based on employee record review and staff interview, the facility failed to ensure Certified Nursing Assistants (CNA) were provided 12 hours of continuing education per year. This had the potential to affect all 85 residents residing in the facility. Findings Include: 1. Review of the employee file for CNA #106 revealed a hire date of 06/10/22. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. 2. Review of the employee file for CNA #119 revealed a hire date of 08/28/19. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. 3. Review of the employee file for CNA #208 revealed a hire date of 02/08/21. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. On 01/22/25 at 5:45 P.M., interview with Human Resource (HR) #187 and the Director of Nursing (DON) verified the employees had not completed the 12 hours of continuing education per year.

Based on medical record review, review of facility contracts, interviews, and policy review the facility failed to ensure medications were available for administration as ordered. This affected four residents (#1, #31, #85, and #191) of seven residents reviewed for medication review. Findings included: 1. Medical record review revealed Resident #31 was admitted to the facility on [DATE] at 5:05 P.M., with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia, depression, gastro-esophageal reflux, insomnia, chronic kidney disease, deformity of the head, atrial fibrillation, chronic pain, and iron deficiency anemia. Review of Resident #31's current orders dated 01/2025 revealed meropenem two grams intravenous every eight hours (6:00 A.M., 2:00 P.M., and 10:00 P.M.) and vancomycin 750 mg intravenous every 12 hours (goal trough range 15-20 mcg/ml) at 8:00 A.M. and 8:00 P.M. Review of Resident #31's Medication Administration Record (MAR) dated 12/16/24 to 01/15/25 revealed the resident didn't receive meropenem (antibiotic) on 12/18/24 10:00 P.M., 12/19/24 at 6:00 A.M.,12/29/24 at 2:00 P.M. due to the medication was not available. Further review revealed the resident was not administered Vancomycin on 12/18/24 8:00 P.M., 12/19/24 at 8:00 A.M., 12/23/24 at 8:00 A.M., 12/29/24 at 8:00 P.M., 12/30/24 at 8:00 A.M. and 8:00 P.M. and 12/31/24 at 8:00 A.M., due to the medication was not available. The physician was not notified until 12/31/24 the medication was not available. Interview on 01/21/24 at 12:56 P.M. and 1:38 P.M., with Licensed Practical Nurse (LPN) #177 confirmed Resident #31 did not receive meropenem on 12/18/24 10:00 P.M., 12/19/24 at 6:00 A.M.,12/29/24 at 2:00 P.M. and vancomycin on 12/18/24 8:00 P.M., 12/19/24 at 8:00 A.M., 12/23/24 at 8:00 A.M., 12/29/24 at 8:00 P.M., 12/30/24 at 8:00 A.M. and 8:00 P.M. and 12/31/24 at 8:00 A.M., due to the medications were not available to administer. LPN #177 confirmed the facility has had issues getting medication timely from the pharmacy. The pharmacy was four hours away from the facility and was not local. 2. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, gout, insomnia, generalized anxiety, hypertension, hyperlipemia, and wandering. Review of Resident #85's MAR and orders dated 12/16/24 to 01/15/25 revealed on 01/07/25 the resident was not administered Vitamin C (supplement) two tablets once daily and Calcium 500 (supplement) milligrams (mg) due to the medications were not available. The resident did not receive carvedilol (beta-blocker) 25 mg A.M. and P.M. dose on 01/01/25, the P.M. dose on 01/02/25 and 01/03/25, 01/06/25, 01/07/25, 01/08/25, and 01/10/25 due to the medication was not available. On 01/01/25 the resident was not administered the 0.25 mg and the 0.5 mg dose of clonazepam (antianxiety) due to not being available. On 01/02/25 the resident did not receive four doses of polymyxin (antibiotic) due to the medication was not available. On 01/20/25 the pravastatin (cholesterol medication) was not administered due to it was not available. Interview on 01/22/25 at 2:37 P.M., with LPN #177 confirmed Resident #85 did not receive the above medications because they were not available from the pharmacy to administer. 3. Medical record review revealed Resident #191 was admitted to the facility on [DATE] at 7:00 P.M. with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. Review of Resident #191's MAR and orders dated 01/06/25 to 01/15/25 revealed the resident did not receive amiodarone (antiarrhythmic), budesonide (steroid), prempro (estrogen), Xarelto (anticoagulant), Flonase nasal spray, Lipitor (cholesterol), and Zoloft (depression) on 01/07/25 or 01/08/25, due to the medications were not available. The resident did not receive Prevacid (proton pump inhibitor) on 01/07/25, 01/08/25, 01/11/25, 01/13/25, 01/14/25, due to the medication was not available. The midodrine (alpha 1 agonists) was not administered three doses on 01/07/25, and two doses on 01/08/25 due to the medication was not available. Interview on 01/16/25 at 9:20 A.M., with Resident #191 confirmed she did not receive most of her medication for two or three days after she was admitted . Interview on 01/16/25 at 11:06 A.M., with LPN #177 confirmed Resident #191 was admitted on [DATE] and did not receive the above medication due to they were not available from the pharmacy. The LPN reported it has been an issue with pharmacy not delivering medication timely. The facility has an emergency stock of medication, however most of Resident #191's medications were not available in the emergency stock nor did staff remove the two (Lipitor and Xarelto) that were available to administer. Review of the pharmacy agreement (dated 10/01/22) revealed the pharmacy shall deliver medications and provide services to the facility seven days a week, three-hundred sixty-five days a year, with modified schedules for national holidays based on a daily delivery schedule mutually determined by the facility and pharmacy. Emergency delivery of medications shall be done by the Pharmacy during normal business hours, except for circumstances beyond reasonable control, and emergency services shall be available after hours through an answering service with a pharmacist on-call. The Pharmacy shall establish an emergency system for backup and/or interim order dispensing. Any emergency drug supply provided under Section shall be property of the Pharmacy as prescribed by applicable laws. During the course of the survey, the surveyor requested information regarding the pharmacy emergency system from the Administrator, however no information was received. 28923 4. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included paraplegia, neurogenic bowel, colostomy status, neuromuscular dysfunction of the bladder, supra-pubic catheter status, stage IV pressure ulcer on her buttock, chronic pain syndrome, chronic obstructive pulmonary disease (COPD), major depressive disorder, attention deficit/ hyperactive disorder, bipolar disorder, anxiety disorder, nicotine dependence, neuralgia, and neuritis. Review of Resident #1's physician's orders revealed she had an order in place to receive Dayvigo 5 milligrams (mg) by mouth every night at bedtime for insomnia. The order had been in place since 11/22/24. Review of Resident #1's medication administration records (MAR's) for December 2024 and January 2025 revealed the resident was not receiving Dayvigo 5 mg by mouth every night at bedtime as was ordered for insomnia. The MAR for December 2024 showed the Dayvigo was not administered on 12/07/24, 12/15/24, 12/16/24, or on 12/17/24 due to the medication being unavailable. The MAR's for January 2025 revealed the resident was not given Dayvigo on 01/01/25 and then again between 01/06/25 through 01/12/25. The reason specified on the MAR as to why the Dayvigo was not given as ordered was again due to the medication being unavailable. Review of pharmacy delivery manifests revealed the facility's contracted pharmacy was sending Dayvigo for Resident #1's use in the quantity of three tablets with each delivery. Three tablets of Dayvigo was indicated to have been delivered on 11/22/24, 11/27/24, 12/01/24, 12/11/24, 12/25/24, and again on 12/31/24. Five tablets of Dayvigo was delivered on 12/18/24. The doses provided as indicated on the delivery manifest did not allow the resident to receive the Dayvigo on a nightly basis as ordered for insomnia. On 01/16/25 at 10:20 A.M., an interview with LPN #125 revealed the facility was having issues with receiving medications from their contracted pharmacy when needed. She stated it was just not for Resident #1, but for other residents too. She indicated refills could be ordered ahead of time using the computer, but there were times they would be told it was too soon to order a refill. She acknowledged there were four days in December and nine days in January 2025 in which Resident #1's MAR's indicated the resident had not received her Dayvigo as ordered due to the medication not being available for administration. She was not sure if there was some insurance issue going on and the medication needed pre-authorization. She acknowledged Dayvigo was a scheduled medication the resident had ordered and had been receiving since 11/22/24. She agreed it should be made available to them by the pharmacy for administration to the resident since it was a scheduled medication. She reported she would contact the pharmacy to get clarification as to why there had been issues having the medication on hand to administer. On 01/16/25 at 12:25 P.M., a follow up interview with LPN #125 revealed she had spoken to the pharmacist regarding Resident #1's Dayvigo. She was told the resident's insurance was not covering the medication. She was not able to state if or when the pharmacist had been in contact with the facility to let them know what the issue was with delivering the Dayvigo so it was available for administration as ordered. She had reached out to the psychiatrist and they were going to restart the resident on Belsomra for her insomnia that had been used in the past.

Based on medical record review, observation, interview and policy review the facility failed to ensure medications were properly stored, medication carts were locked when unsupervised, and insulin medications were dated when opened. This had the potential to affect all 22 of 22 residents on 200 hall, all 14 of 14 residents on 300 hall, and all 22 of 22 residents on 400 hall. Findings included: 1. Observation of medication administration on 01/15/25 at 7:51 A.M., with Registered Nurse (RN) #110 revealed the RN left the medication cart unlocked with the keys in the lock and walked into Resident #67's room to administer medications. The medication cart was not in RN #110's view. Interview on 01/15/24 at 8:33 A.M., with RN #110 confirmed he left the 400-medication unlocked and left the keys in the lock and the medication cart was not in his view. 2. Observation on 01/16/25 at 10:16 A.M. of the 400 hall medication cart revealed the medication cart was left unlocked and unattended. No staff were observed on the 400 hall. The surveyor waited a few minutes and then walked down to 300 hall to get the nurse (RN #110). Interview on 01/16/25 at 10:19 A.M. RN #110 confirmed he was responsible for 300 and 400 medication carts today and he had left the 400-medication cart unlocked and unattended. 3. Observation on 01/22/25 at 1:45 P.M., the 400 hall cart was left unlocked and unattended. Interview on 01/22/25 at 1:48 P.M. RN #162 confirmed she left the medication cart unlocked and unattended. Review of the facility's policy titled Medication Administration-General Guidelines (dated 11/2018) revealed medication are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. During administration of medications, the medication cart was kept closed and locked when out of sight of the facility medication administration personnel. 28923 4. On 01/22/25 at 9:35 A.M., an observation of the 300 hall medication administration cart revealed there were two insulin flexpens found in the top drawer of the medication cart that were not dated when first used. There was a Lantus (slow acting insulin) flexpen that belonged to Resident #9 that was stored in a plastic bag. The plastic bag had a label that identified what the medication was and who it belonged to. There was not a date written on the plastic bag or the flexpen itself that showed when the Lantus flexpen was first used. A second insulin flexpen was also found in the top drawer of the medication administration cart for Resident #54. The flexpen was Insulin Lispro 100 units/ ml Kwikpen and had a label that indicated it was pulled out of the facility's Omnicell medication dispensing system. The resident's name was written on the bag, but there was no date that indicated when the flexpen was first used. Due to the insulin flexpens not being dated when first put in use, it could not be known when the insulin flexpens should be disposed of. Findings were verified by RN #162. On 01/22/25 at 9:37 A.M., an interview with RN #162 confirmed the two insulin flexpens found in the top drawer of the 300 hall medication administration cart did not include a date to show when it was first used. She acknowledged a date should have been added on the plastic bag the insulin flexpens were being stored in or on the flexpens themselves so the nurses would know what their expiration dates were. She knew the flexpens were only good for a certain number of days, after they had been removed from the refrigerator and put in use. On 01/22/25 at 9:40 A.M., an interview with the Director of Nursing (DON) revealed she and the unit manager had just went through the medication administration carts last evening to check and ensure all items were properly labeled and dated. She acknowledged two flexpens were found in the 300 hall medication administration cart that had not been dated when first used. She confirmed insulin flexpens should be dated when first used, so they knew when to discard them. Review of the facility's Insulin Reference Guide (updated February 2024) revealed Lantus (Insulin Glargine) should be refrigerated until it's expiration date or could be stored at room temperature for up to 28 days. In-use storage indicated it should be stored at room temperature for up to 28 days. They were not to refrigerate it, after being put in use. Insulin Lispro was also only to be stored at room temperature for up to 28 days.

Based on observation, record review, interviews and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection in the area of tracheostomy care, dressing change, medication administration and enhanced barrier precautions (EBP). This affected ten residents (Residents #1, #9, #22, #30, #31, #54, #61, #74, #191, #240) of 85 residents who require enhanced barrier precautions and four residents (#1, #10, #67, and #191) of 20 residents reviewed for infection control practices. Additionally, the facility failed to ensure the infection control log was accurate and tracked bacteria from nosocomial infections and infection control polices were reviewed annually. This had the potential to affect all 85 residents residing in the facility. Findings Included: 1. Observation on 01/13/25 during the initial tour of the facility revealed no evidence of the facility implementing EBP for those residents observed having tracheostomy, enteral tubes, indwelling urinary catheter and dialysis port. Review of the facility provided list revealed Resident #1, #9, #22, #30, #31, #54, #61, #74, #191, #240 required EBP and was not implemented. On 01/15/25 at 11:30 A.M., interview with the Director of Nursing (DON) confirmed the lack of EBP being implemented for those residents with wounds and/or an indwelling medical device. Review of the facility policy titled, Enhanced Barrier Precautions, (dated 04/01/24) revealed it was the policy of the facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multi-drug-resistant organisms (MDRO). EBP refer to an infection control intervention designed yo reduced transmission of MDRO that employs targeted gown and gloves use during high contact resident care activities. A physician's order will be obtained for EBP for residents with any of the following , wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcer) and indwelling medical device (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes), even if the resident is not known to be infection or colonized with a MDRO. Implementation of EBP include make gowns and gloves available immediately near or outside of the resident's room. The Infection Preventionist will incorporate monitoring and assessment of adherence to determine the need for additional training and education. High contact resident care activities included, dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. EBP should be used for for the duration of the affected resident's stay in the facility or until the resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 2. Review of the August, September, October, November and December 2024 infection control log revealed the facility was not tracking all bacteria, including nosocomial bacteria. On 01/22/25 at 12:50 P.M. interview with the Director of Nursing (DON) verified the lack of infection control monitoring, infection control log not being correct. 3. Review of the facility policy titled, Infection Control and Prevention Policy and Guidelines, (last revised 08/19) revealed no documented evidence the policy is reviewed annually. On 01/22/25 at 3:21 P.M., interview with the DON verified the infection control policy is not reviewed yearly and policies are being sent to her by the facility's consultant. 32801 4. Observation of medication administration pass on 01/15/25 from 7:35 A.M. to 7:51 A.M., with Registered Nurse (RN) 110 removed a Potassium (supplement) 20 milliequivalent (meq) tablet from a blister packet into his ungloved hand and then broke it in half and placed the two halves into a medication cup. Next, RN #110 moved another blister packet from the mediation cart of Bumetanide (diuretic) 2 milligrams (mg) and popped one pill into his ungloved and un-sanitized hand and placed it in the medication cup with Potassium. The RN took the medication cup to room [ROOM NUMBER] (Resident #10) and gave the medication to the resident to take. The resident consumed the medication the nurse had touched with his bare and un-sanitized hands. RN #110 returned to the medication cart and performed hand hygiene with hand sanitizer and then took his keys out of his pocket to open the medication cart to administer the next residents' medications. RN #110 removed 10 pills from blister packets/pill bottles using the same technic by popping the pills into his bare un-sanitized/ungloved hands or pouring into his hands and then placed the pills into a medication cup. The RN took the pills to room [ROOM NUMBER] and administered the medication to Resident #67. Resident #67 had consumed the medications. Interview on 01/15/25 at 8:33 A.M., with RN #110 verified he pops medication from the blister packages/bottles into his bare hands first and then place the pills into the medication cups instead of popping/pouring them directly into the medication cup preventing contamination. The RN also confirmed he broke the Potassium pill with his bare hands and then placed it into the medication cup instead of using gloves. Review of the facility's policy titled Medication Administration-General Guidelines (dated 11/2018) revealed medication are administered as prescribed in accordance with good nursing principles and practices and only by legally authorized person to do so. The person administering medication adheres to good hand hygiene. If breaking a tablet performs appropriate hand hygiene prior to handling tablets and examination gloves must be worn to prevent touching the tablet during the process. 5. Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. A. Observation on 01/13/25 at 10:24 A.M., and 01/15/25 at 10:16 A.M. of Resident #191's room, revealed no evidence the resident was in enhanced barrier precautions (EBP). Review of Resident #191's current orders dated 01/2025 revealed no evidence of orders for EBP. Interview on 01/15/25 at 10:30 A.M., with Licensed Practical Nurse (LPN) 177 and Registered Nurse (RN) #212 reported they have never heard of enhanced barrier precautions (EBP) and were not aware residents that had a foley catheter, chronic wound, or indwelling mech device required to follow EBP. The LPN and RN confirmed the resident was not on any type of precautions and had a tracheostomy and gastrostomy tube. B. Observation of Resident #191's tracheostomy care on 01/15/25 at 10:16 AM with RN #212 performing the procedure and LPN #177 assisting revealed neither staff had applied a gown or mask. RN #212 had set up a sterile field to perform tracheostomy care. During the procedure the RN cleaned the cannula with a brush and then placed the contained brush back in the middle of the sterile field. The pipe cleaners, four by fours, and split drain sponge were still on the sterile field. After the RN cleaned the cannula, she placed the clean cannula into the stoma and did not change her gloves and wash her hands. The RN wore the same gloves throughout the entire procedure. Interview on 01/15/25 at 10:30 A.M., with LPN #177 and RN #212 confirmed they did not wear a gown or mask during tracheostomy care. RN #212 confirmed she had placed the contaminated brush on the sterile field instead of throwing the brush in the trash that was next to her, and she didn't wash her hands after cleaning the cannula and replacing the cannula back into the stoma per the facility's policy to prevent the spread of infections. Review of the facility's policy titled Enhanced Barrier Precaution (dated 04/01/24) revealed the facility responsibility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. EBP refers to an infection control intervention designed to reduce transmission of multi-drug-resistant organism that employs targeted gown, and gloves used during high contact resident care activities. All staff received training on EBP upon hire and at least annually and are expected to comply with all designated precautions. An order for EBP would be obtained for residents with an of the following: wound, and/or indwelling, medical devices (tracheostomy) even if the resident was not known to be infected or colonized with a MDRO. EBP include make gowns and gloves available immediately near or outside of the resident's room. Faced protection may also be needed if performing activity with risk of splash or spray example tracheostomy care. High-contact resident care activity dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, devices care use, tracheostomy and wound care. Review of the facility policy titled Tracheostomy Care (dated 04/2021) revealed when providing cannula care a sterile field must be maintained. Soak the cannula in hydrogen peroxide/saline solution mixture, clean with a brush, rinse with saline and dry with pipe cleaners. Remove and discard gloves into appropriate receptacles. Wash hands and put on fresh gloves and replace the cannula carefully and lock in place. 28923 6. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included paraplegia, neurogenic bowel, colostomy status, neuromuscular dysfunction of the bladder, supra-pubic catheter status, peripheral vascular disease, chronic pain syndrome, muscle weakness, and a stage IV pressure ulcer (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) on her buttocks. Review of Resident #1's physician's orders revealed the resident had an order in place to cleanse her wounds with normal saline, pat dry, lightly pack her wounds with 1/4 inch Iodoform packing gauze, cover with Mepilex border dressing or equivalent, may use ABD pad and tape to cover. The order had been in place since 11/08/24. Review of Resident #1's active care plans revealed she had a care plan in place for having pressure ulcers on her buttocks. The care plan originated on 02/24/23. The goal was for the resident's pressure ulcers to heal without complications. Interventions included providing treatment as per the physician's orders. On 01/14/25 at 3:10 P.M., a treatment observation was made of the treatment to Resident #1's pressure ulcers. The treatment was provided by RN #162 and she was assisted by LPN #165. The resident was not noted to be in enhanced barrier precautions despite being known to have chronic wounds and medically invasive devices, which included a colostomy and a supra-pubic catheter. The nurses did not don a gown while preparing to do her treatments. Treatments were observed for the resident's stage IV pressure ulcers to her left buttocks and her right hip. LPN #162 performed the treatments to both the resident's pressure ulcers at the same time and did not treat each wound separately to prevent any potential cross-contamination between the two wounds. She was observed to don disposable gloves, after washing her hands, and removed the old dressings covering the pressure ulcer to the right hip followed by the left buttocks. The old dressing over the right hip ulcer had a moderate amount of serosanguineous drainage on it. The old dressing covering the left buttock ulcer had a small amount of serosanguineous drainage. Both dressings were disposed of in a plastic bag sitting at the foot of the bed. The nurse removed her disposable gloves and donned new disposable gloves without performing any hand hygiene between glove changes. She cleansed the right hip wound first using a 4x4 gauze that she moistened with wound cleanser. She wiped around the wound and then the center of the wound, without using separate areas of the moistened gauze. She was not noted to pat the wound to the right hip with a dry 4x4 gauze, after it was cleansed. She then proceeded to clean the wound on the left buttock in the same fashion she did the right hip wound. She did not change gloves or perform any hand hygiene between cleansing the two wounds. After cleansing the left buttock wound, she removed her disposable gloves and donned new gloves, again without performing hand hygiene. She did not bring in a pair of scissors with her to use during the treatment. The resident informed the nurse that she had a pair of surgical scissors she got when out to the wound clinic and gave them to the nurse to use. The resident's scissors were stored in a fanny pack pouch. The nurse was not observed to disinfect the scissors before she was noted to use them to cut off the amount of Iodoform packing gauze she needed to pack the right hip wound. A cotton tip applicator was then used to pack the wound on the right hip. The right hip had a circular red area around the opening of the ulcer that was larger than the size of a golf ball. The nurse then obtained another piece of the Iodoform packing gauze from it's bottle cutting a piece off using the same scissors she had that had not been properly disinfected. She did not dispose of her gloves, perform hand hygiene, and don new gloves before she proceeded to pack the resident's left buttock pressure ulcer. The left buttock wound was packed using less Iodoform packing gauze than what was used to pack the right hip pressure ulcer. She laid an ABD pad on the resident's right hip area above the wound opening with the surface of the ABD pad that was going to be placed over the right hip wound in direct contact with the resident's skin. While the ABD pad was resting on the resident's skin above the right hip area, she applied tape along the four edges of the ABD pad. After securing the tape, she then placed the same side of the ABD pad that had been in contact with the resident's skin over the right hip wound before securing it in place by pressing down on the taped edges. She was then observed to use the scissors that had not been properly disinfected to cut a second ABD pad in half. The half of the ABD pad she intended to use was laid on top of a paper towel that she had previously placed on the bedside table to use as a barrier. She did not lay the ABD pad on the inside of the dressing package that it came in. The surface side that was going to be applied over the resident's left buttock pressure ulcer was laid directly on the paper towel. She then placed tape around the border of the ABD pad that had been cut in half. She placed the side of the ABD pad that had been in direct contact with the paper towel directly over the resident's wound on her left buttock. She then secured the dressing by pressing over the taped edges of the ABD pad. She dated the dressings and gathered her supplies putting all used supplies in her plastic bag. The nurse left the resident's room taking her used treatment supplies that were put in a plastic bag to the nurses's station without performing any hand hygiene. On 01/14/25 at 3:30 P.M., an interview with RN #162 confirmed she completed the treatments to Resident #1's two pressure ulcers at the same time instead of doing each treatment separately. She acknowledged by doing them at the same time she increased the risk of cross-contamination if one of the two wounds would have been infected. She further acknowledged that she did not perform proper glove changes and hand hygiene at appropriate times during the course of the treatments, as she should have. She was informed changing disposable gloves did not negate the need to perform hand hygiene between glove changes. She confirmed she did not bring in a pair of scissors to use during the dressing changes and used a pair that the resident had in her fanny pack. She denied she disinfected the scissors before she used them to cut the Iodoform packing gauze or the ABD pad, which could have contaminated the dressing supplies that she placed in and over the resident's wounds. She also confirmed she had placed the sides of the ABD pads that she used to cover the resident's open wounds on surfaces that were not clean, while placing the tape around the ABD pads' edges. She agreed it would have been easier to cut the tape to the lengths she needed prior to getting the ABD pads out of their packaging so she could have placed the ABD pads directly over the wounds with clean surfaces and then tape the edges of the ABD pads to the resident's skin. She acknowledged the practice she followed did not follow proper infection control practices, as it was possible the resident had bacterial organisms on her skin and she was more likely to introduce bacterial organisms into the wounds causing infections by doing what she did. She then confirmed she had removed her gloves and gathered the trash bag containing the used supplies and left the resident's room without performing any hand hygiene. Review of the facility's policy on Dry/ Clean Dressings (revised September 2013) revealed the purpose of the procedure was to provide guidelines for the application of dry, clean dressings. Steps in the procedure included the need to remove gloves after removing the old dressing and discard both the gloves and the dressing into a plastic or biohazard bag. The nurse was then directed to wash and dry their hands thoroughly. The nurse was then directed to remove her disposable gloves and discard into a designated container and to wash and dry hands thoroughly upon leaving the resident's room.

Based on medical record review, review of the concern log, review of personnel files, interviews, and policy reviews the facility failed to ensure residents were treated with respect and dignity by nursing staff. This affected one resident (#9) of six residents interviewed on 300 halls. Findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, respiratory disease, diabetes, difficulty walking, and was currently under hospice care. Interview on 01/13/25 at 9:15 A.M., and 01/21/25 at 1:58 A.M., with Resident #9 revealed Registered Nurse (RN) #126 was rude and rough with care such as pulling on her arms when administering insulin. Resident #9 reported several residents had voiced complaints about RN #126 and she had observed RN #126 make another staff member cry. The RN works on 3rd shift. Interview on 01/13/25 at 11:10 A.M., with Resident #78 revealed there's a nurse on nightshift, but she could not recall her name, that doesn't treat her with respect and dignity. The nurse just doesn't like her and yells at her if she tries to ambulate on her own. The nurse was always in a hurry. Interview on 01/16/25 at 11:14 A.M., with Licensed Practical Nurse (LPN)/Unit Manger #177 revealed she had heard other staff members having issues with RN #126, however she had not heard anything related to residents. The LPN reported she had just started as the Unit Manager last Friday. Interview on 01/16/25 at 11:26 A.M., with LPN/Unit Manger #165 revealed RN #126 had a dry personality but was a good nurse. She had also just started as the Unit Manger last Friday and been off for a few months. LPN #165 reported she was unaware of any concerns regarding RN#126 and residents. Interview on 01/16/25 at 11:49 A.M., with the Director of Nursing (DON) revealed there had been concerns with RN#126, however she thought she had provided education to the RN and placed the education in her personnel files. The DON reported she had just recently received a complaint from a resident that RN #126 rushes when providing care. The DON reviewed the concerns forms with the surveyor and could not recall which concerns were related to RN #126 and she would have to look into them a little deeper. Interview on 01/16/25 at 3:07 P.M., with the Administrator revealed the DON had found some education for RN #126 on her computer and handed the surveyor a one-page typed letter from the DON that was signed at the bottom and undated. The letter indicated on 08/23/24 and 09/11/24 RN #126 was provided verbal education accordingly. On 11/20/24 the DON had met with RN #126 and explained there had been concerns with her in the past and explained if there were any further complaints that they would result in a suspension. The Administrator reported there had been no further concerns since 11/20/24. Interview on 01/22/25 at 2:14 P.M., with Hospice RN #340 revealed she had reported on at least three occasions Resident #9's concerns regarding RN #126 to the Social Service Director (SSD) #190. The SSD #190 told her she wrote up concern forms and reported the incidents to the Administrator. The RN could not recall the dates she had reported the residents concerns to the SSD. Interview on 01/22/25 at 3:54 P.M. with SSD #190 confirmed there had been other resident besides Resident #9 that had voiced concerns regarding RN #126. SSD #190 verified that the Hospice RN #340 had reported concerns related to RN #126, however she cannot recall the dates or information, and she could not locate the concerns forms she had started regarding the concerns. The SSD reported she starts the concern form and then gives the form to the department responsible and she must have not received the form back. The SSD verified she does not document on the form in the space that indicates the resolution was communicated to the person filing the concern. Review of resident concern forms dated 08/20/24 to 01/07/25 revealed: On 07/23/24 Resident #9 had reported RN #126 the nurse was yelling and hollering. The resolution was to speak to the nurse regarding volume when speaking. There was no evidence the resident was notified of the resolution, or the nurse was educated. On 08/22/24 Resident #14 (not interviewable) was upset that the nurse (RN #126) told her to get rid of her snacks and was rude. The resident was crying. The resolution was the nurse would be addressed. There was no evidence the nurse was addressed, or the resident was notified of the resolution. On 09/10/24 a former resident reported staff (RN #126) was rude when asking for medications. The resolution was staff would be re-educated on attitude. There was no evidence the resolution was discussed with the resident or staff was re-educated. On 11/19/24 a family member had voiced concerns that she had called into the building for an update on her husband (no longer a current resident at the facility during the annual survey) and RN #126 was extremely rude. The form indicated the nurse was educated on customer service. The resolution was blank. There was no evidence the family member was notified of the outcome of the concern, or the nurse was educated. Further review of the concern log/forms dated 07/15/24 to 01/07/25 revealed no evidence there were any concerns reported, or forms completed for Resident #9 regarding RN #126. Review of RN #126's personnel file revealed the RN was hired on 09/26/23 and there was no evidence the RN had any verbal education/disciplinary actions. The surveyor had requested the file include any disciplinary actions. Review of the facility policy titled Grievances/Complaints (dated 04/2017) revealed the administrator and staff would make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. The resident or person filing the grievance and/or complaint on behalf of the resident, would be informed (verbally and in writing) of the findings of the investigation and the actions that would be taken to correct any identified problems. Review of the facility's policy titled Dignity (dated 08/2009) revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents should be treated with dignity and respect at all times. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, record review, interview and facility policy review, the facility failed to ensure timely and necessary care and services were provided to meet the total care needs of all residents. Actual Harm occurred on 09/24/23 at 10:00 P.M. when the facility failed to timely treat and seek medical intervention for Resident #44 following a fall with left hip fracture. On 09/24/23 at 10:30 P.M. Resident #44 was assessed to have an elevated blood pressure of 216/68, followed by multiple other elevated blood pressures. On 09/25/23 at 2:28 A.M. the resident exhibited groin pain and on 09/25/23 at 1:04 P.M. the resident exhibited pain not controlled by Tylenol. The facility did not notify the physician of the pain until 09/25/23 at 6:12 P.M. when an order was given for left hip and femur x-rays and Percocet (a narcotic analgesic) was ordered for pain. The x-rays were not obtained until 09/26/23 and the facility was subsequently informed Resident #44 had a hip fracture on 09/26/23 at 2:00 P.M. The resident arrived at the emergency department on 09/26/23 at 5:03 P.M., 43 hours after the fall occurred, where she rated her pain a 10 on a scale of zero to 10 and presented with signs of deformity in her left hip. Resident #44 had surgical repair of her hip on 09/27/23. Actual harm occurred on 06/12/23 when the facility failed to timely treat and seek medical intervention for Resident #29 following a fall with subsequent nondisplaced fracture of the 5th metacarpal. At the time of the fall, Resident #29 complained of wrist pain, did not receive any pain medications, and no new orders were given for evaluation. On 06/13/23, Resident #29 exhibited worsening injury to her wrist when it began to swell and bruise. The physician and Resident #29's family were not made aware and no further assessment was completed. On 06/14/23 Resident #29 continued to have bruising to her wrist along with edema, and new onset of bruising to her face. Resident #29 was then sent to the hospital for evaluation and treatment where she was diagnosed with nondisplaced fracture of 5th metacarpal. This affected three residents (#29, #44, and #188) of seven residents reviewed for quality of care and treatment. The facility census was 85. Findings included: 1. Review of Resident #44's medical record revealed she was admitted on [DATE] with diagnoses including generalized muscle weakness, unsteadiness on feet, difficulty in walking, chronic obstructive pulmonary disease (COPD), type two diabetes, and hypertensive heart disease. Review of Resident #44's significant change Minimum Data Set (MDS) 3.0 assessment, dated 10/17/23, revealed she was mildly cognitively impaired. Further review revealed she was dependent for sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet. Additionally, the MDS revealed she had not had any falls since the prior assessment. Review of Resident #44's most recent documented vital signs prior to her fall, dated 09/19/23 at 1:48 P.M., revealed her blood pressure was 138/80, her pulse was 78, and her respirations were 20. Review of Resident #44's progress note, dated 09/24/23 at 10:00 P.M. revealed the State tested Nursing Assistant (STNA) approached the nurse and reported Resident #44 was on the floor. Resident #44 was lying on the floor with her head under the foot of the bed and her legs extended towards the center of the room. There was juice spilled on the floor and her. Resident #44 denied pain other than from hitting her head on the bed. She reported the head pain was when she actively hit it and the pain had gone away. There were no injuries noted from the fall. Resident #44 reported she was trying to switch from lying at the foot of the bed to the head of the bed. Resident #44 reported, I was not walking. I just slipped. Vital signs were within normal limits per her baseline except for an elevated blood pressure. Resident #44's blood pressure was 170/70, her pulse was 68, and her respirations were 16. Neurological assessments were initiated at 10:00 P.M. and normal. The situation with the vital signs were reported to the nurse practitioner and to hospice. Both entities directed to continue to monitor the resident's blood pressure due to the elevated blood pressure could be situational and from being irritated. Review of Resident #44's documented vital signs, dated 09/24/23 at 10:30 P.M., revealed her blood pressure was 216/68 (hypertensive), her pulse was 64, and her respirations were 17. Review of Resident #44's documented vital signs, dated 09/24/23 at 10:45 P.M., revealed her blood pressure was 191/77 (hypertensive), her pulse was 68, and her respirations were 18. Review of Resident #44's fall event documentation, dated 09/24/23 at 11:14 P.M., revealed she had fallen in her room and had pain to the back of her head which she rated a one on a scale of zero to ten. Resident #44's pupils were 3 mm round and brisk to light, her speech was clear, and she was alert and oriented to person and place. There was no change noted in mental status. There was no injury noted, she had range of motion to all four extremities without pain or limitations, there was no rotation/deformity/shortening noted to her lower extremities. Her upper and lower left and right extremities were strong. Review of Resident #44's documented vital signs, dated 09/24/23 at 11:45 P.M., revealed her blood pressure was 145/93 (hypertensive), her pulse was 63, and her respirations were 18. Review of Resident #44's documented vital signs, dated 09/25/23 at 12:15 A.M., revealed her blood pressure was 163/66 (hypertensive), her pulse was 71, and her respirations were 16. Review of Resident #44's progress note, dated 09/25/23 at 12:32 A.M., revealed she voiced complaints of shoulder pain to the STNA. Resident #44 had told the STNA not to tell the nurse. Resident #44 was found lying on her left side when she fell . Resident #44 stated she had always had issues with the shoulder, but falling had just made it sore. Range of motion (ROM) of the shoulder was normal at the time of the fall. Resident #44 now showed pain when moving the shoulder but was still able to more it. Review of Resident #44's documented vital signs, dated 09/25/23 at 12:45 A.M., revealed her blood pressure was 178/68 (hypertensive), her pulse was 71, and her respirations were 16. Review of Resident #44's documented vital signs, dated 09/25/23 at 1:45 A.M., revealed her blood pressure was 178/68 (hypertensive), her pulse was 64, and her respirations were 16. Review of Resident #44's progress note, dated 09/25/23 at 2:28 A.M., revealed she continued to voice complaints about her shoulder and was now voicing complaints about groin pain. Resident #44 would grab her inner thigh when speaking of the pain. The note indicated there were no signs of hip fracture at the time as leg lengths were even. Resident #44 denied pain in the hip area when the nurse touched it. As needed Tylenol was given per physician order. Review of Resident #44's Medication Administration Record (MAR), dated 09/23, revealed on 09/25/23 at 2:28 A.M. she received Tylenol 650 milligram (mg) (no pain level document) and it was effective for her pain. Review of Resident #44's documented vital signs, dated 09/25/23 at 2:45 A.M., revealed her blood pressure was 160/63 (hypertensive), her pulse was 73, and her respirations were 16. Review of Resident #44's documented vital signs, dated 09/25/23 at 3:45 A.M., revealed her blood pressure was 154/65 (hypertensive), her pulse was 65, and her respirations were 16. Review of Resident #44's interdisciplinary department note, dated 09/25/23 at 9:15 A.M., revealed she had slipped off the edge of the bed while attempting to switch to the other end of the bed. No injury was noted. New interventions of bed in the lowest position so feed can reach the floor due to the resident being short in stature. The facility would monitor the new intervention for effectiveness and notify medical doctor if not effective. Review of Resident #44's MAR, dated 09/2023, revealed on 09/25/23 at 1:04 P.M. she received Tylenol 650 mg (no pain level documented) and it was not effective for pain. Review of Resident #44's Certified Nurse Practitioner (CNP) progress note, dated 09/25/23 at 6:08 P.M., revealed the nurses called and stated Resident #44 had rolled out of bed and hit her head. Resident #44's blood pressure was initially 170/70, then 128/70, then 216/68, then 191/77 and then 145/70. Hospice was aware of the fall. Resident #44's neurological assessments were within normal limits. Resident #44 was denying any pain, and her assessments were within normal limits. There was no pain in hips or rotation upon the nursing assessment. Review of Resident #44's CNP progress note, dated 09/25/23 at 6:12 P.M. revealed the nurses called and stated Resident #44 was now complaining of left hip/leg pain after rolling out of bed. There was no external rotation noted but the pain was new for her. The medical provider's plan of care included: left hip and femur x-ray, Percocet 5/325 mg by mouth every six hours as needed for pain, and if fracture is indicated on the x-rays, please send her to the emergency department as soon as possible. Review of Resident #44's MAR, dated 09/23, revealed no Percocet was administered for pain. Review of Resident #44's progress note, dated 09/25/23 at 9:30 P.M., revealed the portable x-ray provider telephoned and stated they would come on 09/26/23 to complete the x-ray and would call the facility when they were 20 to 30 minutes away. Review of Resident #44's progress note, dated 09/26/23 at 12:22 A.M., revealed she continued to voice complaints of pain in her left hip/leg and x-ray was ordered for this date. Review of Resident #44's physician order, dated 09/25/23, revealed an order for a left upper hip and left femur x-ray. Review of Resident #44's radiology results, dated 09/26/23 at 10:41 CDT, revealed an acute fracture of the femoral neck. Review of Resident #44's progress note, dated 09/26/23 at 2:00 P.M., revealed x-ray results received from portable x-ray provider and the medical director in the facility and aware of the results. Orders were received to send Resident #44 to the emergency department for treatment. The next of kin was contacted along with the hospice provider. Emergency Medical Services (EMS) was notified of need for transport. Review of Resident #44's emergency department report, dated 09/26/23 at 5:03 P.M., revealed she presented to the emergency department from a nursing home with a femur fracture due to a fall two days ago. Her blood pressure was 173/81, her pulse was 79, and her respirations were 28. Resident #44 rated her pain a 10 on a scale of zero to 10 and described it as intermittent, sharp, and nonradiating (stayed in one location). She reported she did not have pain when she was not moving the leg but had significant pain with movement. Resident #44's left leg was shortened and rotated (signs of a hip fracture) and deformity was noted. She was not able to perform range of motion. Review of Resident #44's hospital discharge summary, dated 10/01/23, revealed she had a left hip hemiarthroplasty (surgical procedure that involves replacing half of the hip joint) surgery on 09/27/23 to correct her left femoral neck fracture. Telephone interview on 12/11/23 at 10:20 A.M. with CNP #225 revealed she was not informed Resident #44 developed pain in her shoulder on 09/25/23 at 12:32 A.M., developed groin pain on 09/25/23 at 2:28 A.M., or had the many elevated blood pressures. CNP #225 revealed she would have sent Resident #44 out to the emergency department (ED) for assessment and care if Resident #44's hospice company had approved. CNP #225 also revealed when she provided the telephone order for the left hip and femur x-ray it was to be completed stat. CNP #225 revealed she was not informed the portable x-ray was not available until 09/26/23 or she would have sent Resident #44 out the evening of 09/25/23 to the ED for assessment and care if Resident #44's hospice company had approved. Telephone interview on 12/11/23 at 1:35 P.M. with Hospice Nurse #223 revealed based on hospice documentation, they received a phone call on 09/24/23 at 10:45 P.M. that Resident #44 had fallen, but there were no injuries. She reported the next documentation was on 09/26/23 when the facility received x-ray results of a fractured hip and Resident #44 was sent to the local emergency department for care. Hospice Nurse #223 verified there was no documentation to support hospice was notified between the 09/24/23 10:45 P.M. note and the 09/26/23 fracture confirmed by radiology note. Hospice Nurse #223 verified there was no documentation of shoulder pain, groin pain, or elevated blood pressures. Hospice Nurse #223 verified hospice would not have stopped transport to local emergency department for care and services. Interview on 12/11/23 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #44 did have a delay in care and services on 09/24/23 at 10:00 P.M. when she fell out of bed and presented with a blood pressure at 10:30 P.M. of 216/68 and continued to have elevated blood pressures, then continued to develop new symptoms of injury and pain not controlled by the medication ordered. She verified there was an additional delay in care and services when the portable radiology company could not complete the x-rays until 09/26/23. The DON verbalized there was a need for training with their staff regarding residents not experiencing a delay in care and services. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. 47985 2. Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of a nursing note from 06/12/23 at 7:05 P.M. by Nurse #235 revealed a hospice aide had notified her Resident #29 was on the floor in the common area. Resident #29 complained of right wrist pain but had no visible injuries, all assessments were within normal limits, vital signs and neuro checks were within normal limits. Review of the medication administration record (MAR) from 06/12/23 revealed Resident #29 did not receive any medication related to her complaint of pain. Review of a nursing note from 06/13/23 at 2:01 P.M. by Registered Nurse (RN) #197 revealed Resident #29 was noted to have bruising to right wrist with slight swelling, but range of motion was intact and there were no complaints of pain. RN #197 did not notify the physician or resident representative of the change in condition. Review of a nursing note from 06/14/23 at 3:59 P.M. by Nurse #235 revealed Resident #29 was noted to have a deformity to her nose with light bruising under her eyes, right wrist noted with edema, redness, and bruising status post fall on 06/12/23. Nurse #235 notified the physician and received a new order to send Resident #29 to the emergency department for evaluation; family was also made aware. Review of nursing note from 06/14/23 at 8:43 P.M. by Licensed Practical Nurse (LPN) #194 revealed Resident #29 would be returning from the emergency department with a diagnosis of right fifth digit metacarpal nondisplaced fracture and was refusing to keep her splint on. Interview on 12/06/23 at 8:52 A.M. with DON revealed an x-ray was not completed at the time Resident #29 fell and complained of pain and the physician was not notified of worsening bruising and swelling until 06/14/23 which demonstrated a delay in care and treatment for the resident. The DON verified the resident had sustained a fracture as a result of the fall. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. 32801 3. Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. Review of Resident #188's hospital note dated 10/31/23 revealed the resident had bilateral lower extremity swelling. Review of Resident #188's current orders and medication administration records dated 11/06/23 to 12/06/23 revealed the resident was receiving Lasix (diuretic) 20 mg once daily between 7:00 A.M. to 11:00 A.M. and Spironolactone (diuretic) 20 mg once daily between 7:00 A.M. to 11:00 A.M. The resident an as needed order for Oxycodone 5 mg one every six hours for pain and which she had received 12 doses. There was no evidence non-pharmacological intervention were attempted or pain was assessed prior to administration of the Oxycodone. Review of Resident #188 base line plan of care dated 11/06/23 revealed the resident had a venous/stasis ulcer. Interventions include notifying physician of any adverse finding with skin integrity and to inspect the skin when repositioning, toileting, assisting with ADL's and notifying the nurse of any adverse findings. The resident had no pain. The resident was receiving analgesics/opioids and diuretics and to administer medication as order and notify the physician if any side effects. There was no evidence the resident had edema. Review of Resident #188's skin integrity plan of care related to decreased mobility and ascites dated 11/27/23 revealed weekly skin assessment, pressure reduction cushion to chair, and moisture barrier protectant to perineal area as needed. Review of Residents #188's care plan for high-risk medication dated 11/27/23 revealed the resident received diuretic medication related to hypertension. The intervention included to observe for cardiovascular system and fluid status to determine the effectiveness of diuretic therapy (e.g., edema, jugular vein distention, mental confusion, shortness of breath, abnormal breath sounds, abnormal heart sounds). Review of Resident #188's care plan for pain dated 11/27/23 revealed the resident had pain related to cirrhosis of the liver and decreased bed mobility. The intervention included administering medication as ordered and notifying the physician if any side effects observed or lack of effectiveness and notifying the physician of increased pain. Observe for and record for verbal and non-verbal signs of pain. Attempt non-pharmacological interventions. Observation on 12/04/23 at 3:06 P.M., of Resident #188 revealed the resident was sitting in a recliner with her feet on the floor and no compression stockings were noted. The resident had severe swelling in her bilateral lower extremities (BLE) and verbalized complaints of pain. The resident reported her current pain management program was not effective due to staff does not administer pain medication timely upon request or not at all upon request. The resident reported her pain was so bad at night it was affecting her sleep. Review of Resident #188's skilled charting notes dated 12/03/23 12/04/23, and 12/05/23 revealed the resident had no lower extremity edema. Further review of Resident #188's medical record dated 11/06/23 to 12/05/23 revealed there was only one documentation regarding lower extremity edema on 12/01/23 that indicated the resident had bilateral lower extremity edema. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the Director of Nursing (DON) revealed the resident was sitting in the recliner and her legs were not elevated nor did she have compression stocking in-place. The resident's socks were so tight around the top of her legs that it left indentation around her legs when they were pushed down by staff. The ADON continued to remove the resident's socks and the resident had severe pitting edema in bilateral lower legs. The left leg had blister like areas forming on the lower leg. The ADON had assessed the edema by pushing down on the tops of the residents' feet and the front of the legs. The area did not return to normal, and the indentation stayed where the nurse had pushed down. The ADON reported she would classify the edema as four plus pitting edema. The resident reported again to the staff the pain was so bad at night in her legs and feet that she couldn't sleep. She confirmed she had requested pain medication and sometimes she doesn't get it all or she must wait a long time to get it. The resident reported she has a high tolerance for pain but the pain at night was rated a 10 out of 10. The DON reported she would have the physician assess the resident today. Interview on 12/06/23 10:00 A.M., with the DON confirmed staff had been charting no edema except the one progress note on 12/01/23 that indicated the resident continued to have edema and there was no documented evidence the physician was notified of the edema or pain. The DON confirmed there was no documented evidence the pain was assessed prior to administration of the Oxycodone or non-pharmacological attempted prior. The DON reported the nursing staff were new to the facility and were new graduates with not much nursing experience. The facility did not have a policy regarding edema, however staff should utilize the change of condition policy. Review of Resident #188's progress note dated 12/06/28 at 5:28 P.M. revealed the resident continued with increased edema to BLE. The left lower extremity (LLE) was noted with redness and increased warmth. The in-house physician visited and wrote new orders for an antibiotic, Keflex 250 milligrams (mg) twice daily for seven days, laboratory testing including a complete blood count (CBC) and comprehensive metabolic profile (CMP) in one week and to schedule Oxycodone 5 mg every night as the resident stated the pain was at night and requested pain medication to be given every night. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. Review of the facility policy titled Skin Care dated 08/2019 revealed to notify the wound nurse, physician, dietician, and resident representative upon observation of a skin change in condition or new skin area. Review of the facility policy titled Wound Care dated 12/2020 revealed wounds would be evaluated when they are observed and weekly until resolved. Wounds would be monitored for location, size (length, width, depth), undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue or epithelialization. Only pressure ulcers would be staged.

Based on observation, record review and interview the facility failed to provide comprehensive and individualized interventions to Resident #188 to prevent the deterioration of a pressure ulcer. The facility also failed to ensure pressure ulcer assessments were comprehensive and completed weekly. Actual Harm occurred on 12/06/23 when Resident #188, who was admitted with a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer to the buttocks was identified to have deterioration to the ulcer which was now assessed to be unstageable (obscured full-thickness skin and tissue loss) related to the lack of comprehensive and individuated interventions being in place and lack of ongoing monitoring and timely identification of the wound deterioration. This affected one resident (#188) of one resident reviewed for pressure ulcers. Findings include: Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. There was no evidence the resident had diagnoses of pressure ulcers on the diagnoses list. Review of Resident #188' Braden score dated 11/06/23 revealed the resident was at risk for the development of pressure ulcers. Review of Resident #188's admission skin event note for pressure dated 11/06/23 revealed the resident had area on the right buttocks that measured 0.5 centimeters (cm) in length by 0.5 cm width. The assessment did not included a documented depth or stage of the pressure ulcer. Review of Resident #188 base line plan of care dated 11/06/23 revealed the resident had a venous/stasis ulcer. The baseline care plan did not reflect pressure ulcers or pressure ulcer risk. Interventions include notifying physician of any adverse finding with skin integrity and to inspect the skin when repositioning, toileting, assisting with activities of daily living (ADL) care and notifying the nurse of any adverse findings. Review of Resident #188's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer present on admission. Review of Resident #188's plan of care revealed no evidence the facility developed a comprehensive and individualized plan of care related to pressure ulcers. Review of Resident #188's wound management note revealed on 11/10/23 the resident had a pressure ulcer on right buttocks, however no staging of the pressure ulcer was completed. The first wound management note (on 11/10/23 at 2:16 P.M.) reflected the wound measured 1.4 cm in length by 1.9 cm width with 0.1 cm depth and no exudate, granulation tissue present and an order to apply zinc topically. The next wound management note was dated 11/17/23 which reflected the wound measured 0.9 cm by 1.4 cm by 0.1 cm with granulation tissue and was improving. The last wound management note dated 11/21/23 reflected the wound measured 0.9 cm by 0.9 cm by 0.1 cm and had granulation tissue and no exudate. There were no more measurements in the electronic medical record (EMR) after 11/21/23. Review of Resident #188's wound consult notes dated 11/10/23 to 12/01/23 revealed the resident had a Stage II pressure ulcer on her buttocks since admission to the facility. The area measured 1.4 cm by 1.9 cm by 0.1 cm. The wound base was shallow and composed of 100% clean tissue, no drainage, and peri wound area appeared normal. The note indicated to apply Desitin or equivalent to area every shift and as needed. On 11/17/23 the area measured 0.9 cm by 1.4 cm by 0.1 cm assessment of wound bed; continue with Desitin. On 11/21/23 the area was 0.9 cm by 0.9 cm by 0.1 cm; continue treatment and assessment no change. On 12/01/23 the area measured 0.7 cm by 0.9 cm by 0.1 cm; same assessment and treatment. Review of Resident #188's skin integrity related to decreased mobility and ascites plan of care, dated 11/27/23 revealed weekly skin assessment, pressure reduction cushion to chair, and moisture barrier protectant to perineal area as needed. Observation on 12/04/23 at 3:06 P.M. and 12/05/23 at 8:05 A.M., revealed no evidence the resident had a pressure relieving cushion under her while she was noted sitting in her recliner. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the Director of Nursing (DON) revealed Resident #188 was sitting in a recliner with her feet on the floor. The staff members stood the resident up and there was no pressure relieving cushion under the resident. The resident had an open area on her buttocks the size of a pea. The area had yellow stingy tissue in the wound bed and the depth appeared to measure 0.3 cm. ADON #150 reported she was the facility wound nurse; however, had not taken any formal classes and she was not aware the wound had declined nor was there any documentation indicating the wound had declined. Interview on 12/06/23 at 8:37 A.M., 10:20 A.M., and 10:44 A.M., with ADON #150 and the DON revealed they had gone back and measured the resident's pressure ulcer. The area measured 0.7 cm by 0.9 cm by 0.3 cm, which was a decline from 12/01/23. The DON confirmed the resident did not have a comprehensive plan of care for the pressure ulcer nor did the resident have a pressure relieving cushion on the chair during the observation at 7:36 A.M. The ADON reported she updated the wound consultant on the measurements, and she indicated to continue to use the zinc and foam dressing. The ADON confirmed she did not update the wound consultant on the changes of the wound bed (yellow slough). The DON reported she would have the medical director look at the wound today as well due to zinc probably not being an appropriate treatment due to the wound being now unstageable. The ADON and DON confirmed the pressure ulcers assessments were not comprehensive to include the staging of the wound. There was no evidence a weekly pressure ulcer assessment was completed by the facility or wound consultant from 11/21/23 to 12/01/23. The facility staff had not documented an assessment since 11/21/23 in the medical record. The ADON reported she had just received the wound consultation notes from the consultant; however, she had not had time to enter the facility notes yet. The ADON reported she usually rounded with the wound consultant and they observed the wounds together. She doesn't enter her notes at that time and would wait until she received the wound consultants' notes. The DON reported the wound measured 0.7 cm by 0.9 cm by 0.3 cm with edges epibole thick and rounded. The wound bed was 85% pale pink granulation and 15% white/yellow slough, however the computer system only allowed staff to enter one option for the wound bed so for example she would have to enter the slough or granulation she couldn't enter both. Review of Resident #188's physician wound consult note dated 12/06/23 revealed the resident was a seen by a digital visit. The wound note indicated the resident's pressure area measured 0.7 cm by 0.9 cm by an undetermined depth (UTD). The wound base was composed of 50% granulation and the wound was unstageable. The wound would likely benefit from debridement when the physician group visited in a couple days. The plan was to protect with Alginate (dressing) until that time. The wound had a moderate amount of serous drainage and a decline in the wound status was noted. The note included, due to the resident's unavailability the electronic data was evaluated and then discussed with the nurse caring for the resident. The resident was in mild transient pain during the wound assessment, which was resolved post assessment. The treatment/dressing was chosen to help promote autolytic debridement of the wound. Interview on 12/06/23 at 2:10 P.M., with the DON reported she had sent an encrypted photo to the wound consult doctor whom oversees the nurse practitioner who comes to the facility and he reviewed the photo and he felt the wound bed was 50% granulation and 50% slough and staged the pressure ulcer as unstageable. Review of the facility undated Pressure Injury Staging Guide revealed a Stage II pressure ulcer was partial-thickness skin loss with exposed dermis. Unstageable pressure ulcers were defined as obscured full-thickness skin and tissue loss. The facility reported they didn't have a policy and procedure related to pressure ulcers.

Based on record review and interview, the facility failed to develop and implement an effective and comprehensive plan to address the dementia/behavioral health care needs of Resident #47 to prevent a resident to resident altercation resulting in harm to Resident #29. Actual harm occurred on 11/23/23 when Resident #47 physically pushed Resident #29 after Resident #29 tried to take a paper away from Resident #47. As a result of the altercation, Resident #29 fell to the ground, hitting her head on a wheelchair, leaving a laceration which required three staples. This affected two residents (#47 and #29) of six residents reviewed for abuse. The facility census was 85. Findings included: Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of nursing note from 11/23/23 at 2:30 P.M. by Registered Nurse (RN) #137 revealed Resident #29 had tried to take a paper away from Resident #47, when Resident #47 shoved Resident #29 backwards. Resident #29 hit her head and back on a wheelchair and had a one inch laceration at the bottom of the back of her head. Staff had to hold pressure to the laceration until the ambulance arrived. Family was notified of the incident. Review of nursing note from 11/24/23 at 6:26 A.M. by Licensed Practical Nurse (LPN) #133 revealed Resident #29 was returning to the facility from the emergency department with three staples in the back of her head. Review of nursing notes for Resident #47 revealed there was not a note made to document the incident. Review of a Behavior Event assessment completed on 11/23/23 at 6:59 P.M. by RN #137 revealed immediate actions by the facility included redirecting Resident #47 and relocating to a quiet location. Review of Resident #47's care plan revealed no interventions in place regarding Resident #47's aggressive behaviors toward other residents. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #47 does have some behaviors that are very territorial regarding his belongings. Interview on 12/07/23 ar 4:30 P.M. with Resident Care Associate (RCA) #163 revealed Resident #47 can be aggressive when he is writing and coloring on his papers. RCA #163 stated he has seen Resident #47 push someone and reminded him he cannot push other residents which usually calmed him down. RCA #163 stated the intervention in place to protect other residents from Resident #47 when he was agitated was to keep an eye on him. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #47 does have some behaviors that are very territorial regarding his belongings. Interview on 12/11/23 at 5:01 P.M. with Director of Nursing (DON) revealed the intervention in place to prevent Resident #47 from having aggressive behaviors towards other residents was redirection due to a lack of the resident's cognition. Interview on 12/12/23 at 11:05 A.M. with the Director of Nursing (DON) revealed the location of 15-minute checks for Resident #47 following incident on 11/23/23 could not be located. Interview on 12/12/23 at 1:56 P.M. with State tested Nursing Assistant (STNA) #132 revealed Resident #47 does get agitated at times, specifically when he was writing with his pen and paper and if he thought someone was stealing it, he would let them know. STNA #132 stated she was not aware of any interventions in place to prevent Resident #47 from becoming aggressive with other residents. Interview on 12/12/23 at 2:16 P.M. with STNA #148 revealed Resident #47 had behaviors regarding his pen and papers, and if he was told to move them from the table during meals, he would use the bathroom in the dining room chair. STNA #148 stated interventions in place to prevent Resident #47 from becoming aggressive with other residents included taking Resident #47 to his room to calm down.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of a self-reporting incident (SRI), review of the facility's investigation, observation, staff interview, and policy review, the facility failed to provide adequate supervision to prevent Resident #7, whose cognition was severely impaired, was known to be at high risk for elopement and had verbalized a desire/ intent to leave the facility, from eloping from the facility. This resulted in Immediate Jeopardy on 08/28/21 at 9:15 P.M. when Resident #7 exited the building through the facility's main entrance without the staff's knowledge. Although the resident was wearing a wandering alert system bracelet, the resident was able to exit the building without the lock on the front door being engaged or an audible alarm sounding alerting the staff the resident had left. The likelihood of actual harm, serious injury or death occurred when Resident #7 was able to leave the building and was found by staff approximately 100 feet from the building across a main state route between the facility's upper and lower parking lots on a sloped grassy area. This affected three of three (Residents #7, #41, and #52) residents reviewed for elopement. The facility's census was 69. On 09/16/21 at 2:01 P.M., the Administrator, Regional Director of Clinical Operations #50, Director of Nursing (DON), and Registered Nurse (RN) #67 were notified Immediate Jeopardy began on 08/28/21 at 9:15 P.M. when Resident #7, who displayed exit seeking behaviors, was able to exit the facility through the main entrance without his wandering alert system bracelet engaging the locking mechanism on the front door when he approached it or sound the audible alarm when he exited through it. Resident #7 was found outside of the building approximately 100 feet from the main entrance across a state road and between the facility's upper and lower parking lots. Resident #7 was initially admitted to the facility's secured/ locked unit on 08/19/21 where he remained until 08/24/21, when his family requested that he be taken off that unit. Resident #7 began to verbalize the desire to leave the facility beginning on 08/25/21 and was known to increase his exit seeking behavior on 08/28/21 at 6:00 P.M. when he inquired as to how to go about leaving the facility, asked staff for the code to exit the building, requested his wandering alert system bracelet be removed, and was observed to attempt to remove the bracelet himself. The resident was not re-evaluated for the need to be placed back onto the secured/ locked unit or provided with additional supervision to prevent him from eloping from the facility as the DON was not notified of his new exit seeking behaviors. The facility also failed to timely check the proper functioning of the wandering alert system, after the elopement occurred, to ensure other residents at risk for eloping who also had the use of a wandering alert system bracelet would not be able to successfully elope from the facility without the staff's knowledge. The Immediate Jeopardy was removed, and the deficient practice corrected on 09/01/21 when the facility implemented the following corrective actions: · On 08/28/21 at 9:20 P.M.- State tested Nurse Aide (STNA) #6, Licensed Practical Nurse (LPN) #14, and LPN #35 immediately brought Resident #7 back into the facility. LPN #14 notified the physician, family and Director of Health Services (DHS) of Resident #7's elopement and placement on the secured unit. · On 08/28/21 at 9:30 P.M.- LPN #14 attempted a head-to-toe assessment but Resident #7 refused. No signs or symptoms of any discomfort was noted. · On 08/30/21 at 4:00 A.M.- Director of Social Services performed a psychosocial assessment on Resident #7. Results of that assessment revealed the resident recalled the incident and showed no signs of distress. · On 08/30/21 at 8:30 A.M.- Director of Plant Operations checked all doors for proper functioning of wander guard system as he did every Monday through Friday. All door alarms were found to be functioning properly. · On 08/30/21 at 8:30 A.M.- The Director of Health Services (DHS) provided education on elopement risk assessment, guideline for elopement and missing residents, and Front Entrance locked doors, including quick tips for situations with residents wanting to leave, alerting nurse in charge, attempt to redirect away from entrance, moving resident to Legacy, providing supervision to residents, and Calling the DHS/and or ED with their phone numbers. This education was provided to 10 LPNs, 11 STNAs, two (2) Activity Staff, four (4) Dietary Staff, seven (7) House-Keeping Staff, one (1) Administration, two (2) Resident Care Assistants. Twelve (12) PRN employees to be educated prior to return to work. Four (4) employees on FMLA to be educated prior to return to work. Two (2) employees on vacation to be educated prior to return to work. · On 08/30/21 at 10:00 A.M.- the Director of Plant Operations contacted the contracted fire and security company (that installed the system and provided ongoing maintenance checks when needed) to request they come to check the door/wander guard system for proper functioning. · On 08/30/21 at 9:30 A.M.- exit seeking residents (Resident #41 and #52) were reviewed in Clinical Care Meeting and to be continued daily. · On 08/30/21 at 10:14 A.M.- Director of Social Services performed psychosocial assessment on Resident #7. Resident #7 was able to recall the incident and showed no signs of distress. · On 08/31/21 at 7:00 A.M.- the ED and LPN #19 checked Resident #41 and #52's wander guards for functionality. Both functioned as they should. · On 08/31/21 at 9:30 A.M.- the Director of Plant Operations contacted the contracted fire and security company a second time to request they come to check door/ wander guard system. · On 8/31/21 at 10:00 A.M.- the ED, DHS, and Assistant Director Health Services (ADHS) reviewed all residents (Resident #41 and #52) with wander guards. · On 08/31/21 at 11:10 A.M.- Director of Social Services performed BIMS assessment on Resident #7 and identified the resident's cognition to be severely impaired. · On 08/31/21 at 12:00 P.M.- all Elopement Risk Binders were updated by the DHS. · On 08/31/21 from 12:00 P.M. through 3:00 P.M.- Elopement Risk Assessments were completed on all residents by the DHS and the ADHS. · On 08/31/21 at 4:06 P.M.- The ED completed education on Elopement Missing Resident Policy and Front Entrance locked doors to five (5) RNs, 12 LPNs, 14 STNAs, eight (8) Dietary Staff, two (2) Admissions Staff, two (2) Activity Staff, two (2) Business Office Staff, one (1) House Keeping Staff, one (1) Social Service Director, five (5) Therapy staff and two (2) RCAs. The remainder of staff were educated on this date except one (1) employee still on FMLA. This staff will be educated if and when the staff returns to work. · On 08/31/21 at 4:42 P.M.- all wander guards (2) were replaced as a precaution by the ED. · On 08/31/21 at 6:00 P.M.- front door reprogrammed by the Director of Plant Operations so doors automatically lock starting at 6:00 P.M. instead of 10:00 P.M. · On 09/01/21 at 4:00 A.M.- Director of Social Services performed psychosocial assessment on Resident #7. The resident was able to recall the incident and showed no signs of distress. · On 09/01/21 at 6:00 A.M.- The ED and/or designee began audits to complete checks of the wander guard system. This will be ongoing 3x a day, 5 days a week, for a total of one month. · On 09/01/21 at 1:15 P.M.- the contracted fire and security company arrived and checked doors/ wander guard system. · On 09/01/21 at 9:10 P.M.- an elopement drill was completed on second shift. Staff responded appropriately during the drill in accordance with the elopement policy. · On 09/01/21 (no time identified)- weekend managers to check doors for proper wander guard function on Saturday and Sundays during the six hours they were on site when Director of Plant Operations not there to complete checks. Weekend manager checklist was updated to reflect the need to check the wander guard system for proper functioning. · Beginning 09/01/21- Monthly elopement drills to continue on varied shifts by completing one drill each month on rotating shifts to ensure a drill was conducted on each of the three shifts at least every three months. · Interviews were completed with STNA #6 on 09/15/21 at 3:30 P.M., LPN #14 on 09/15/21 at 3:54 P.M., LPN #19 on 09/16/21 at 8:35 A.M. and LPN #92 on 09/20/21 at 2:58 P.M. to verify they received education on the facility's elopement policy. The staff were knowledgeable about the need to update the DHS or ED regarding a resident displaying new exit seeking behaviors and how to properly respond to elopements. Findings include: A review of Resident #7's medical record revealed he was admitted to the facility on [DATE] with diagnoses including paranoid [CONDITION(S)], schizo-affective disorder, obsessive compulsive disorder, and generalized anxiety disorder. He was placed on the facility's secured/ locked dementia unit. A review of Resident #7's admission observation and data collection assessment dated [DATE] revealed the resident was assessed to be alert and oriented to person, place, time and situation. He was full weight bearing and did not have any limitations in his activity level. An elopement assessment completed as part of the admission assessment identified the resident was at risk for elopement. Risk factors included him demonstrating confusion and he had the ability to exit the facility. A wandering device was not deemed to be necessary at that time since he was admitted to the secured/ locked unit. A review of Resident #7's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident did not have any communication issues and his cognition was severely impaired. He was known to have displayed delusions and hallucinations as potential indicators of [CONDITION(S)]. Wandering behaviors was indicated to have occurred daily during the seven-day assessment period. He required supervision and set up help for transfers, walking in his room, and locomotion on and off the unit. He required supervision with the assist of one for walking in the corridor. Balance issues were noted when going from a seated to standing position and walking but he was able to stabilize himself without staff assistance. He did not have a functional limitation in his range of motion in either of his upper or lower extremities bilaterally and a wheelchair was the only mobility device used. A review of Resident #7's care plans revealed he was known to demonstrate exit seeking behaviors. The care plan was initiated on 08/24/21. The goal was for the resident not to elope from the facility. The interventions were initiated on 08/30/21 and included assessing the need for a wander guard and to apply as appropriate, evaluate the need for a secured unit and transfer if needed, monitoring for wandering triggers to include inactivity and the time of day, offer diversional activities as needed, provide a structured routine to the resident's day, and re-direct the resident away from doors/ exits as needed. The care plan was updated to reflect the resident was transferred to the secured unit on 08/28/21. A review of Resident #7's physician's orders from 08/19/21 through 09/16/21 revealed an order for the resident to be on the secured/ locked unit between 08/19/21 and 08/24/21 and again on 08/28/21 that was an open-ended order. He also had an order for the use of a wander guard alarm with the need to check the placement every shift and the function daily between 08/24/21 and 08/30/21. He was placed on every 15-minute checks for 72 hours on 08/28/21 that was to continue through 08/31/21. A review of Resident #7's treatment administration record (TAR) for August 2021 revealed the nurses were initialing to reflect they were checking the placement of the resident's wandering system bracelet every shift and the function daily on the 11:00 P.M. to 7:00 A.M. shift. The function of the wandering alert bracelet was initialed as having been checked on 08/27/21 by LPN #44. A review of Resident #7's nurses' progress notes revealed a nurse's note from LPN #19 dated 08/24/21 at 10:50 A.M. that indicated the resident had been moved off the secured/ locked unit to a room on the 300 hall (front hallway where the facility's main entrance was located at the end of that hall) per the family's request. The resident expressed being fearful of his peers on the secured/ locked unit. A wander guard bracelet was indicated to have been applied at that time. A nurse's progress note from LPN #78 dated 08/25/21 at 1:41 A.M. revealed Resident #7 was up in his wheelchair in the hallway and was trying to leave. The resident was provided education on the safety reasons as to why he could not leave and he indicated he would leave later. An interdisciplinary (IDT) note dated 08/25/21 at 7:22 A.M. revealed Resident #7 had a wander guard applied for the resident's safety post move from the secured unit. The note indicated they would continue to address as needed. A nurse's progress note from LPN #78 dated 08/26/21 at 1:16 A.M. revealed the resident's wander guard was on his ankle. A nurse's progress note later that same day indicated the resident was delusional indicating he needed to go to [NAME], Ohio to get new blood ran through him so he would be healed. He was indicated to be self-propelling himself in his wheelchair. A nurse's progress note from LPN #14 dated 08/28/21 at 6:00 P.M. revealed Resident #7 was asking how to get out of there and what the code was to be able to get out. He sat in the main entrance and watched people as they left the facility. He made statements about wanting to leave the facility as he claimed he had a hot date to go to. He was noted to be pulling on his wander guard and was also asking staff to remove it. Staff attempted to redirect the resident, but he became agitated when redirection was attempted. There was no indication in the progress notes of the facility's DON, or the physician had been notified of the resident's exit seeking behaviors. A nurse's progress note from LPN #14 dated 08/28/21 at 9:20 P.M. indicated Resident #7 continued to have exit seeking behaviors. The note indicated he opened the front entrance doors and was escorted to the secured unit for his safety due to exit seeking behaviors. A review of an exit seeking event note dated 08/28/21 completed by Licensed Practical Nurse (LPN) #14 revealed Resident #7 was found or observed exit seeking at 9:20 P.M. by STNA #6. The exit seeking event form asked if the resident was seen exiting the building with directions to confirm prior to answering the question. LPN #14 indicated that question was not applicable as the resident was only exit seeking. The resident was indicated to have been found on the facility's property. Resident #7 was indicated to have a wandering alert device in place at the time of the attempt or exit. He was also indicated to have exhibited the following behaviors prior to exit seeking: packing belongings, resisting redirection from staff, verbalizing statements about leaving and wandering with no rational purpose and attempting to open doors. The resident was indicated to exhibit the following as a change in mental status of new onset: anxiety, confusion, and restlessness. Other factors identified included the resident having the ability to learn door codes and refusing to comply with safety measures such as the use of wander guard/ Secure Care alarms. Immediate actions taken after the exit seeking event included placement on the secured unit. A review of SRI # 1 revealed an allegation of neglect was reported to the Ohio Department of Health with a date of discovery of 08/29/21. The date, time and location of the occurrence was 08/28/21 at 9:15 P.M. at the facility's main entrance. A brief description of the allegation was that a resident went out the front entrance doors and was brought back in by facility staff. The involved resident was identified as Resident #7. A narrative summary of the incident indicated the DON, and the Administrator were notified of the incident. Resident #7 exited the front door momentarily and was brought back in by three facility employees. Resident #7 was assessed and not found to have any injuries. Out of an abundance of precaution, the facility indicated they immediately placed Resident #7 back onto the secured dementia unit. All residents with the use of a wander guard had them replaced. All doors were to be tested three times a day on all shifts Monday through Friday for one month to ensure continued functionality of the wander guard system. A review of the facility's investigation into the elopement occurring with Resident #7 on 08/28/21 revealed witness statements were obtained from the resident and staff involved in the incident. A statement from STNA #6 obtained on 08/28/21 revealed she was in a resident's room when she came out and noticed Resident #7 was not sitting in his wheelchair by the front door as he had previously been observed sitting in. STNA #6 went outside to look and saw him out there. She ran back inside the facility to alert the nurse of the resident being outside before she went to retrieve the resident. The nurses came out to help her get the resident back in the building. A witness statement written by STNA #6 on 08/30/21 revealed Resident #7 was pleasant the evening of 08/28/21 but had been wandering back and forth from his room to the front lobby. At dinner time, he had asked if he could have his bracelet removed and remained sitting in his wheelchair in the front lobby. She alleged she checked on him routinely about every 10 minutes. At 9:15 P.M., he wasn't sitting in his wheelchair anymore. She then went to the front entrance and saw him in the parking lot directly out from the entrance. When she approached the resident outside and reached for his hand, they both slid down onto the grass. An initial handwritten witness statement on a piece of paper given by LPN #14 on 08/28/21 revealed she was notified of Resident #7's elopement by STNA #6 yelling down the hall he is outside. Resident #7 was across the road and in the parking lot. His wheelchair remained inside at the front entrance. STNA #6 was at the resident's side by the time she made it out there. The door alarm did not sound, and the door did not lock when the resident exited through it. LPN #14 indicated she took three different wander guards to the front door and stood by the door for a good 30 seconds before the door locked. A witness statement on a Statement of Witness Form written by LPN #14 on 08/30/21 revealed, on 08/28/21 between 9:15 P.M. and 9:20 P.M., Resident #7 had been going to the main doors, was asking how to get out, and was pulling on his wander guard bracelet. He was stating that he wanted to see his girlfriend. He had last been seen at 9:10 P.M. The resident was found across the street in the parking lot standing up and walking. The front door was indicated not to have been locked and the alarm system was not alarming. The resident was indicated to have his wander guard bracelet in place on his ankle, but the door did not lock down as it should have. The resident did have a fall outside of the facility, but no injuries occurred. A statement obtained from Resident #7 on 08/29/21 at 10:44 A.M. revealed he was asked how he got out of the door as part of the resident's interview. The resident replied he just walked out. On 09/15/21 at 11:15 A.M., an interview with the facility's DON and Administrator confirmed Resident #7 had eloped from the facility on 08/28/21 at 9:15 P.M. The Administrator reported the resident was found outside about a hundred feet away from the facility's main entrance across the road and by the facility's parking lot. They reported the resident was under every ten-minute check as he verbalized a desire to leave the facility. They confirmed a wander guard was in use on the resident at the time the elopement occurred. They speculated he was out of the facility for at least 10 minutes before he was found as he was last checked on 10 minutes prior to his elopement. STNA #6 reportedly checked on the resident to see if he was still sitting in the lobby and noted him gone. She looked outside and saw that he had exited the facility. The DON denied any alarms sounded at the time the resident eloped from the facility. They suspected the resident would have had to follow a visitor/ staff member out or the facility's wandering alert system malfunctioned allowing him to go out. On 09/15/21 at 2:10 P.M., an observation during a tour of the facility revealed the main entrance was located at the proximal end of the 300 hall near the main offices. There was a small lobby at that end of the hallway inside the entry way. The main entrance door was comprised of two sets of double doors. The main entrance was equipped with a wandering alert system with a keypad on the wall to the left of the door. A code was required to disarm the alarming system and to disengage the lock if the door was in a locked mode. A person wearing a wander guard bracelet would engage the lock (if the door was not already in the locked mode) and an audible alarm would sound when the door was pushed on. The lock would release after 15 seconds of pushing on the door as a fire safety measure. A second distinct auditory alarm would sound if the door was actually opened by a person wearing a wander guard bracelet. The door was tested in lock down mode and in the unlocked mode with a wander guard bracelet used to verify proper function. No concerns were noted with the door not operating properly when tested . An observation of the area where the resident was found after he had eloped was about 100 feet from the facility's main entrance. It was down a downward sloped sidewalk that led into a road before crossing over into the facility's parking lot. The road was a state route where the speed limit was 35 MPH in front of the building but increased to a speed of 55 MPH approximately 150 feet down the road. The road also had hills on each end of the building with one being before you came up on the building and the other in the middle section of the building where the entrance to the parking lot was. The crosswalk that led to the parking lot was near the hump in the road that was at the building's mid- section where visibility and reaction time could have been of concern when traveling in a [NAME] direction towards town. The location the resident was first found was between the upper and lower parking lot on a grassy slope. On 09/15/21 at 2:23 P.M., an interview with the Director of Plant Operations #70 revealed he was not made aware of Resident #7's elopement he had on 08/28/21 until he came to work on the following Monday. He stated 08/28/21 was a Saturday and he was not there, nor was he asked to come in that night to check the facility's wander guard system after the elopement had occurred. It was not until Monday (08/30/21) that he and the Administrator tested the door as part of the facility's investigation into the elopement to ensure the wander guard system was functioning properly. He denied they noted anything wrong with the functioning of the alarm system when they tested it. He suspected the resident followed someone out as he could have done that without the alarm sounding as long as the door did not close before he walked through it. On 09/15/21 at 3:03 P.M., a phone interview with Laundry Aide #21 revealed she worked the evening of 08/28/21 when Resident #7 eloped and she left the facility at 8:57 P.M. She recalled the resident was sitting in the lobby by the main entrance when she left. She stated she screened herself out and left through the main entrance door. She denied it was locked as she did not have to enter a code in order for her to be able to open the door to leave. She stated she thought about having the resident go up the hallway when she left so he did not try to follow her out, but she decided not to say anything to him to prevent agitating him. She denied the resident followed her out as she turned around halfway down the sidewalk to make sure the door closed, and he did not come out. He remained sitting inside in the lobby as she proceeded to head towards the parking lot. She pulled out of the parking lot and headed in the direction of town (passing in front of main entrance) and did not see the resident outside when she passed by. It was not until the next day that she had been made aware the resident got out and it was around the time she left. She denied the facility's administrative staff had interviewed her as part of their investigation of the resident's elopement. On 09/15/21 at 3:15 P.M., a follow up interview with the Administrator and Director of Plant Operations #70 confirmed the main entrance doors were not programmed to automatically lock at 6:00 P.M. as they previously indicated. They stated they were programmed to lock at 10:00 P.M. when the elopement occurred. It was not until after the elopement that they reprogrammed it to lock at 6:00 P.M. and remain locked until 8:00 A.M. On 09/15/21 at 3:30 P.M., an interview with STNA #6 revealed she was working on 08/28/21 when Resident #7 eloped from the facility and was the one who first noticed he was gone. She confirmed the resident had previously been on the secured unit but had been moved to her hall only after a few days of being on that unit as per the family's request. She confirmed he verbalized the intent to leave the facility the day same day he eloped. She was not aware of him making those comments prior to 08/28/21. He had watched others come and go and did not know why he could not leave as well. Once he verbalized the desire to go outside, she took it upon herself to check on him every 10-15 minutes. She denied every 15-minute checks was an order, just something she thought should be done. She reported the resident was sitting lobby by the front door where he was still visible from the hallway. She checked on him before going into another resident's room to provide care and when she came out, she noticed he was no longer sitting in his wheelchair. She went to the front door to look out and observed him in the parking lot across the street. She came back into the hallway and called for a nurse to let her know she needed help outside before going out to retrieve the resident. She confirmed the resident had a wander guard in place before the elopement occurred but denied it sounded when he left the facility to go outside. For some reason that day, she stated it did not work. She confirmed she found the resident on a small slope between the upper and lower parking lots. She went to grab his hand and at that time they both fell down. She denied he had any injuries as a result of his fall. She reported LPN #14 and LPN #35 helped her get him back inside. She confirmed, at the time the elopement occurred, you could go in and out of the main entrance door without needing to put a code in. It did not automatically lock at that time but the wander guard he was wearing should have locked it when he approached. STNA #6 stated she asked Resident #7 when the elopement occurred how he got out and he just replied he pushed on the door and he went out. On 09/15/21 at 3:54 P.M., an interview with LPN #14 revealed she was the nurse on 08/28/21 when Resident #7 eloped from the facility. She was the nurse assigned to the resident's care on that night. She reported he had been on the 300 hall for less than a week before the elopement occurred. Prior to that, he was on the secured unit. The family had requested he be placed on the 300 hall as they reported he had no prior history of trying to leave a facility. She confirmed he was considered an elopement risk and he had the use of a wander guard alarm when he was taken off the secured unit. She also confirmed it was known he had verbalized the desire to leave the facility. LPN #14 denied she had known him to make any physical attempts to leave though. She recalled on 08/28/21 he was sitting at the main doorway in his wheelchair visible from the hallway. When staff went in and out of the other resident rooms, they could see him sitting there. She denied he was on an official watch, but they were just keeping a close eye on him. She stated everyone was responsible for checking his wander guard, but night shift was responsible for checking it every night with a transmitter box they had to verify it was actually working. The checks were documented on the TAR when they were done. She denied the front door alarmed when he had eloped and was not sure why. She thought it was the door that malfunctioned not his alarm. STNA #6 was the one that first noticed he was not there in his wheelchair by the front entry when she came out of a resident's room. She went to the front entry and saw that he had gotten outside. She then yelled for the nurse and her and another nurse (LPN #35) responded. The resident was in the upper parking lot across the road when she got out there. She was not sure where STNA #6 had originally found him. She reported the wander guard system did not alarm when the resident was brought back into the facility. It should have locked when he was near it. She denied that she looked up to see if the system activated as evidenced by the green light on the system turning red. She denied anyone had checked the wander guard system to make sure it was properly working when they brought him back inside. They took him straight to the secured unit after he came back in. She denied LPN #35 would have any additional information that she had not already provided. On 09/16/21 at 9:47 A.M., an interview with LPN #44 confirmed she was the nurse that worked the 11:00 P.M. to 7:00 A.M. shift on 08/27/21, the night before Resident #7 eloped. That was the first night she took care of the resident and when asked if he was at risk for elopement, she stated he was at risk for everything. She was not 100% sure but thought he had the use of a wander guard. Most wander guards were put on a resident's ankle or wrist but could not recall where his was. She confirmed the night shift nurse was responsible for checking to see if the wander guard bracelets were functioning properly. If the resident was close to a door, she would check it that way. Most of the time that was how she checked them. She doubted that she checked that night (08/27/21) as she had two halls and it was not her normal shift. She reported they could use a transmitter box to check the wander guard but could not recall if she checked his. She denied he went close enough to a door that night where she would have checked to see if it was working properly that way. She then stated she could not recall if he had the wander guard at that time or if it had been put on afterwards. She had so many people to take care of it was hard to remember. She was informed she initialed the TAR indicating his wander guard was checked the evening of 08/27/21. She reported she has initialed the box before indicating it had been checked when in fact, she did not actually check it for proper function. She stated some nights you work as the nurse and aide and did not have time to do all the things you sign off that you did. She denied she used the transmitter box to test the wander guards for those residents that were in bed on her shift. She said she could not verify if she checked the resident's wander guard or not that evening for proper function but again confirmed just because it was initialed in the TAR as having been checked did not mean it always was. On 09/16/21 at 11:50 A.M., an interview with the DON revealed she was not aware of Resident #7 making any comments about wanting to leave the facility prior to his actual elopement. She was not made aware of the comments he made

Based on review of the medical record, a facility self-reported incident (SRI), surveillance video footage, incident investigation documentation, the procedural guidelines related to Abuse and staff interview the facility failed to ensure one resident (Resident #6), who was cognitively impaired and resided on a secured memory care unit was free from physical and emotional abuse by Registered Nurse (RN) #101. This resulted in Immediate Jeopardy and actual physical and psychosocial harm on 12/03/19 when RN #101 was observed on video footage over a period of approximately one half hour repeatedly pushing Resident #6 down in her wheelchair as she was attempting to stand up. The resident was subsequently assessed with [REDACTED].#101. In addition to the physical harm, Resident #6 displayed signs of anxiety and fear by repeatedly hitting her hand on a table and verbally crying out after the incident had occurred. Under the reasonable person concept under similar circumstances, the incident would cause physical and emotional trauma. This affected one of three residents reviewed for abuse. The facility census was 95. On 12/19/19 at 3:10 P.M., the Administrator, Director of Health Services (DHS) and Regional Clinical Director #102 were notified Immediate Jeopardy began on 12/03/19 at approximately 5:20 [NAME]M. when RN #101 repeatedly, with force, physically pushed and pulled Resident #6 back into her wheelchair as she was attempting to stand. As a result of RN #101's actions, Resident #6 sustained bruising to her chest and upper left arm, and suffered immediate emotional harm displayed as crying/yelling and attempting to physically hit RN #101 after he used physical force. Resident #6 displayed increased anxiety/fearfulness during and after the incident as she was constantly looking over her shoulder as if someone was going to harm her, was repeatedly tapping her hand on the table and stated to multiple staff, he got me, he will get you too. The incident was captured on facility surveillance camera and verified by the facility management staff. Review of the facility investigation confirmed the bruising to Resident #6, which was identified the following day (12/04/19) was consistent with the physical force that was used by RN #101. The Immediate Jeopardy was removed on 12/06/19, when the facility implemented the following corrective actions: · On 12/03/19 at approximately 9:10 [NAME]M. the administrator and DHS were notified by Licensed Practical Nurse (LPN) Manager #90 of inappropriate behavior from RN #101 toward Resident #6. An investigation was initiated at this time. · On 12/03/19 at approximately 9:45 [NAME]M., RN #101 was suspended from the facility. The RN had previously completed his shift and left the facility at 7:00 [NAME]M. that morning. The RN did not return to the facility. RN #101 was subsequently terminated on 12/05/19 and the incident was reported to the State Board of Nursing. · On 12/03/19 at approximately 10:15 [NAME]M. a self-reported incident (SRI) was generated and submitted to the State Agency. · On 12/03/19 from approximately 10:30 [NAME]M. to 12:00 P.M., the Administrator, DHS and Assistant Director of Health Services (ADHS) interviewed all residents who had an intact cognitive status. For residents who were not interviewable skin assessments were completed. There was no evidence of abuse based on the interviews/observations. · On 12/03/19 at 10:40 [NAME]M. the Administrator notified local law enforcement of the incident between RN #101 and Resident #6 and of the video information. Local law enforcement arrived, completed an initial investigation, gathered relevant information and provided an incident report number, 19- 24-12. Local law enforcement indicated a criminal investigation would be completed. · On 12/03/19 at approximately 4:00 P.M., Medical Director #200 was in the facility and assessed Resident #6. Since the resident had a previous [MEDICAL CONDITION], the facility requested and an order was obtained for a hip x-ray which was negative. The facility indicated the medical director would continue to monitor the resident's health conditions on a monthly basis or as needed. · On 12/03/19, 12/04/19 and 12/05/19, Director of Social Services (DSS) #110 completed a psychosocial evaluation on Resident #6. · From 12/03/19 to 12/06/19 the Administrator, DHS and Regional Director #102 completed staff education for all 16 LPNs, 39 direct care staff (state tested nursing assistants), nine dietary staff, eight housekeeping/laundry staff, three RNs, three therapists and 17 leadership staff related to resident abuse, reporting abuse, how to manage escalating situations with residents with dementia and how to effectively communicate with those that have dementia. A plan for the training to occur on an annual basis and as needed was implemented. As of 12/06/19 all staff had received the education. · On 12/03/19 a plan for floor nurses and STNAs to monitor and record maladaptive behaviors for all residents in the facility, each shift was initiated. Twenty-two (22) residents with maladaptive behaviors were identified and had their behaviors and documentation for the behaviors reviewed to ensure the residents had accurate tracking tools. A plan was implemented for the resident behavior documentation to be reviewed every morning on an on-going basis by the Administrator, DHS, ADHS, SSD #110 and LPN #90 with no end date. · Beginning on 12/03/19 (and on-going) a plan for an equal number of residents (approximately 6-10) to have a psychosocial assessment/evaluation completed by SSD #110 based on an audit schedule was implemented. This new assessment would be completed once per quarter. If there were changes that needed to be made to the resident ' s medical record due to the outcome of this evaluation, it would be made immediately. All new admissions would have a psychosocial evaluation/assessment complete by the following Tuesday after their admission. · On 12/05/19, RN #101 and STNA #103 (who was working at the time of the incident on 12/03/19) were called and interviewed by the Administrator, DHS and ADHS regarding the incident. Both employees were terminated at this time and RN #101 was notified the incident was being reported to the Board of Nursing. · On 12/05/19, the Administrator reviewed all facility surveillance footage for 12/03/19 and 30 days prior to determine if there was a pattern/other behaviors that needed to be reviewed. There were no other concerning instances found. · Beginning 12/05/19 a plan was implemented for video camera footage to be reviewed by the Administrator each day after the last management team member left the facility until the first management team member entered the building the next day (approximately 12 hours of video), three times weekly for the next four weeks. · Beginning 12/09/19 a plan for the facility to conduct random audits/interviews with 27 residents who were cognitively intact regarding the abuse policy/procedures. For those who were not cognitively intact, random skin audits would be completed (at the time of assessment, it was 67 residents.) Finally, the facility implemented random interviews/questioning of five staff regarding the abuse policy. The resident interviews, random skin assessments, and staff interviews would be completed each week for the next four weeks. · On 12/11/19 and 12/12/19, 22 residents identified as having maladaptive behaviors had a behavior meeting with the psychiatrist. Resident #6 obtained a new order to increase her anti-psychotic medication. All residents with behaviors were assessed by the psychiatrist, and there were no new onset behaviors noted that needed to be addressed. A plan for the facility psychiatrist to monitor residents with psychiatric or mental health issues as ordered and as needed was noted. · Beginning 12/20/19 a plan for the Administrator, DHS and ADHS to review all 22 resident's documentation (care plans, physician orders, behavior tracking logs) to determine the resident ' s baseline for behaviors and functioning level and ensure the resident documentation was correct with adjustments as needed so that all resident's behaviors, behavior tracking, medications, and interventions when behaviors occur were accurate and beneficial. A plan for this to be completed by 12/27/19 was identified. · Interviews on 12/19/19 from 8:00 [NAME]M. to 4:00 P.M. and 12/20/19 from 11:00 [NAME]M. to 11:30 [NAME]M. with the Administrator, DON, LPN #90, STNA #81, STNA #82, STNA #113, STNA #116, STNA #126, Dietary Aide #120, and LPN #124 revealed all staff interviewed were knowledgeable of the Abuse policy and indicated they would immediately report any allegations of abuse to the Administrator and/or DON. Although the Immediate Jeopardy was removed on 12/06/19, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings Include: Review of Resident #6's medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident resided on a secured memory care unit. Review of Resident #6's Minimum Data Set (MDS) 3.0 assessment, dated 10/25/19 revealed the resident had severe cognitive impairment. The resident required extensive assistance and two-person physical assist with locomotion between locations as the resident was ambulatory only with a walker or mobile with a wheelchair. Review of Resident #6's current plan of care revealed the resident demonstrated cognitive impairment thought processes related to dementia. Interventions included assessing the resident's Brief Interview for Mental Status (BIMS) status periodically, encouraging the resident to engage in familiar activities, and referring to psychiatric services for significant changes or deterioration in cognitive functioning. The resident also had a current plan of care in place for impaired functional status related to bed mobility, transfers, toileting, and eating due to her [DIAGNOSES REDACTED]. Finally, Resident #6's care plan revealed she presented with anxious, restless and exit seeking behaviors. Interventions include observing mood, affect, and behaviors with all hands on care and contacts. Review of Resident #6's nursing/progress notes revealed on 12/03/19 at 8:49 [NAME]M., LPN #90 documented when she arrived to work, day shift staff (later found out to be STNA #81, STNA #82, STNA #122, and LPN #51) reported to her an incident from midnight shift. The incident was reported to the Administrator and DHS. At 10:00 [NAME]M., LPN #90 completed a head to toe skin assessment of Resident #6 and no new areas were visible at that time. At 10:56 [NAME]M., Resident #6's guardian was notified of a physical abuse incident/allegation. At 4:00 P.M., the physician increased Resident #6's anti-depressant medication, [MEDICATION NAME] to 100 milligrams (mg) daily and recommended she see the facility psychiatrist the next time the psychiatrist made rounds. On 12/04/19 at 2:18 [NAME]M., the physician increased Resident #6's [MEDICATION NAME] again to 150 mg daily. Both increases were justified on 12/04/19 at 5:19 [NAME]M. due to her increased behaviors on 12/03/19. RN #101 (who was identified to be involved in an incident with Resident #6 on 12/03/19) did not document any progress/nursing notes about Resident #6 behavior from the night of the incident. Review of a facility self-reported incident (SRI), tracking number 4, dated 12/03/19 and facility investigation revealed an allegation of physical abuse and restraint involving Resident #6 was reported to the facility administrator and Director of Health Services (DHS) at approximately 8:30 [NAME]M. by LPN #90. At that time, the administrative staff reviewed the surveillance video from 5:20 [NAME]M. to approximately 5:50 [NAME]M. and confirmed there was behavior that was not consistent with safe and healthy care for the residents, so they started an investigation. The investigation revealed RN #101 (and STNA #103) were immediately suspended pending the outcome of the investigation. As part of the facility investigation, interview statements were taken from STNA #81, STNA #82, STNA #122 and LPN #51 on 12/03/19 which revealed Resident #6 was acting differently when they arrived for work that morning (12/03/19). The STNAs stated the resident was yelling/screaming in the common area. The STNAs also revealed RN #101 looked irritated and stated to them, How do you guys handle her (Resident #6)? After taking Resident #6 away from RN #101's care, Resident #6 made the statement, He got me, and he will get you too. She wasn't specific to who he was, but the only he that was in the immediate vicinity was RN #101. After Resident #6 left for therapy, the staff statements revealed Resident #4 came to the common area and stated, he was grabbing and smacking her. When Resident #4 made that statement, she pointed to RN #101. The investigation revealed when LPN #51 arrived at the facility at 7:00 [NAME]M., the STNA staff told her what RN #101, Resident #6 and Resident #4 had stated. At approximately 8:00 [NAME]M., STNAs #81, #82, #122 and LPN #51 reported the incident to LPN #90, who was the unit manager. LPN #90 reviewed the video surveillance, saw there were inappropriate actions by RN #101, and reported the findings to the administrator and DHS. Following the facility investigation, the administrator and DHS determined RN #101 was physically abusive to Resident #6 and terminated him. The facility substantiated the allegation of physical abuse associated with SRI tracking number 4. On 12/03/19, law enforcement was contacted, an incident report was filed and information was communicated that law enforcement would be submitting the investigative information to the prosecutor's office for review of criminal charges. Review of Resident #6's nursing progress notes and facility event dated 12/04/19 at 2:39 P.M. and 2:53 P.M. revealed a blue/black bruise (1.5 centimeters (cm) by 2.5 cm) was noted on the resident ' s chest and a purple/black bruise (14 cm by 8.5 cm) was discovered on Resident #6's left upper arm that had not been previously identified. According to the documentation, the bruising was consistent with the physical abuse incident by RN #101 that occurred on 12/03/19. As part of the investigation, on 12/05/19 RN #101 was interviewed by the Administrator, DHS, and ADHS. RN #101 denied doing anything inappropriate to Resident #6. When he was told they had seen video evidence that he pushed/pulled, physically abused and restrained Resident #6 on 12/03/19, his only response was, are you going to press charges. The interview ended at that point. On 12/05/19, STNA #103 was also interviewed by the Administrator, DHS and ADHS. They explained to her what they saw on the video (STNA #103 was in the presence of the abuse incident on two occasions.) STNA #103's response was that she felt RN #101 was not being abusive. She stated she did not see the time when RN #101 grabbed Resident #6's arm and jerked her back into her wheelchair. She gave the explanation that when she was working on a task, she was focused on that task and nothing else, so she did not see the abuse the interviewers were talking about. At the end of the interviews both STNA #103 and RN #101 were terminated. Review of local law enforcement Incident Report, number 19- 24-12, dated 12/03/19 revealed a law enforcement officer arrived at the facility on 12/03/19 at approximately 11:40 [NAME]M. The report revealed an incident occurred on 12/03/19 from 5:00 [NAME]M. to 6:00 [NAME]M. (as reported by the facility). The report indicated Resident #6 was not injured, but the offense listed was assault by RN #101 under Ohio Revised Code (ORC) 2903.13. A summary of the report narrative reflected the Administrator contacted local law enforcement in reference to physical abuse of Resident #6. The law enforcement officer watched the video surveillance and noted he saw RN #101 grab Resident #6 several times by the arm and pull her into her wheelchair. He also noted RN #101 slapped Resident #6 on top of the head. A copy of the video was provided to law enforcement. On 12/04/19, law enforcement contacted RN #101 and asked him to come to the station to be interviewed, RN #101 agreed. RN #101 was afforded his Miranda rights (which he signed acknowledging). RN #101 denied touching/hurting/grabbing Resident #6. The law enforcement officer informed RN #101 he had a copy of the video and confirmed RN #101 had grabbed/pulled Resident #6 and slapped her on the head. RN #101 was then showed the video and he confirmed the video was accurate, but he continued to state he had never harmed Resident #6. RN #101 left the station at that time. The report indicated the case would be submitted to the prosecutor's office for review. On 12/19/19 at approximately 9:30 [NAME]M. the video surveillance recording from 12/03/19 from 5:20 [NAME]M. to 5:50 [NAME]M. was reviewed by the surveyor with the Administrator and DHS present. The recording showed the incident of physical abuse toward Resident #6 by RN #101. During the review of the video, there were approximately 7-10 instances where RN #101 placed his hands directly on Resident #6 and pushed or pulled her back into her wheelchair (as she attempted to stand). At least three of the incidents caused Resident #6 and/or her wheelchair to move significantly. One of the instances where RN #101 forcefully pushed Resident #6 back into her wheelchair caused her wheelchair to move backwards approximately 8 to 12 inches from the desk she was sitting at. During the recording, RN #101 was observed to touch/grab Resident #6's upper and lower left arm, across her chest and flicked her head with his index/thumb fingers. While reviewing the surveillance video, it was noted STNA #103 was looking directly at RN #101 and Resident #6 when RN #101 forcefully pushed the resident back into her wheelchair. After watching the surveillance video, it was confirmed RN #101 physically abused Resident #6, and caused physical and emotional harm to her as a result of his actions. This was verified by Administrator and DHS at the time of the review of the footage. Interview with the Administrator and DHS on 12/19/19 at approximately 9:50 [NAME]M. revealed they were disgusted with the actions of RN #101 on 12/03/19. They confirmed RN #101 used enough force to actually cause harm to Resident #6. They confirmed after their investigation, there was no doubt RN #101 had physically abused and restrained Resident #6. On 12/19/19 at 10:58 [NAME]M. telephone interview with STNA #103 revealed she did not know the physical abuse incident happened. However, she stated she had seen the surveillance video, and it looked horrible. She stated she did not know RN #101 used that much force with Resident #6. She stated he told her he was trying to keep her in her wheelchair so she wouldn't fall again; she had fractured her hip not long ago. She agreed she was near Resident #6 and RN #101 when he pushed her back into her wheelchair, but she stated she did not hear or see anything that would have caused alarm. She agreed on the video, it looked much worse than what she knew about. She stated she did not report anything because she did not see/hear anything. But she also stated Resident #4 was in the area at the time she was near Resident #6 and RN #101, and Resident #4 yelled to her, that man hit her. When she turned around, she saw Resident #6 hitting at RN #101. She stated she never saw RN #101 hit Resident #6, so she did not think Resident #4 was making an accurate statement. Interview with LPN #90 on 12/19/19 at 11:25 [NAME]M. revealed when she arrived the morning of 12/03/19 at approximately 8:15 [NAME]M., she was told by STNA #82, STNA #81, and LPN #51 that RN #101 was acting weird. They stated Resident #6 said a guy got her and was going to get them. Then, she stated STNA #81 and STNA #82 told her Resident #4 said a big black man had hit Resident #6. At that time, LPN #90 looked at the video tape, saw inappropriate behaviors by RN #101, and reported it to the DHS and Administrator. On 12/19/19 at 11:34 [NAME]M. an attempt to interview Resident #6 was unsuccessful as the resident exhibited cognitive impairment and was unable to answer questions. An attempt to interview Resident #4 on 12/19/19 at 11:30 [NAME]M. was also unsuccessful as the resident exhibited cognitive impairment. Neither resident was able to provide pertinent information to the investigation. Interview with STNA #81 and STNA #82 on 12/19/19 at 11:45 [NAME]M. revealed when they arrived at the facility at approximately 6:00 [NAME]M. on 12/03/19, they heard someone yelling. They thought it was another resident who has a history of yelling, but when they walked back the hall, they saw it was Resident #6 sitting at the nurse's desk with RN #101. There was nothing inappropriate happening at that time, but when they walked back, they saw Resident #6 yelling. RN #101 asked how they handle her when she is acting like that. They told him that they take her to a different setting or find an activity for her. At that time, they took Resident #6 to the dining table. While at the table, Resident #6 kept looking over her shoulder and they thought she looked scared. She made the statement, he got me, he's gonna get you. The only male who was in the area was RN #101. At that time, therapy took Resident #6 for treatment. Then, Resident #4 stated to them, He hit her, indicating RN #101 hit Resident #6. STNAs #81 and #82 waited for the oncoming nurse to arrive at 7:00 [NAME]M. (LPN #51) to report to her what they had heard. The STNAs said LPN #51 reported the incident to the unit manager, LPN #90, around 7:30 [NAME]M. Review of an employee personnel file revealed RN #101 was suspended from the facility on 12/03/19 and terminated on 12/05/19 for physical abuse of a resident. Attempts to reach RN #101 via telephone on 12/19/19 were unsuccessful. Review of the facility Abuse, Neglect, and Exploitation procedural guidelines, dated 08/29/19 revealed the facility had developed and implemented processes, which strived to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. The policy defined abuse as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy also defined willful as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse included all, but was not limited to, hitting, slapping, punching, biting and kicking. It also included corporal punishment. Items listed as corporal punishment were pinching, spanking, slapping of hands, flicking, or hitting with an object. This deficiency substantiates Control Number OH 817 and Complaint Number OH 784.

Based on review of the medical record, a facility self-reported incident (SRI) and investigation, surveillance video camera footage, the facility Restraint policy and staff interview the facility failed to ensure one resident (Resident #6), who was cognitively impaired, was not physically restrained. This resulted in Immediate Jeopardy when Registered Nurse (RN) #101 restricted the voluntary movement of Resident #6 by forcibly pushing and pulling her back into her wheelchair restricting her ability to stand as desired. Actual harm occurred when Resident #6 sustained bruising to her chest and arms and displayed signs of emotional anxiety and fear by crying/yelling and striking out. Under the reasonable person concept these actions by a person in authority would result in fear and emotional upset. This affected one resident of three residents reviewed for physical restraint. The facility census was 95. On 12/19/19 at 3:10 P.M., the Administrator, Director of Health Services (DHS) and Regional Clinical Director #102 were notified Immediate Jeopardy began on 12/03/19 at approximately 5:20 [NAME]M. when RN #101 with force, physically restrained Resident #6 in her wheelchair and intentionally restricted the resident ' s voluntary movement. RN #101 repeatedly pushed and pulled Resident #6 back into her wheelchair when she attempted to stand up and pushed her wheelchair arm rests under a table resulting in the resident sustaining bruising to her chest and upper left arm. Resident #6 displayed increased anxiety, tapping her hand repeatedly on the nurse ' s desk, crying and showing signs of fear by constantly looking over her shoulder as if someone was going to harm her. The resident also reported to staff, he got me, he will get you too. The incident was videotaped by the facility. The Immediate Jeopardy was removed on 12/06/19, when the facility implemented the following corrective actions: · On 12/03/19 at approximately 9:10 [NAME]M. the administrator and DHS were notified by Licensed Practical Nurse (LPN) manager #90 of inappropriate behavior from RN #101 toward Resident #6. An investigation was started at that time. · On 12/03/19 at approximately 9:45 [NAME]M., RN #101 was suspended from the facility. RN #101 had previously completed his shift at 7:00 [NAME]M. and was gone from the facility at the time he was suspended. The employee did not return to work and was subsequently terminated on 12/05/19. The incident was reported to the Ohio Board of Nursing. · On 12/03/19 at approximately 10:15 [NAME]M. a self-reported incident (SRI) was reported to the State Agency. · On 12/03/19, 12/04/19 and 12/05/19, Director of Social Services (DSS) #110 completed a psychosocial evaluation on Resident #6. · On 12/03/19 from approximately 10:30 [NAME]M. to 12:00 P.M., the Administrator, DHS and Assistant Director of Health Services (ADHS) interviewed all residents who had an intact cognitive status. For residents who were not interviewable, skin assessments were completed. There was no evidence of improper physical restraint based on the interviews/observations. · From 12/03/19 to 12/06/19 the Administrator, DHS and Regional Director #102 completed staff education for all 16 LPNs, 39 direct care staff (state tested nursing assistants {STNA}), nine dietary staff, eight housekeeping/laundry staff, three RNs, three therapists and 17 leadership staff related to how to manage escalating situations with residents with dementia, how to effectively communicate with those who have dementia and resident restraints. A plan for the training to occur on an annual basis and as needed was implemented. As of 12/06/19 all staff had received the education. · On 12/03/19 a plan for floor nurses and STNAs to monitor and record maladaptive behaviors for all residents in the facility, each shift was initiated. Twenty-two (22) residents with maladaptive behaviors were identified, had behaviors documented, reviewed to ensure all residents had accurate tracking tools. The resident behavior documentation was reviewed every morning on an on-going basis by the Administrator, DHS, ADHS, SSD #110, and LPN #90 with no end date. · Beginning on 12/03/19 (and on-going) a plan for an equal number of residents (approximately 6-10) to have a psychosocial assessment/evaluation completed by SSD #110 based on an audit schedule was implemented. This new assessment would be completed once per quarter. If there were changes that needed to be made to the resident's medical record due to the outcome of this evaluation, it would be made immediately. All new admissions would have a psychosocial evaluation/assessment complete by the Tuesday following their admission. · On 12/03/19 and daily moving forward a plan for the facility to review every resident event form for restraints/enablers in the clinical care meeting to determine if there were any potential restraints in use. This would include every resident event/restraint form on a daily basis and would have no end date. · On 12/05/19, the Administrator reviewed all facility surveillance footage for 12/03/19 and 30 days prior to determine if there was a pattern/other behaviors that needed to be reviewed. There were no other concerning instances found. · Beginning 12/05/19 a plan was implemented for video camera footage to be reviewed by the Administrator each day after the last management team member left the facility until the first management team member entered the building the next day (approximately 12 hours of video), three times weekly for the next four weeks. · On 12/09/19, the facility began random audits/interviews with residents who were cognitively intact regarding restraint policy/procedures. For those who were not cognitively intact, they completed random skin audits. A plan for the resident interviews, random skin assessments and staff interviews to be completed randomly for five residents and five staff, each week for the next four weeks was initiated. · On 12/11/19 and 12/12/19, the facility had a monthly behavior meeting with the psychiatrist. Resident #6 obtained a new order to increase her anti-psychotic medication. All residents with behaviors were assessed by the psychiatrist, and there were no new onset behaviors noted that needed to be addressed. The facility psychiatrist will continue to monitor residents with psychiatric or mental health issues as ordered and as needed. · Interviews on 12/19/19 from 8:00 [NAME]M. to 4:00 P.M. and 12/20/19 from 11:00 [NAME]M. to 11:30 [NAME]M. with the Administrator, DHS, LPN #90, STNA #81, STNA #82, STNA #113, STNA #116, STNA #126, Dietary Aide #120, and LPN #124 revealed all staff interviewed were knowledgeable of the facility restraint policy and restraint requirements. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #6's medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident resided on a secured memory care unit. Review of Resident #6's Minimum Data Set (MDS) 3.0 assessment, dated 10/25/19 revealed the resident had severe cognitive impairment. The resident required extensive assistance and two-person physical assist with locomotion between locations as the resident was ambulatory only with a walker or mobile in a wheelchair. Review of Resident #6's current plan of care revealed the resident demonstrated cognitive impairment thought processes related to dementia. Interventions included assessing the resident's Brief Interview for Mental Status (BIMS) status periodically, encouraging the resident to engage in familiar activities, and referring to psychiatric services for significant changes or deterioration in cognitive functioning. The resident also had a current plan of care in place for impaired functional status related to bed mobility, transfers, toileting, and eating due to her [DIAGNOSES REDACTED]. Finally, Resident #6's care plan revealed she presented with anxious, restless and exit seeking behaviors. Interventions include observing mood, affect, and behaviors with all hands on care and contacts. Review of Resident #6's nursing/progress notes revealed on 12/03/19 at 8:49 [NAME]M., LPN #90 documented when she arrived to work, day shift staff (later found out to be STNA #81, STNA #82, STNA #122, and LPN #51) reported to her an incident from midnight shift. The incident was reported to the Administrator and DHS. At 10:00 [NAME]M., LPN #90 completed a head to toe skin assessment of Resident #6 and no new areas were visible at that time. At 10:56 [NAME]M., Resident #6's guardian was notified of a physical restraint incident/allegation. At 4:00 P.M., the physician increased Resident #6's anti-depressant medication, [MEDICATION NAME] to 100 milligrams (mg) daily and recommended she see the facility psychiatrist the next time the psychiatrist made rounds. On 12/04/19 at 2:18 [NAME]M., the physician increased Resident #6's [MEDICATION NAME] again to 150 mg daily. Both increases were justified on 12/04/19 at 5:19 [NAME]M. due to her increased behaviors (which included anxiety) on 12/03/19. RN #101 did not document any progress/nursing notes about Resident #6's behavior from the night of the incident. Review of a facility self-reported incident (SRI), tracking number 4, dated 12/03/19 and facility investigation revealed an allegation of physical abuse and restraint involving Resident #6 was reported to the facility administrator and DHS at approximately 8:30 [NAME]M. by LPN #90. At that time, they reviewed the surveillance video from 5:20 [NAME]M. to approximately 5:50 [NAME]M. and confirmed there was behavior that was not consistent with safe and healthy care for the residents, so an investigation was initiated. The investigation revealed RN #101 (and STNA #103) were immediately suspended pending the outcome of the investigation. As part of the facility investigation, interview statements were taken from STNA #81, STNA #82, STNA #122 and LPN #51 on 12/03/19 which revealed Resident #6 was acting differently when they arrived for work that morning (12/03/19). The STNA staff stated she was yelling and screaming in the common area. The STNA staff also revealed RN #101 looked irritated and stated to them, How do you guys handle her (Resident #6)? After taking Resident #6 away from RN #101's care, Resident #6 made the statement, He got me, and he will get you too. She wasn ' t specific to who he but the only male that was in the immediate vicinity was RN #101. After Resident #6 left for physical therapy, the STNAs said Resident #4 came to the common area and stated, he was grabbing and smacking her. When Resident #4 made that statement, she pointed to RN #101. STNAs #81,#82 and #122 stated when LPN #51 arrived at the facility at 7:00 [NAME]M., they told her what RN #101, Resident #6 and Resident #4 stated. Then, at approximately 8:00 [NAME]M., all four staff (STNAs #81, #82 and #122 and LPN #51) reported these statements to LPN #90, who was the unit manager. LPN #90 then reviewed the video surveillance, observed there were inappropriate actions (which included physical restraint) by RN #101, and reported the findings to the administrator and DHS. After the facility completed their investigation, they determined RN #101 was physically abusive, which included physically restraining Resident #6 and they terminated RN #101. The facility substantiated an allegation of physical abuse associated with SRI tracking number 4. Review of Resident #6's nursing progress notes dated 12/04/19 at 2:39 P.M. and 2:53 P.M. revealed a blue/black bruise (1.5 centimeters (cm) by 2.5 cm) was noted on Resident #6's chest and a purple/black bruise (14 cm by 8.5 cm) was discovered on her left upper arm that had not been identified before. According to the documentation, the bruising was consistent with the physical abuse and physical restraint incident that occurred on 12/03/19 by RN #101. As part of the investigation, on 12/05/19 RN #101 was interviewed by the Administrator, DHS, and ADHS. RN #101 denied doing anything inappropriate to Resident #6. When he was told they had seen video evidence that he pushed/pulled, physically abused and restrained Resident #6 on 12/03/19, his only response was, are you going to press charges. The interview ended at that point. On 12/05/19, STNA #103 was interviewed by the Administrator, DHS and ADHS. They explained to her what they saw on the video (she was observed in physical presence of the incident on two occasions) Her response was that to her, RN #101 was not being abusive. She stated she did not see the time when RN #101 grabbed Resident #6 ' s arm and jerked her back into her wheelchair, and did not see RN #101 restraining Resident #6 in her wheelchair. She gave the explanation that when she was working on a task, she was focused on that task and nothing else, so she did not see the incident the interviewers were referring to. At the end of the interviews both STNA #103 and RN #101 were terminated. Review of local law enforcement Incident Report, number 19- 24-12, dated 12/03/19 revealed a law enforcement officer arrived at the facility on 12/03/19 at approximately 11:40 [NAME]M. The report revealed the incident occurred on 12/03/19 from 5:00 [NAME]M. to 6:00 [NAME]M. (as reported by the facility). The report indicated Resident #6 was not injured, but the offense listed was assault by RN #101 under Ohio Revised Code (ORC) 2903.13. A summary of the report narrative reflected the Administrator contacted local law enforcement in reference to abuse/physical restraint to Resident #6. The law enforcement officer watched the video surveillance and noted he saw RN #101 grab Resident #6 several times by the arm and pull her into her wheelchair, which would be consistent with physical abuse and physically restraining Resident #6. He also noted RN #101 slapped Resident #6 on top of the head. A copy of the video was provided to law enforcement. On 12/04/19, law enforcement contacted RN #101 and asked him to come to the station to be interviewed, RN #101 agreed. RN #101 was afforded his Miranda rights (which he acknowledged by signature). RN #101 denied touching/hurting/grabbing Resident #6. The law enforcement officer informed RN #101 he had a copy of the video and confirmed RN #101 had grabbed/pulled (physically restrained) Resident #6 and slapped her on the head. RN #101 was then showed the video and he confirmed the video was accurate (physical abuse and physical restraint), but he continued to state he had never harmed Resident #6. RN #101 left the station at that time. The report indicated the case would be submitted to the prosecutor's office for review of criminal charges. On 12/19/19 at approximately 9:30 [NAME]M. the video surveillance recording from the 12/03/19 incident was reviewed by the surveyor with the Administrator and DHS. The recording showed the incident of physical abuse and physical restraint of Resident #6 by RN #101. During the review of the video, there were approximately 7-10 instances where RN #101 placed his hands directly on Resident #6 and pushed or pulled her back into her wheelchair (as she attempted to stand), restricting her freedom of movement. At least three of the incidents caused Resident #6 and/or her wheelchair to move significantly. One of the instances where RN #101 forcefully pushed Resident #6 back into her wheelchair caused her wheelchair to move backwards approximately 8 to 12 inches from the desk she was seated at. There were between 15-20 instances where RN #101 grabbed the arm rest of Resident #6's wheelchair, pulling it back underneath the desk so she could not stand up or voluntarily move away from RN #101. In addition RN #101 placed his foot behind the wheel of Resident #6's wheelchair while she was underneath the desk, preventing her from leaving the area. While reviewing the surveillance video, it was noted STNA #103 was looking directly at RN #101 and Resident #6 when RN #101 forcefully pushed the resident back into her wheelchair and prevented Resident #6 from voluntarily moving. There were between three and five instances where Resident #6 attempted and actually hit RN #101 after he physically restrained her. Also, there were between five and seven other instances in which she would tap her hand vigorously on the desk and constantly look over her shoulders after RN #101 physically placed her back into her wheelchair or physically restrained her. There was no audio with the video footage, but a reasonable person could visually see that RN #101's actions of physically restraining Resident #6 caused anxiety and fear. The Administrator and DHS confirmed RN #101 was physically abusive and restrained Resident #6 at the time of the review of the footage. Interview with the Administrator and DHS on 12/19/19 at approximately 9:50 [NAME]M. revealed they were disgusted with the actions of RN #101 on 12/03/19. They confirmed RN #101 used enough force to actually cause harm to Resident #6. They confirmed after their investigation RN #101 had physically abused and restrained Resident #6. On 12/19/19 at 10:58 [NAME]M. telephone interview with STNA #103 revealed she did not know the physical abuse and physical restraint incident happened. However, she stated she had seen the surveillance video, and it looked horrible. She did not know RN #101 used that much force with Resident #6. She stated he told her he was trying to keep her in her wheelchair so she wouldn't fall again as she had fractured her hip not long ago. She agreed she was near Resident #6 and RN #101 when he pushed her back into her wheelchair, but she stated she did not hear or see anything that would have caused alarm. She agreed on the video, it looked much worse than what she knew about. She stated she did not report anything because she did not see or hear anything. STNA #103 stated Resident #4 was in the area at the time she was near Resident #6 and RN #101, and Resident #4 yelled to her, that man hit her. When she turned around, she saw Resident #6 hitting RN #101. She stated she never saw RN #101 hit Resident #6, so she did not think Resident #4 was making an accurate statement. Interview with LPN #90 on 12/19/19 at 11:25 [NAME]M. revealed when she arrived the morning of 12/03/19 at approximately 8:15 [NAME]M., she was told by STNA #82, STNA #81, and LPN #51 that RN #101 was acting weird. They stated Resident #6 said that a guy got her and was going to get them. Then, she stated STNA #81 and STNA #82 told her that Resident #4 said a big black man had hit Resident #6. At that time, LPN #90 looked at the video tape, saw inappropriate behaviors by RN #101, and reported it to the DHS and Administrator. On 12/19/19 at 11:34 [NAME]M. an attempt to interview Resident #6 was unsuccessful as the resident exhibited cognitive impairment and was unable to answer questions. An attempt to interview Resident #4 on 12/19/19 at 11:30 [NAME]M. was also unsuccessful as the resident exhibited cognitive impairment. Neither resident was able to provide pertinent information to the investigation. Interview with STNA #81 and STNA #82 on 12/19/19 at 11:45 [NAME]M. revealed when they arrived at the facility at approximately 6:00 [NAME]M. on 12/03/19, they heard someone yelling. They thought it was another resident who has a history of yelling, but when they walked back the hall, they saw it was Resident #6 sitting at the nurse's desk with RN #101. There was nothing inappropriate happening at that time. RN #101 asked how they handle her (Resident #6) when she is acting like that. They told him that they take her to a different setting or find an activity for her. At that time, they took Resident #6 to the dining table. While at the table, Resident #6 kept looking over her shoulder and they said she looked scared. She made the statement, he got me, he's gonna get you. The only male who was in the area was RN #101. At that time, therapy took Resident #6 for treatment. The STNAs indicated Resident #4 stated to them, He hit her, indicating RN #101 hit Resident #6. STNAs #81 and #82 stated they waited for the oncoming nurse (LPN #51) to arrive at 7:00 and reported what they had heard to her. LPN #52 reported to the unit manager, LPN #90 who then reported to administration. Attempts to reach RN #101 via telephone on 12/19/19 were unsuccessful. Review of facility Guidelines for Restraint/Enabler Use policy, dated 10/09/17 revealed the purpose of the policy was to ensure completion of observation and evaluation for appropriate and safe use of restraints/enablers for each resident. The policy defined convenience as, the results of any action that has the effect of altering a resident's behavior such that the resident required a lesser amount of effort or care and was not in the resident ' s best interest. It also defined freedom of movement as any change in place or position for the body or any part of the body that the person is physically able to control. Finally, the policy defines physical restraint as, any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body, and cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body. Within the procedures of the policy, the facility was to evaluate the resident, review all medical documentation, review with the physician, review with the interdisciplinary team, and make a final decision to determine if a restraint is necessary. The policy also stated that the use of physical restraints was prohibited except to treat medical symptoms. This deficiency substantiates Control Number OH 817 and Complaint Number OH 784.

Based on record review and interview the facility failed to complete an accurate comprehensive bladder and bowel assessment and implement an individualized bladder and bowel training program for Resident #114 who exhibited a decline in bladder and bowel functions. Actual harm occurred when Resident #114, who was assessed on admission to be always continent of bladder and bowel, experienced a decline in function and became frequently incontinent of bladder and bowel without appropriate reassessments to determine the cause of the declines or the type of incontinence the resident exhibited. The facility failed to implement any training program or interventions to attempt to restore normal function and prevent additional decline for the resident. This affected one resident (Resident #114 ) of one sampled resident who was identified to experience a decline in bladder and bowel status based on the Minimum Data Set (MDS) 3.0 assessment. Findings included: Record review revealed Resident #114 had [DIAGNOSES REDACTED]. Review of Resident #48's admission assessment dated [DATE] indicated Resident #114 was cognitively intact, alert and oriented. The admission assessment revealed the resident was continent of bladder and bowel and was not at risk for incontinence of bladder. The resident's initial care plan for elimination was blank. Resident #114's three day elimination record dated 12/04/16 to 12/05/16 confirmed Resident #114 was continent of bladder and bowel. Review of Resident #114's MDS 3.0 assessments and bladder and bowel documentation revealed the following: On 12/10/16- Resident #114 was occasionally incontinent of bladder and always continent of bowel, did not need a toileting program. The resident's bladder and bowel documentation confirmed the resident was continent of bowel and bladder and had two episodes of bladder incontinence during the time period reviewed. From 12/17/16 through 12/31/17 Resident #114 was noted to be frequently incontinent of bladder and continent of bowel without evidence of a toileting program. There was no evidence the facility completed a comprehensive bladder and bowel assessment to attempt to determine the cause of Resident #114's incontinence and the type of incontinence. There were no interventions attempted to prevent further decline/or improve his bladder and bowel function when these declines were identified. On 01/11/17 - Resident #114 was noted to be frequently incontinent of bladder and frequently incontinent of bowel without evidence of a toileting program. The resident's bladder and bowel documentation dated 01/05/17 to 01/11/17 indicated Resident #114 had 16 episodes of bladder incontinence and three episode of bowel incontinence. There was no evidence the facility completed a comprehensive assessment to attempt to determine the cause of Resident #114's incontinence or the type of incontinence. There was no evidence of any interventions implemented to prevent further decline and/or improve her bladder and bowel function. Resident #114 was hospitalized from [DATE] to 01/18/17. Record review revealed Resident #114's readmission assessment dated [DATE] indicated the resident was occasionally incontinent of bowel and always incontinent of bladder. The resident was noted to be unable to recognize the need to void, couldn't get to the bathroom in time and was on medication that effected continence. There was no evidence a new elimination plan of care was imitated. On 01/26/17-Resident #114 was documented to be always incontinent of bladder and bowel without evidence of a toileting program. The resident's bladder and bowel documentation dated 01/20/17 to 01/26/17 however revealed the resident had 12 episodes of bladder continence and no episodes of bowel incontinence. There was no evidence the facility completed a comprehensive assessment to attempt to determine the cause of Resident #114's incontinence or the type of incontinence. There was no evidence of any interventions implemented to prevent further decline and/or improve her bladder and bowel function. From 02/02/17 through 02/16/17 Resident #114 was noted to be frequently incontinent of bladder and bowel without evidence of toileting program. There was no evidence the facility completed comprehensive assessment to attempt to determine the cause of Resident 114's incontinence or the type of incontinence. There was no evidence of any interventions implemented to prevent further decline and/or improve her bladder and bowel function. Review of Resident #114 bladder and bowel documentation dated 02/17/17 to 05/16/17 revealed the resident had five episodes of bladder continence and incontinent 202 times. The resident was continent of bowel three times and incontinent 20 times with out evidence of any interventions implemented to prevent further decline and/or improve her bladder and bowel function. Review of Resident #114's updated bladder and bowel care plan initiated on 12/16/17 revealed she was continent of bowel and incontinent of bladder. The goals indicated Resident #114 remain free of skin breakdown and remain clean and dry. The interventions indicated staff were to check Resident #114 as needed for incontinence, provide care, assist with clothing changed and incontinence products, and to ensure call light was in reach. On 05/16/17 at 12:55 P.M., interview with State tested nursing assistant (STNA) # 89 confirmed Resident #114 was always incontinent of bladder and bowel and wore incontinence products. STNA #89 verified Resident #114 was not on an individualized toilet program. On 05/17/17 at 10:00 A.M., interview with Resident #114's son revealed it was his belief that staff were not checking and changing his mother every two hours or before or after meals. Resident #114's son revealed he was at the facility before 8:00 A.M. this morning and it was 10:00 A.M. and staff had not checked his mom for incontinence. He reported staff usually just let her go in her incontinence brief. The son reported he visited daily for all meals except for dinner on Tuesday, Thursday, and Sundays. On 05/17/17 at 1:55 P.M., interview with STNA #75 verified Resident #114 was not on a toileting program. On 05/17/17 at 2:00 P.M., interview with Resident #114's son revealed he had been in Resident #114's room from 11:50 A.M. to 2:00 P.M. on this date and staff had not checked or changed his mother. He stated staff did bring in her lunch tray however never checked her for incontinence. On 05/17/17 at 2:20 P.M., interview with Director of Nursing (DON) confirmed Resident #114 had a decline in bladder and bowel function without evidence of a toileting program or an individualized toileting program. The DON was not aware of any bladder and bowel assessments completed by the facility to determine the type of incontinence Resident #114 experienced and confirmed the nurse aide documentation and MDS 3.0 documentation for her was not accurate. On 05/18/17 at 10:10 A.M., interview with Resident #114's son revealed the facility had brought in a better side commode for his mom. The son reported he arrived around 7:45 A.M. this morning and his mother was already up and in her recliner. The son indicated it was 10:10 A.M. and staff had not checked and changed his mom since he arrived this morning. Review of the bowel and bladder continence policy and procedure, dated 05/10/16 revealed staff were to provide the resident who was incontinent appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Urinary incontinence was often a symptom of a condition and may be reversible. It was important to understand the cause and address incontinence to the extent possible. If the cause for incontinence was reversible or able to be partially mitigated a continence program should be established with routine toileting times as indicated by the patterns established in the elimination records or designated times such as upon rising, before/after meals and at bedtime. If a resident required a structured continence program, they should be placed in a restorative nursing program with documentation completed per the program guideline. The elimination care plan should include individualized interventions to maintain or improve continence status of a clean, dry condition for those unable to re-establish continence.

Based on closed record review, staff interviews, family interview, review of the facility incident and accident log, review of the Procedure Guidelines Missing Resident policy and procedure and review of staff in-services for elopement, the facility failed to provide adequate supervision for Resident #89 who successfully eloped on 09/13/15 at approximately 6:30 P.M. Resident #89 was found lying in the middle of the road in front of the facility by a passing by motorist. The resident initially complained of pain, however subsequent nursing assessment revealed no injuries. Resident #89, had been admitted to the facility secured (Legacy Lane/Inspirations) dementia unit on 09/12/15 (one day prior to the elopement) for a respite stay. This resulted in Immediate Jeopardy for one of 26 residents, Resident #89, residing on the secured Impressions unit. On 01/27/16 at 2:30 P.M. the Executive Director (ED), Director of Nursing (DON) #17 and Administrator In Training #27 were notified that Immediate Jeopardy began on 09/13/15 at approximately 6:30 P.M. when Resident #89, who was assessed to exhibit wandering behavior and confusion, eloped from the facility. Prior to the incident, the resident had been observed by State tested Nursing Assistant (STNA) #9 pushing on the exit door leading to the courtyard. The resident was observed to apply sufficient pressure to the door causing it to alarm and then subsequently unlock. After the alarm sounded, the resident was re-directed away from the door by STNA #9, however, instead of monitoring the unlocked door or monitoring the continued whereabouts of Resident #89, both STNA #9 and STNA #10, two of the three direct care staff who were working on the Legacy Lane unit at the time of the incident, left Resident #89 and the area where the unlocked door was located to try to find a key to reset the door alarm. During the time when STNA #9 and STNA #10 were looking for the key to the door, Resident #89 exited the facility without staff knowledge and proceeded though an open courtyard gate which led to the highway (State Route 376) where the resident was found by an unidentified motorist, laying on the ground in the middle of the road. The Immediate Jeopardy was removed on 09/17/15 when the facility implemented the following corrective actions: · On 09/13/15 at 8:00 P.M., Assistant Director of Nursing (ADON) #11 and the Former Director of Nursing (FDON) #12 provided education to 96 staff members, which the facility identified as all staff from all facility departments. Topics included responding to alarms, including door alarms, immediately. Not assuming a resident did not exit the building. Search premises, if a resident is found bring the resident to safety. If no resident is found, perform a head count to account for all residents. Be aware that if the alarms are sounding, the gates outside are not locked. · On 09/15/15 (no time noted) FDON #12 provided inservice training to nine licensed nurses related to Keys. The information provided was that keys to medication cart and doors were to be left with another nurse before leaving facility for lunch break. · On 09/17/15 at 10:00 A.M., FDON #12 simulated an actual elopement drill on the secure unit. Twenty-six staff, including nursing and activities staff, participated in the drill. · On 09/21/15 Resident #89 was permanently discharged from the facility. · Between 09/17/15 and 01/27/16 there was no evidence any resident had successfully eloped from the facility. · Interviews on 01/27/16 at 8:42 A.M. with Licensed Practical Nurse/Legacy Lane Coordinator (LLC) #15, at 8:35 A.M. with Housekeeper #21, at 8:42 A.M. with Licensed Practical Nurse (LPN) #42, at 8:48 A.M. with STNA #22, at 8:53 A.M. with STNA #23, at 8:56 A.M. with STNA #24 and at 9:00 A.M. with Activity Director #25 revealed these staff, who worked on the Legacy Lane secured unit were knowledgeable of the facility Missing Person policy and what to do in the event a resident was missing. Although the Immediate Jeopardy was removed on 09/17/15 when staff training was completed and an elopement drill was conducted, the facility remained out of compliance at Severity Level 3 (Actual Harm). Findings Include: Review of Resident #89's closed medical record revealed the resident was admitted to the facility on [DATE] with the admitting [DIAGNOSES REDACTED]. Prior to admission, the resident resided at home with his spouse. The resident was admitted for a respite stay and was admitted to the facility secured (Legacy Place/Inspirations) unit. Review of the resident's nursing admission assessment dated [DATE] indicated the resident was at risk for elopement due to unaware of safety limitations related to the [DIAGNOSES REDACTED]. Review of the safety plan of care included in the nursing admission assessment dated [DATE] indicated interventions implemented included providing clear directions, ensure resident understanding, redirect resident and observe door codes and change as needed. Review of the admission physician's orders [REDACTED]. Review of Resident #89's nurse's notes revealed the following: On 09/12/15 at 2:50 P.M., the resident continued to ask for his wife, resident was very confused and the staff re-directed the resident as needed. On 09/13/15 at 6:00 A.M., the resident was up frequently asking for his wife. The resident was redirected without difficulty. The next entry in the nursing progress notes revealed, on 09/13/15 at 6:25 P.M., LPN #13 was made aware Resident #89 exited the facility and had fallen in the road with possible injuries. The note indicated the nurse immediately went to the secured unit and assessed the resident. No injuries were found. Review of the facility exit seeking circumstance investigation form, dated 09/13/15 at 6:20 P.M., revealed Resident #89 was found outside the secure unit courtyard door. The exit from the facility was not witnessed by facility staff and the section on the form for staff to document the last time the resident was observed was left blank. Resident #89's activity prior to exiting the facility was documented as wandering in the hallway and or common area. Resident #89 was assessed as being at risk for elopement. Review of the accident/incident report, dated 09/13/15 at 6:25 P.M., revealed Resident #89 exited the facility and fell in the road with possible injuries. LPN #13 and #14 immediately entered the secure unit and assessed the resident for injuries. Resident #89 had no injuries upon assessment. The investigation report indicated the resident had been wandering prior to the elopement. Review of STNA #10's written statement dated 09/13/15 at 7:35 P.M., revealed the STNA heard the door alarming while she was in the dining room. There was no documented evidence the STNA responded to the alarming door until STNA #9 came to the area of the dining room looking for the keys to turn the alarm off. Review of STNA #9's written statement which was dated 09/13/15 and timed 7:45 A.M., revealed STNA #9 was unsure of the exact time but indicated she witnessed Resident #89 push on the door, causing the alarm to activate and then saw the resident walk away. There was no evidence STNA #9 remained at the unlocked door but rather left the unlocked door area to go to an office and then the nurse's station to try to find keys to turn the alarm off. Review of Assistant Director of Nursing (ADON) #11's written statement dated 09/13/15 (no time specified) revealed she was notified Resident #89 had gotten out of the building and fallen in the road at approximately 6:30 P.M. ADON #11 questioned STNA #9 as to how the incident occurred to which the STNA replied the alarm went off , so I was looking for the key. When asked why the STNA did not investigate why the alarm went off, she said I didn't know he got out. Review of a typed summary, which was not signed by any staff member, involving Resident #89's elopement from the facility dated 09/13/15 revealed STNA #9 and STNA #10 reported after dinner they observed Resident #89 approach the door in the back dining room by the side entrance of the courtyard and press on the door handle. The door alarm sounded, resident walked away from door, STNA (doesn't specify which one) redirected resident down the corridor towards sitting lounge away from door. STNA #9 began to search for the key to silence alarm/secure door and did not observe Resident #89 in the area. Upon returning to the area where the door was located, STNA #9 and STNA #10 proceeded to go outside and noticed the back gate door (which allowed for exit from an enclosed courtyard) slightly ajar. They looked out the gate and saw Resident #89 standing next to a gentleman in the road. On 1/25/16 at 4:25 P.M., interview with STNA #9 revealed she was assigned to work on the secured unit on 09/13/15. The STNA stated she witnessed Resident #89 push on the door to the outside of the facility and set the door alarm off. The door, which was to be locked at all times, could be opened if pressure was applied for 15 seconds. An alarm also sounds when attempts are made to open it. The door will continue to alarm until silenced or reset and will also remain unlocked until reset with a key. She said, I re-directed him away from the door and I went to look for the keys to turn off the alarm, he must have got past me. She said, I could not find him so I went out in the court yard and seen the gate was open. I went down the sidewalk and saw him standing in the road with the unidentified truck driver. On 01/26/16 AT 9:20 A.M., interview with STNA #10 revealed she was assigned to work on the secured unit on 09/13/15. She stated she did hear the alarm sounding, and said, I don't know exactly how long the alarm was going off, maybe 5 minutes. She said STNA #9 and herself went and counted residents and we thought we made sure everyone was accounted for and we went outside to make sure no one was out there. She said, the gate was ajar a little, and then we saw him on the road. STNA #10 said a truck was in the road with a guy standing there. The guy in the truck said Resident #89 was lying in the road and he helped him up. She said, we thought he got hit by the truck, but the guy said he didn't hit him but saw him in the road and so he stopped and helped him. On 01/26/16 at 9:50 A.M., interview with LPN #13 revealed she was on duty when Resident #89 exited the facility and sustained a fall on the road. She said, the most I remember a staff member said the resident had gotten out and me and another nurse went immediately to the unit to assess him. She said, he was back in the building. She said, I found no injuries and then went and notified our bosses. The LPN said she placed a call to the nurse assigned to the secure unit and told her to come back to the facility. On 01/26/16 at 10:05 A.M., interview with LPN #16 revealed she was the assigned nurse to the secure unit the evening of 09/13/15 when Resident #89 eloped from the facility. She said, Well, I went to lunch and it happened when I was at lunch, She said, I came back from lunch and they told me what happened. She said, I was at lunch and really didn't have anything to do with the incident. The LPN did share during the interview that she had left the facility premises during her lunch and had taken the facility keys with her. This included the key needed to reset the exit door on the secured unit. On 01/26/16 at 8:50 A.M., interview with Resident #89's spouse via telephone revealed the facility had notified her within the first 24 hours after he arrived that he had escaped from the facility, he was found in the road by a motorist and he was in the locked ward, She said she had brought her husband to the facility for a week stay while she went on vacation. She said she took him home on 09/21/15. On 01/26/15 at 3:15 P.M., interview with the ED and the Director of Nursing (DON) #17, verified Resident #89 eloped from the secured unit and was found on the highway in front of the facility by an unidentified motorist. During the interview, the concern was shared that after the resident was observed to have activated the door alarm, which unlocked the door, the staff on the unit (STNA #9 and STNA #10) failed to provide the necessary supervision to the resident which resulted in him exiting the facility unsupervised. On 01/27/16 at 8:42 A.M. interview with LLC #15 revealed she had been the unit coordinator since June 2015. LLC #15 indicated she was not working on 09/13/15 when Resident #89 eloped. However, when asked if she felt the facility had followed the proper protocol and facility policy, she indicated she didn't think so. Upon further questioning, no additional information was provided by LLC #15 to elaborate why she didn't think so. On 01/27/16 at 12:10 P.M. interview with the ED revealed she was aware LPN #16 had left the facility for lunch on 09/23/15 and when leaving she took facility keys, including the key to the secured unit outside door. The ED indicated this wasn't the best practice but wasn't sure if the facility had any type of policy related to such. The ED revealed, following the incident on 09/15/15, nursing staff were educated by FDON #12 that if leaving the premises for lunch, nurses had to report off to another nurse and also had to leave their keys with a nurse who was in the building. Review of the facility's Procedure Guidelines- Missing Resident, last revised 09/16/11 revealed the purpose of the policy was to establish guidelines to report and investigate all reports of missing persons. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the charge nurse as soon as practical. For facilities that have a sounding alarm door, staff should respond promptly to a sounding door alarm. The charge nurse, facility supervisor or ED should designate a staff person to perform a facility head count to determine who may be missing. Two additional staff members should exit the alarming doorway and go in opposite directions around the building perimeter. The alarm should be disabled only at the direction of the (ED), or facility supervisor, or when the resident is returned to the facility. Upon return of the resident to the facility, examine the resident for injuries, contact the attending physician, report the findings and condition of the resident and follow orders received. Notify the search team members and the responsible party that the resident has been located. Complete an incident and accident report. Implement an intervention to prevent further occurrences. Notify the appropriate agency in accordance with State regulations and make an appropriate entry in the resident's medical record. This deficiency substantiates Complaint Number OH 277 and is an example of continued non-compliance from the complaint survey completed on 11/30/15.

Based on record review, policy review and staff interview, the facility failed to ensure hot packs were properly used during heat application treatments which resulted in a burn to Resident #86. Harm occurred to Resident #86 when he sustained second degree burns to his back caused by a heat treatment that was incorrectly applied. The nursing staff failed to ensure the heat application was only applied for the recommended amount of time and an appropriate assessment of the resident's skin was completed every five minutes during the course of the treatment as per their policy. This affected one resident (Resident #86) of three residents reviewed for heat application treatments. Findings include: A review of Resident #86's closed medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's admission orders [REDACTED]. A nursing admission assessment and data collection form dated 09/25/15 revealed the resident was dependent on staff for most of his activities of daily living which included transfers and bed mobility. His cognition was assessed as part of his admission assessment and indicated he had difficulty following what had been said. His cognitive impairment was indicated to affect his safety and judgement. He also had difficulty understanding and following directions. His mental functioning varied over the course of a day. His skin assessment did not document any known burns or blisters on his body at the time of his admission. A nursing progress note dated 09/29/15 at 1:00 A.M. revealed the resident complained of not being able to sleep due to lower back pain. The note indicated he was not due for any pain medication at that time. The progress note indicated the nurse had applied warm, moist heat to the resident's back. The nurse's progress notes indicated he was documented on two more times that night at 2:00 A.M. and 2:30 A.M. The progress note for 09/29/15 at 2:00 A.M. documented his vital signs and indicated he was still ringing his call bell frequently but would deny ringing it when staff responded. The last progress note for 09/29/15 at 2:30 A.M. revealed he was resting quietly with eyes closed. There was no additional progress notes documented on night shift for 09/29/15. There was no evidence showing the nurse who applied the hot pack to the resident's back was monitoring his skin, how the resident tolerated it, how long it was applied for, or when it had been removed. An incident report dated 09/30/15 at 1:00 P.M. revealed the nurse was called to Resident #86's room by a therapy staff member. Resident #86 was noted to have three blisters on his back. The therapist informed the nurse that she had found heat packs from therapy one morning that week in the resident's chair. The anatomical diagram on the incident report used to document the location of the blisters was marked to show there was one blister on the resident's left mid back, one on the right mid back and one on the right lower back. The incident report revealed the resident was not sent out for treatment. A skin impairment circumstance assessment and intervention form dated 09/30/15 revealed Resident #86 had three blisters to his back that were caused by hot packs used to manage pain. The form was marked to reflect the resident did not have the ability to change positions himself. He was assessed to have pain present in the wound. A telephone order sheet dated 09/30/15 revealed an order had been received for the use of Z-Guard topical ointment to the blisters on the resident's mid back to be applied daily until healed. An investigation report dated 09/30/15 for a new skin issue revealed the staff found three blisters to Resident #86's back, two of which had opened and drained and the other still fluid filled. The incident that caused the blisters was indicated to have occurred in the resident's room. The investigation report stated the root cause of the incident was unknown. There were comments added at the bottom of the report under other pertinent information that revealed someone used hot packs recently on his back to help with pain. An admission Minimum Data Set (MDS) 3.0 assessment, dated 10/07/15 revealed Resident #86 did not have any communication issues. He was able to make himself understood and was able to understand others. His Brief Interview for Mental Status (BIMS), an assessment tool used to identify cognitive impairment, score was 12 which indicated moderate impairment. He required an extensive assist of two staff for bed mobility and dressing and was dependent on two staff for transfers. A progress note from a certified nurse practitioner dated 10/08/15 revealed Resident #86 was seen on that date as a follow up to a request from the resident's family about his back pain. While she assessed his back pain she noted two open areas to the middle of his back. There was a dressing that was covering the area and was clean, dry and intact. She described the wounds as being superficial and due to moist heat injury. A review of the facility's guidelines for utilization of hot packs from the hydrocollator dated 04/21/15 revealed the purpose of its use was to increase circulation to the applied area to manage pain in addition to other benefits. The guidelines indicated the water temperature should be checked and maintained at approximately 150 to 170 degrees Fahrenheit prior to patient administration. The resident was then to be instructed regarding the purpose of the treatment and the temperature they should experience during treatment. The sensation should be warmth and not a hot or burning sensation. The staff was then to remove the hot pack from the hydrocollator unit and place it in a cloth cover or wrap it in towels with six to eight layers. When possible they were to put the hot pack on the resident rather than putting the resident on the hot pack. They were to check the resident's skin every five to 10 minutes during the treatment. If the skin became bright red or warm to touch, they were to add another layer of toweling. The duration of the hot pack treatment was generally 15-25 minutes or to the resident's tolerance. They were to place the call light in reach to allow the resident to alert staff if the hot pack became too warm. They were to remove the hot pack after the desired duration, observe the skin and return the hot pack to the hydrocollator unit for reheating. They were then to document the duration and tolerance to the treatment in the medical record. On 11/30/15 at 11:20 A.M., an interview with Therapist #5 confirmed the therapy department did not provide hot pack treatments to Resident #86 but it was provided to the resident by the nursing department. She stated up to two weeks ago they had access to the key that unlocked the hydrocollator but did not have access anymore. On 11/30/15 at 2:35 P.M., an interview with Registered Nurse (RN) #9 revealed she was the nurse that worked the night shift on 09/29/15. She confirmed Resident #86 had complaints of low back pain that night and was not due for any additional pain medication. She denied that the resident had an order for [REDACTED]. She reported she had only been employed for about eight weeks and was still learning the ropes. She indicated the resident was worked up about his pain and wanted something done to help relieve it. She stated she did not even know where the hot packs were and the other nurse had to show her. She denied that she had checked the temperature of the water in the hydrocollator prior to pulling the hot pack out. She was not sure if the other nurse who was with her had checked the temperature or not. RN #9 stated it was the other nurse who carried the hot pack to the resident's room. She only assisted with the positioning of the resident so they could get it under him while he was lying in bed. She reported they placed the hot pack in a special covering before it was applied under the resident and there was another towel placed over the cover. She reported the resident had a gown on and the hot pack was placed against the gown and not directly against his skin. She denied that there was six to eight layers between the resident's skin and the hot pack as specified in their policy. She was not sure how long the hot pack had been applied for and denied that she had removed it prior to her leaving at the end of her shift. She was not sure if the other nurse who stayed over had removed it before that nurse left at 3:00 A.M. She stated that she went in to check on the resident after it was applied but only asked how he was doing. She stated the resident replied he was fine. She denied that he had any complaints of the hot pack treatment being too hot or caused him any burning sensations. She also denied that she visually checked the resident's skin during treatment for [REDACTED]. She stated both her and the other nurse were busy with call lights that shift. She reported the other nurse explained what the purpose of the hot pack was but did not recall her explaining to him how the treatment should feel. She denied that she had explained that to the resident either. On 11/30/15 at 3:02 P.M., an interview with RN #13 confirmed she stayed over and worked until 3:00 A.M. on 09/29/15. She stated she was scheduled to stay over and worked as an aide from 11:00 P.M. to 3:00 A.M. that night on Resident #86's unit. She was aware the resident was given a hot pack that evening for complaints of back pain. She denied that she was the one who applied the hot pack and indicated it was RN #9 who applied it. She verified she was in the resident's room at the time it was applied. She also verified she had to show the other nurse where they kept the hot packs, where the covers were and where the key to the hydrocollator was kept. She denied she checked to see what the temperature of the water was in the hydrocollator prior to the hot pack being removed. She stated the temperature of the water was set by the therapy department. She did not know what the required temperature of the hot water should be that was specified in the policy. She reported she helped position the resident when the hot pack was applied. RN #13 verified there was a cover over the hot pack when it was used. She also confirmed an additional towel had been placed between the hot pack and the resident's clothing. She confirmed there were only three layers between the hot pack and the resident's skin and not six to eight layers that was suggested per their policy. She denied that she had any other involvement with the resident or the use of the hot pack. She stated she was working as the aide that night after 11:00 P.M. and did not have any responsibility with the nursing duties. She was not certain of the time the hot pack was applied and was not sure when or if it had been removed. She denied that she removed the hot pack before she left at 3:00 A.M. She indicated the resident was aware of the purpose of the hot pack as it was his request that it be used. He wanted a heating pad but was told they were not able to use one in the facility. He told them that he had used one while at home to help with his back pain. She denied that she or the other nurse explained to the resident how the hot pack should feel. He was not told that the hot pack should feel warm but not hot or burning. She denied that she was in his room after she helped position him on the pad and did not check his skin for warmth or redness as per their policy. She stated when she left at 3:00 A.M. she was not aware if the hot pack was still in place or had been removed by the other nurse. She reported the night shift nurse would have been there until 7:00 A.M. that morning. She stated there should have been a physician's orders [REDACTED]. She denied that she had encouraged the other nurse to use the hot packs and knew the resident did not have an order for [REDACTED]. She thought maybe it was considered a nursing judgement until a time in which the nurse could contact the physician for a valid order. On 11/30/15 at 3:17 A.M., an interview with the DON revealed she was in shock when she heard what happened to Resident #86 with the use of the hot pack. She was not aware they even had hot packs in the facility or that the nurses had access to them. She confirmed the nurse should have had a physician order [REDACTED]. She stated when she found out the therapy department had hot packs she ensured they were locked securely with no one having access to the key but therapy. She reported the resident was seen by the nurse practitioner regarding the burns and received treatment for [REDACTED]. She confirmed the resident had second degree burns to his back that were caused by the hot packs. She stated two of the three open areas dried up fairly quickly and was healed by 10/23/15. On 11/30/15 at 4:15 P.M., an interview with Therapist #5 revealed the key to the hydrocollator was now secured and could not be accessed by any of the nursing staff. She stated the therapy department checked the temperature of the water inside the hydrocollator daily and recorded it on a log. She reported they used a regular thermometer to check the temperature as there were no gauges that gave a reading. She stated the temperature was usually maintained between 160 and 165 degrees Fahrenheit. She indicated there was a thermostat for adjusting the temperature that was located under the hydrocollator by the drain but they did not have to mess around with that. It maintained it's temperature pretty well. She reported when the therapy department used it they check the resident's skin before and after treatment. They also check it every five minutes during the treatment. They monitored for warmth and redness of the skin and would apply an extra layer between the hot pack and skin if those things were noted or the resident complained of it being too hot. She reported the cover they used was the equivalent of two towels. She stated they would use additional towels to ensure there were six to eight layers between the hot pack and the resident's skin. Clothing counted as a layer depending on how thick it was. She reported the hot packs retained it's heat for about 10-15 minutes before it started to cool down. They tried not to lay the resident down on the pad and would position them on their side or up in a chair if using it on the back. She indicated she would only lay the resident directly on the hot pack if they were alert. She would also ensure there were extra layers between the hot pack and the resident's skin when lying directly on it. She stated she was the one who found the hot pack in the resident's chair the next day. She denied she found the blisters and reported it was probably the occupational therapy assistant when the resident was given his bath. This deficiency substantiates Complaint Number OH 582.

Based on medical record review, review of the facility's Self Reported Incident reports (SRI), review of the facility's Fall Management Procedure and staff interview, revealed the facility failed to ensure adequate supervision to prevent resident to resident altercations related to choking, biting, punching and knocking residents to the floor resulting in bloody nose and lip lacerations. This affected eight of 27 residents who resided on the Inspirations Unit (Residents #4, #6, #10, #14, #18, #20, #26 and #27). The total census was 93. Harm occurred when Resident #4 was struck and pushed to the floor and sustained a bloody nose and small lip lacerations. In addition, Harm occurred to Resident #18 had repeated falls without evidence of implementation of appropriate fall interventions to help decrease the risk for falls. Findings include: 1a. Review of a SRI revealed a resident to resident (R-R) altercation occurred on 09/30/13. According to the SRI, Resident #26 was sitting at a table when Resident #14 begin to push Resident #26 into the table. Resident #14 then put her hands on Resident #26's shoulders shaking Resident #26. Resident #26 grabbed Resident #14 by the wrist and Resident #14 had the fingers of her left hand in Resident #26's nostrils. Resident #26 then bit Resident #14 on the right wrist. The skin was not broken on the wrist of Resident #14. A bite impression was left on the wrist of Resident #14. The bite mark resolved after 20 minutes. No other injuries were noted. Both residents were redirected by staff without difficulty. According to the facility's investigation of the SRI substantiated the abuse. Both residents had [DIAGNOSES REDACTED]. There was no evidence staff intervened to prevent the incident. Review of the medical record of Resident #14 revealed a Minimum Data Set (MDS) assessment dated [DATE] indicated the resident could sometimes be understood and understand others. The resident was identified as having both short and long term memory problems. The resident had severely impaired decision making skills. The assessment indicated physical behaviors occurred 1-3 times per week, verbal behavior symptoms directed toward others 4-6 times per week. The resident had behaviors of wandering daily. Review of the Individual Plan of Care (POC) for Resident #14 last revised on 09/27/13 under section for cognition revealed due to my progressive [DIAGNOSES REDACTED]. "My short and long term memory display deficits. I have a short attention span. Please redirect and remind me often of your task or communication. Please redirect me to areas of need, dining, activity, showers, beauty shop if you take my hand I will usually cooperate". Under the section of Mood and Behaviors "I recently returned/readmitted to the facility from a brief psychiatric stay. I have had a few visits this year. My [DIAGNOSES REDACTED]. Observation of Resident #14 on 12/13/13 from 6:00 A.M. to 3:00 P.M. revealed the resident wandered about aimlessly on the Inspirations Unit except for meals. The resident wandered in and out of other resident rooms. Intermittent observation of Resident #14 on 12/17/13 and 12/18/13 revealed the resident walked about the unit, wandering in and out of other resident rooms. The resident was independently ambulatory. 1b. Review of the medical record for Resident #26 revealed the MDS assessment completed on 11/21/13. The assessment revealed the resident sometimes understood others and made herself understood. The resident had both short and long term memory problems. The resident was assessed as severely impaired to make decisions. The resident was documented as having behaviors daily. The resident was documented as wandering daily. Review of the POC of Resident #26 last updated for cognition on 11/25/13 revealed "I have a [DIAGNOSES REDACTED]. I am unable to comprehend most action/messages. Please remain patient with me and ask needed information. I may become easily annoyed/agitated but generally will answer you as I am passing by. I display deficits of long and short term memory". Under the section Mood and Behavior section "I display moods/behaviors almost on a daily basis. Due to this I received psychiatric services as needed. He prescribes and monitors my medications to help with stabilization. Please monitor me for side effects that could be related to my taking these medications and notify my doctor if you see any of these. Please redirect me as needed even though I may become somewhat physical and or verbally aggressive with staff and others-depending on my day. I do wander daily. Please make sure my pathways are unobstructed and others are clear of my destination". Observation of Resident #26 on 12/13/13 revealed she ambulated without difficulty, spit in the trash can frequently and yelled at other residents. On 12/17/13 at 4:15 P.M. one resident kept requesting ice cream. Resident #26 yelled at him "you don't need it". Staff were observed to give Resident #26 ice cream. 2a. Review of a SRI for R-R altercation involving Residents #20 and #26 on 10/24/13 substantiated by the facility revealed at the Front Hall, Resident #20 twisted Resident #26's nose then shoved her to the floor. Review of Nurse Progress Note for 10/24/13 at 5:15 P.M., revealed Resident #20 had been wandering on the unit. Staff heard shouting, then saw Resident #20 approach Resident #26, twisted her nose and then shoved her to the floor. Staff immediately provided one on one redirection by directing Resident #20 to another area. Review of facility substantiated R-R altercation with the Executive Director on 12/16/13 at 2:45 P.M. verified the R-R abuse occurred as submitted. 3a. Review of SRI dated 11/26/13 between Resident #4 and Resident #27 was substantiated as abuse by the facility. Review of the facility Summary of the Incident between Resident #27 and Resident #4 on 11/26/13 at 2:30 P.M. revealed the incident occurred in Room 217 on the Inspirations Unit. The narrative summary of the incident and investigation documented the licensed practical nurse (LPN) on the dementia unit heard a loud noise in Resident #27's room. The LPN entered the room and observed Resident #4 getting up off of the floor. The LPN observed Resident #27 trying to hit Resident #4. The LPN observed Resident #4 with a bloody nose and redness under the right eye. The residents were separated immediately. A head to toe assessment was completed on both residents and first aid administered to Resident #4. Review of the Altercation Form dated 11/26/13 revealed Resident #4 went into Room 217 and a physical and verbal incident occurred. The physical injury description of Resident #4 revealed he had a nose bleed, his nose was red, had two small slits on his lip. The form was marked as a yes for emotional distress. Resident #4 was very upset after the altercation. The physician and family was notified. The intervention listed was to keep Resident #4 out of Room 217. Review of the Nurse Progress Note for 11/26/13 at 2:30 P.M. revealed the nurse heard a commotion and ran to Room 217. Resident #4 was bent over a tipped chair trying to set up. His helmet was intact. The nurse helped Resident #4 up. The LPN noted Resident #4 had a bloody nose and the resident had been hit in the face. Resident #4 was removed from the room. Review of the medical record for Resident #4 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the Inspirations Unit. Review of the MDS assessment for Resident #4 dated 10/04/13 revealed the resident had severely impaired cognition. The resident was documented with behavioral symptoms of wandering and pacing every day. Review of the Nurse Progress Note dated 11/27/13 revealed Resident #4's nose was slightly swollen and there was a discolored area at end of nose. According to additional nurse progress documentation the following occurred: a. On 11/28/13 at 2:00 P.M., Resident #4 ambulated much of the day. Up and down corridor and in and out of rooms. The documentation did not evidence any redirection was attempted. b. On 12/04/13 at 11:45 A.M. Resident #4 ambulates in hall and wanders into other residents rooms. Redirected per staff without difficulty. c. On 12/14/13 at 12:00 P.M. Resident #4 ambulates in hallway and into other Residents rooms. Redirected by staff without difficulty. A Social Worker note dated 11/27/13 at 8:50 A.M. revealed the social worker was notified by LPN charge nurse of Resident #4's 11/26/13 incident. Resident on secured unit due to him wandering about without purpose or direction or regard to personal safety. The note revealed he wandered into present fell ow males room and said male became aggressive and physically hit resident in facial area. Resident unable to voice any discomfort due to dementia. Observation of Resident #4 on 12/13/13 and 12/17/13, revealed he wandered aimlessly and entered other resident rooms without redirection by staff. The resident wore a protective helmet to prevent fall injury. 3b. Review of the medical record for Resident #27 revealed original admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the medical record for Resident #27 revealed he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was identified as severely cognitively impaired and had behaviors of verbal outbursts and wandering. Review of the POC for Resident #27 dated 9/26/13 revealed a [DIAGNOSES REDACTED]. Moderate cognition deficit noted. I am forgetful and need reminded of meals and activities. I can usually understand and I can usually be understood. Moods and behaviors: Dementia and behaviors had no reference to behavior of striking another resident on 11/26/13. Review of an Altercation Form in the record of Resident #27 dated 11/26/13 revealed Resident #4 was in Room 217 where a physical and verbal incident occurred. Physical injury description: Resident had nose bleed, nose red, two small slits on lip. Emotional distress marked yes. Resident very upset after altercation. Resident wandered into Room 217. Intervention: keep resident out of Room 217, other resident put on every 15 minute checks for 24 hours. Review of Nurse Progress Notes for Resident #27: a. On 07/31/13 at 11:20 A.M. another resident wandered into the resident's and Resident #27 struck the resident with his closed hand. Staff witnessed and removed resident from the room. Redirection effective. no injury. b. On 09/04/13, resident upset with roommate who was asking for help. Staff responded to roommate. Resident #27 threatens roommate and then goes toward him with closed fist. Resident then threatened staff. c. On 09/08/13, upset due to roommate talking out. States he's going to shut him up. The nurse attempted to medicate Resident #27 after several attempts of redirection. Resident jumps up out of bed and swings his fist at nurse and STNA. Hit STNA in the chin. Resident calmed down.. Physician notified. At 6:00 P.M., order for Ativan 2 milligram intramuscularly every four hours as needed for aggression. Will evaluate in the morning. d. On 9/10/13, order for transfer to emergency room via ambulance for medical clearance then admission to psychiatric unit for medication adjustment. e. On 12/06/13 at 5:30 P.M. revealed the nurse heard a loud noise in the back lounge and found Resident #27 and another resident sitting on their bottoms. Resident #27 reported she attacked me, pointing at the other resident. Both residents were removed from the situation. No injury noted. Observation of Resident #27 revealed he stayed in his room except for meals on 12/13/13. He independently ambulated to the dining room. Observation of the resident on 12/17/13 revealed again the resident would eat and go back to his room. The resident talked to staff freely. 4a. Review of another Self Reported Incident (SRI) revealed the SRI was completed on 12/04/13 and involved Resident #6 and #10 on 11/30/13. Under the section: What effect on resident? Resident #10 had a pink area on the left front neck. No distress was noted. It was documented the resident had no recollection of the incident. No signs or symptoms of pain, no difficulty swallowing, breathing and the residents voice was normal. Under the section of the SRI called Summary of the Incident revealed on 11/30/13 at 4:30 P.M. Resident #10 screamed. Staff members State tested Nurse Aide (STNA) #7 and Housekeeper #8 responded. STNA #7 arrived at the doorway slightly before Housekeeper #8 and reported to the nurse that she saw Resident #6 "choking" Resident #10. The nurse evaluated Resident #10 and did not note any areas on shoulders, neck or head. A call was placed to the Director of Health Services (DHS). The residents were separated and one to one supervision was initiated for Resident #6. The DHS documented interview of both employees on 12/01/13 concerning observations made from the doorway revealed during separate interviews, there was a noted discrepancy in statements regarding if Resident #6 was actually choking resident Resident #10. STNA #7 stated that Resident #6 was choking Resident #10. However, Housekeeper #8 indicated that this was not what she witnessed. STNA #7 was again interviewed on 12/02/13 and asked again if this was what she witnessed. STNA #7 was documented as indicated in the report that the more she thought about it, Resident #10 may have just had his hands on her shoulders. Additional questions were asked and STNA #7 indicated that both residents were still. Resident #6 was not shaking the female resident. During this interview, STNA #7 indicated that Resident #6 was not choking Resident #10. However, review of the report evidenced a discrepancy. The report was noted to indicate the nurse documented Resident #10 had a pink mark on her neck and in the Summary of the Incident report it was changed and documented the assessment did not note any areas on shoulders, neck or head. The facility unsubstantiated this incident for physical abuse. The initial report of STNA #7 documented Resident #6 was choking Resident #10 which was completed on the day of the incident. STNA #7 was the first witness of the incident, Housekeeper #8 came to the room after STNA #7. The change in statement was made the day after the incident. 4b. Review of the medical record for Resident #10 in relation to the incident of 11/30/13 at 4:30 P.M. in the Nurse Progress Note documentation revealed STNA #7 heard Resident #10 yelling out and responded to Room 209. The male Resident #6 who resided in Room 204 had his hands around Resident #10's neck squeezing. The STNA intervened immediately and separated the residents. Resident #10 was documented in the nurses notes as having a small slightly reddened area to left side of the front of the neck. The Nurse Progress Note was completed by LPN #20. Review of the Nurse Progress Note dated 12/01/13 at 1:00 P.M. for Resident #10 revealed no redness or bruising noted to Resident #10's neck. No complaints of sore throat, no difficulty swallowing and no recollection of the events. The family was updated. On 12/16/13 at 3:05 P.M., interview with STNA #7 who witnessed the incident on 11/30/13 revealed her initial report was what she saw. STNA #7 stated Resident #10's face was red and her lips were white but she was still breathing OK. STNA #7 stated she yelled Resident #6's name and Resident #6 let go of Resident #10's neck. STNA #7 stated the housekeeper came to the door way behind me after she yelled Resident #10's name. Interview with LPN #20 on 12/17/13 at 4:15 P.M. verified she was the nurse on duty at the time of the incident which occurred on 11/30/13 involving Residents #6 and #10. The nurse stated an aide was running the sweeper but you could hear a loud scream. STNA #7 responded to Room 209, which was not either resident's room. The report she received from STNA #7, who was the first person in the room, on the initial observation of the incident was that Resident #6 was choking Resident #10. An assessment was completed on Resident #10. LPN #20 stated Resident #10 had a thumbprint size red mark on the front of the neck. LPN #20 stated the redness went away in about two hours. 4c. Review of the medical record for Resident #6 revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission MDS completed 11/13/13 revealed the resident was sometimes understood/understands. Resident with a short and long term memory deficit and was severely impaired with decision making. Review of the POC dated 11/21/13 for Resident #6 revealed cognition deficits with both long and short term memory. The plan of care instructed staff to redirect as needed to maintain safety. Under the section mood and behaviors it was documented the resident became easily annoyed/angered daily due to the inability to understand the intent of others. The plan of care documented the resident was physically abusive at times. Approach in a calm manner and allow time to calm down and re-approach. The plan of care indicated the resident seldom talks and answerers with a nod of the head. 5. Review of the medical record for Resident #18 revealed he was admitted to facility on 01/06/10 with [DIAGNOSES REDACTED]. On 11/30/12, [DIAGNOSES REDACTED]. On 12/5/13, a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #18 was usually understood and sometimes understood others. The resident had moderate cognitive impairment. The behavior section indicated the resident had no behaviors. Review of functional status revealed the resident required extensive assist of two for bed mobility. The resident required extensive assist of one staff to transfer. The resident required supervision of one to walk in his room. Walk in corridor required limited assist of one. The resident was assessed as not steady on his feet, only able to stabilize with staff assistance. Not steady with walking, only able to stabilize with staff assistance. The resident required staff assistance to stabilize when turning around. The resident required assist of staff to stabilize when transferring from surface to surface. Review of the POC for Resident #18 last updated 10/28/13 revealed a [DIAGNOSES REDACTED]. I need limited to extensive assist with most of my ADL's because of my diagnosis. I am at a higher risk to fall. Make sure that I have nonskid foot wear on when I am out of bed and keep things that I use frequently close to me. This is to help me meet my goal of not injuring myself because of a fall". "On 9/14/13, I was getting up from my chair and slipped on some urine on the floor. No injuries noted. Resident to be free of falls and injury at all times. Staff will check a urine to rule out a urinary tract infection. Review plan of care on 12/14/13". That was the last update to the part of the POC that made reference to falls. Review of Nurse Progress Notes for Resident #18 revealed a fall on 09/14/13 in his room and was found on the floor beside his bed. No injury was noted. Review of a Fall Report completed on 09/14/13 revealed an order to repeat a urinary analysis in three days. A note dated 09/30/13 at 12:30 A.M. revealed staff found the resident up in his room walking, two STNA's returned the resident to bed. Review of a Nurse Progress Note dated 11/20/13 at 11:40 A.M. revealed Resident #18 was ambulated to the dining room by a STNA. The note indicated the STNA left the room to provide care to another resident and Resident #18 stood up unassisted with his walker and fell backward. The note indicated no apparent injury. Neurological checks were started due to the resident hitting his head on floor. Review of the Fall Assessment completed on 11/20/13 revealed the intervention was to refer for a therapy screen. The form was reviewed on 11/21/13 by staff members with no change made to interventions to prevent the resident from future falls. Review of the physical therapy (PT) screen revealed the screen was not completed until Wednesday 11/27/13. The screen indicated the need for PT services. The assessment revealed the resident's mobility had walking and moving around with functional limitation, current status had been documented based on required assistance to perform sit to stand transfers as well as limited ambulation distance. No treatment was started for Resident #18 before the resident fell on [DATE] and 11/30/13 which resulted in a fractured hip. Review of a Fall Assessment completed on 11/29/13 revealed Resident #18 had another fall at 12:15 P.M. The fall was not witnessed. The investigation indicated staff sat the resident in a chair by the entrance door. The resident was found on the floor. No injury was indicated on the form. The cause of the fall was documented as the resident tipped the chair over getting up on his own. The nurse documented she checked the resident's ears. The section for intervention update was left blank. No new interventions were implemented to prevent future falls for Resident #18. Review of a Fall Assessment completed on 11/30/13 for Resident #18 revealed the resident fell in his room at 4:30 A.M. and was found by staff by the closet. The note indicated the resident was going to the closet to get clothes. The note indicated safety equipment was in place, the bed wheels were locked. The resident's Change in Condition Dorm completed on 11/30/13 at 4:30 A.M. revealed the resident complained of left hip pain and pain of the thigh. The resident was assessed as not being able to walk and guarding his left side. The form noted the resident was turned by staff at 3:30 A.M. on 11/30/13 and an increase in confusion was noted. There was no documentation to indicate staff response to the increased confusion for Resident #18. Review of the hospital notes for Resident #18 revealed [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE]. Review of the Falls Management Program Guidelines dated as revised on March 2008 revealed the purpose maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The procedure under Guide #3 directed should the resident experience a fall the attending nurse shall complete the "Fall Circumstance and Reassessment Form". The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the team to evaluate thoroughness of the investigation and appropriateness of the interventions. At Guide #4. An "accident and incident report should be completed at the time of the incident. Guide #6. An order received from the physician should be noted and carried out. Guide #7. The nursing assistant assignment sheet and resident care plan should be update to reflect any new or change in interventions. The above information related to Resident #18 and multiple fall incidents was reviewed with LPN #2 on 12/13/13 at 1:30 P.M. LPN #2 verified no change in fall interventions were documented. On 12/19/13 at 9:00 A.M., interview with the facility's Executive Director (ED), the Director of Health Services and Physical Therapy Assistant (PTA) #1 reviewed the fall history for Resident #18 and facility interventions to prevent future falls. The staff stated the fall on 11/20/13 intervention was to complete a physical therapy screen. The screen was provided on 11/21/13. Interview of the PTA #1 revealed it was identified the resident required a PT evaluation. The PT evaluation was not completed until 11/27/13 which further identified the resident required care and treatment of [REDACTED]. When questioned why the delay in the PT evaluation, PTA #1 and the ED replied "we had to verify payer source before we could provide service". The surveyor questioned what interventions were put implemented for Resident #18 between the fall on 11/20/13 and the next fall on 11/29/13 to prevent falls and keep the resident safe. Review of the POC with the DHS failed to identify any interventions put in place. This was verified by DHS at 9:30 A.M. on 12/19/13. The resident had an appointment with his Urologist and Optometrist between that time. Questioned the DHS what interventions were put in place after the 11/29/13 fall for Resident #18 to keep him safe from future falls. The DHS replied they checked his ears. Resident #18 fell on [DATE] and fractured his left hip. This deficiency substantiates allegations contained in Master Complaint Control Number OH 936 and Complaint Control Number OH 929.