Every finding on record at Hopewell Grove Rehabilitation and Healthcare

Based on record review, observation, resident and staff interviews, wound nurse practi-tioner interview, review of wound notes, hospital records, wound clinic records, review of the information from the National Pressure Injury Advisory Panel (NPIAP), and policy re-view, the facility failed to ensure the physician ordered treatments were completed as di-rected and failed to ensure interventions were implemented to prevent the development of, worsening of and promote the healing of avoidable facility acquired stage IV and un-stageable pressure ulcers with the development of osteomyelitis (a serious infection and inflammation of the bone or bone marrow, typically caused by bacteria (most commonly Staphylococcus aureus) or fungi. It occurs when infections spread from nearby tissue, open wounds, or the bloodstream, causing symptoms like localized bone pain, swelling, fever, and redness) for Resident #72. Resident #72 was at risk for pressure ulcer [NAME]-opment and dependent on staff for activities of daily living (ADLs) including transfers, bed mobility, turning and repositioning and toileting and a known left ischium stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough, a yellowish, stringy dead tissue or eschar, a layer of dead, dry tissue that forms a dark leathery scab over the ulcer may be present on some parts of the wound bed. Often includes undermining and tunneling). This resulted in Immediate Jeopardy for Resident #72 when the facility failed to implement effective interventions to prevent the development of and adequately treat avoida-ble facility acquired unstageable (full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) pressure ulcers to the right ischium and the bilateral buttocks (sacrum). On 08/27/25, Resident #72 requested to go to the emergency room due to laboratory blood results obtained due to monitoring of the sacrum pressure ulcer on 08/26/25 resulting in a higher white blood cell count 18.6 (K/cm) (high white blood cell count can indicate a range of conditions including infections, inflammation, injury and immune system disorders) compared to results obtained on 08/21/25 of 14.9. Resident #72 was admitted to the hos-pital with a stay of 08/27/25 through 09/01/25 with a diagnosis of osteomyelitis of the sa-cral stage IV pressure ulcer requiring intravenous antibiotics and ongoing treatment for the left and right ischium pressure ulcers. In addition, a concern that did not rise to the level of Immediate Jeopardy but did rise to the level of Actual Harm was identified on 01/12/26 for Resident #6, who was admitted on [DATE], (at risk for pressure ulcer development and altered skin integrity) when the facil-ity failed to implement pressure ulcer prevention strategies and the resident developed an in-house unstageable pressure ulcer. In addition, a concern that did not rise to the level of Immediate Jeopardy or Actual Harm was identified related to the facility's failure to ensure pressure ulcer prevention measures and care were in place for Resident #2.This affected three (Residents #2, #6 and #72) of three residents reviewed for pressure ulcer care. The facility census was 74.On 02/17/26 at 2:56 P.M. the Administrator, [NAME] President of Operations #1051, [NAME] President of Clinical Services (VPCS) #1029, Regional Director of Clinical Services (RDCS)#1050, and Director of Nursing (DON) #1057 were notified Immediate Jeopardy began on 08/27/25 when the facility failed to provide correct treatment orders, necessary interventions and notification to the medical provider of abnormal laboratory results timely for Resident #72 to prevent avoidable facility acquired pressure ulcers to the right ischium and sacrum with the declining of the unstageable sacrum pressure ulcer resulting in hospitalization on 08/27/25 for osteomyelitis. Resident #72 returned to the facility on [DATE] with continued inaccurate treatments and necessary interventions to promote healing of the left and right ischium and sacrum pressure ulcers. Resident #72 continued to have the three areas of pressure ulcers as of 02/10/26.The Immediate Jeopardy was removed on 02/19/26 when the facility implemented the following corrective actions: -On 02/17/26 immediately after being notified at 3:00 P.M. Licensed Practical Nurse (LPN) #1077 initiated skin inspection on all 79 current residents with verifying interventions. All residents were assessed by the LPN #1077 by 10:00 P.M. with treatments initiated for new identified areas. All inspections were completed by LPN #1077. The following residents with new areas identified were: Resident #11 with a loose toenail and a new order for a protective dressing, Resident #24 with a blister to the abdomen and a new treatment order of non-stick pad, Resident #55 with an abrasion to a knee and a new treatment of a bordered foam. -On 02/17/26 immediately after being notified at 3:00 P.M., the current six residents (Residents #2, #3, #6, #61 #72, and #90) with pressure injuries treatment orders were audited by the RDCS #1050. The audits were to verify current orders in the electronic medical record (EMAR) match the order provided by the Wound Consultant Nurse Practitioner (WCNP) #1054. The RDCS #1050 audited wound note visits from the wound clinic visit on 02/17/26 for Resident #72 and verified orders. Resident #72 is the only resident that sees an outside wound clinic at this time. -On 02/17/26 at 5:15 P.M. the facility completed an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting with Medical Director #1028 via phone with attendance of: Administrator, DON #1057, LPN #1077, VPO # 1051, Activity Director #1073, Dietary Manager # 1074, Admissions #1075, Social Service Designee #1079, Medical Records #1072, Maintenance Director #1076, and Housekeeping Director #1080. The meeting discussed and addressed the Immediate Jeopardy and education was initiated post Immediate Jeopardy meeting with the nursing department.-On 02/17/26 the DON #1057 began education to facility nurses and Certified Nurse Assistants (CNA) at 3:30 P.M. CNA and nurse education included skin prevention, daily skin care, skin inspection, skin inspection, skin inspection, documentation of refusal nutrition & hydration, and reporting & documentation. Nurses were educated on treatment implementation when skin alteration identified, ensuring interventions in place, documentation of refusals, following orders given by the physician or nurse practitioner and reporting abnormal labs same day as resulted with documentation. -On 02/17/26-The DON #1057 verbally provided education to the following staff: eight LPNs, 17 CNAs, and two Registered Nurses (RN) on 02/17/26 by 10:00 P.M. Any staff member that did not receive the education at this time, messages were left and unable to speak with, will have verbal education prior to next scheduled shift. At 6:30 P.M., a communication message was sent to all staff that have not received education to contact the DON #1057.-On 02/17/26 education was completed by the DON #1057, at 10:30 P.M. Staff (5 LPNs and 22 CNAs) that a message was left for will be educated prior to next scheduled shift.-On 02/17/26 the clinical management team, DON #1057, LPN #1077 and LPN #1078 were educated by the RDCS #1050 on auditing skin prevention, interventions, order implementation, and documentation. The education was completed at 3:30 P.M. DON #1057 will be completing pressure wound measurements and assessments with the addition of MDS RN #1071, as back up to DON #1057 for wound assessment. -On 2/17/26 VPCS #1029 and the RDCS #1050 reviewed Skin and Wound Policy for accuracy and ensure policy meets regulatory guidelines.-On 2/18/26 at 4:00 P.M. education initiated by the clinical management team, DON #1057, LPN #1077 and LPN #1078 was given to all licensed nurses on changes in resident skin integrity related to decline and interventions and notification of labs to medical profession, to be completed by 7:00 P.M. on 2/18/26. - On 02/19/26 the RDCS #1050 completed an audit on wound evaluations initiated since 02/17/26 wound rounds to identify new skin areas and verified that all new skin issues had new treatments and discovered: Resident #14 with a skin tear and a new treatment of xeroform and kerlix, Resident #6 with a skin tear to left shin with a treatment of xeroform and Kerlix, Resident #22 with two new diabetic ulcers with a treatment of xeroform and kerlix and Resident #94 with new pressure area to sacrum and treatment in place of chamosyn (a multi-purpose, paraben-free, and nourishing barrier ointment formulated with Zinc Oxide, Menthol , Aloe, and Manuka Honey to protect, soothe, and treat skin irritated by moisture, incontinence, or fecal/vaginal fistulas. It is designed to create a protective barrier while reducing inflammation) and leave open to air (LOTA). -Beginning on 02/19/26 DON #1057/designee will audit all new admissions orders for 30 days to ensure skin treatments were implemented as ordered. If the DON #1057 is not available, the RDCS #1050 will audit. The audit will verify each identified area has a treatment in the EMAR and will be completed by DON #1057 or LPN #1077 or LPN #1078 in the DON #1057's absence.-Beginning on 02/19/26 DON #1057/designee will audit all residents seen by wound consultants and outside wound clinics weekly x 4 weeks for resident's treatment orders to verify they match the wound consultant orders, if seen by wound consultant. The audit will verify the orders were implemented timely by the facility nurse. - On 02/19/26 at 3:00 P.M. DON #1057 educated MDS RN #1071 on auditing skin prevention, interventions, order implementation, and documentation.-Beginning on 02/24/26 all audit results will be reported to QAPI for review weekly x four weeks.Although the Immediate Jeopardy was removed on 02/19/26, the facility remains out of compliance at a Severity Level 3 (actual 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: 1.Record review revealed Resident #72 was admitted on [DATE]. Diagnoses included left buttock stage 4 pressure ulcer, paraplegia, generalized anxiety disorder, major depressive disorder, neuromuscular dysfunction of bladder. Review of the hospital stay documents dated 06/18/25 through admission to the facility on [DATE] for Resident #72 revealed a left ischium stage IV pressure ulcer with osteomyelitis with orthopedic surgery recommending follow up care with a tertiary center for potential debridement and plastic surgery consult wound coverage/closure. Documentation did discuss a wound vac for the left ischium Stage IV pressure ulcer, but no discharge wound care treatments were noted. This resident also had a suprapubic catheter and an ostomy. There was no evidence that the orthopedic surgery recommendation of follow up care with a tertiary center for potential debridement and plastic surgery consult wound coverage/closure was completed. Review of the progress note dated 07/03/25 12:30 P.M. for Resident #72 revealed the resident was admitted to the facility. Review of the admission evaluation dated 07/03/25 at 12:30 P.M. for Resident #72 revealed a mental status of knows own limits, a skin impairment of pressure (no location, assessment and measurement), a Braden Scale for Predicting Pressure Sore Risk score of 15 indicated mild risk on a scale of 6 (high risk) to 23 (no risk) and a two person assist with bed mobility. Review of the wound evaluation for Resident #72 dated 07/04/25 at 2:06 A.M. by LPN #1027 revealed a left buttock stage IV pressure ulcer measured 3 centimeters (cm) by 2 cm by 2 cm with no description of the wound bed. Review of the physician order for Resident #72 dated 07/04/25 at 2:15 A.M. by LPN #1027 revealed a treatment for the left buttock, wash wound, apply wound vac every Monday, Wednesday and Friday. Review of the plan of care dated 07/04/25 for Resident #72 revealed impaired skin integrity with no interventions to assist to turn and reposition, float/elevate heels while in bed and a low air loss mattress. Review of the admission evaluation for Resident #72 dated 07/07/25 by Family Nurse Practitioner (FNP) #1052 revealed the only skin impairment was a left ischium pressure ulcer. Per nursing documentation, no noted concerns or changes for care since admission. Review of the Treatment Administration Record (TAR) for Resident #72 revealed on 07/04/25 and 07/07/25, no treatment was signed off as completed for the left buttock pressure ulcer wound vac. Review of the physician order for Resident #72 dated 07/07/25 at 2:53 P.M. by RN #5555 revealed bilateral heel boots as preventative measure every day and night shift. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was moderately cognitively impaired. Resident #72 required substantial/maximal assistance with shower/bathe self and total dependence with bed mobility, transfers, and toilet hygiene. Resident #72 had a pressure injury and was not on a turning/repositioning program. Review of the wound consult visit notes revealed Resident #72 was seen by Wound Certified Nurse Practitioner (WCNP) #1055 on 07/09/25. Upon assessment, the wound vac was not connected to the resident, and the resident was a full two person assist for activities of daily living. Recommended for follow up with a plastic surgeon to discuss debridement and wound closure. The facility documented a left buttock, but it is a left ischium unstageable pressure ulcer measuring 2.6 cm by 1.8 cm by 1.2 cm and wound bed description 40 percent granulation and 60 percent slough. Exposed tissues included dermis, subcutaneous and adipose. Required debridement. A treatment plan of cleanse with wound cleanser, apply Hydrogel, Calcium Alginate with Silver to the base of the wound and cover with bordered foam daily. A new facility acquired area of a left heel unstageable pressure ulcer measured 1 cm by 0.6 cm by no depth. Required debridement. A treatment plan of cleanse with wound cleanser, apply skin prep to the base of the wound, secure with bordered foam and change twice a day. Preventative measures to include but not limited to turning/repositioning per protocol and floating heels while in bed with the use of heel boots. Review of the nutritional risk assessment dated [DATE] at 2:00 P.M. by Dietician #1111 for Resident #72 revealed she was bedridden, and had a skin condition of a pressure ulcer or multiple areas that are at least a Stage III/IV/unstageable with admitted left buttock pressure ulcer and now a left heel unstageable pressure ulcer. Recommend starting Prostat (a protein supplement) 30 milliliters twice a day to assist with wound healing and will continue to monitor and follow up as needed. No acute nutrition concerns at that time. There was no documentation Resident #72 refused care or was non-compliant with care including turning and repositioning. Review of the plan of care initiated on 07/16/25 for Resident #72 revealed at risk for impaired skin integrity related to confined to bed all or most of the time, paraplegia, and requires staff assistance to reposition with interventions including but not limited to assist resident with turning and repositioning as needed and if resident refuses interventions, encourage compliance. Review of the wound consult visit notes revealed Resident #72 was seen by WCNP #1123 on 07/16/25. The left ischium measured at 3.5 cm by 2.5 cm by 2.9 cm and the left heel unstageable wounds were stable. Wound bed description 70 percent granulation and 30 percent slough with exposed tissues now including muscle/fascia. Required debridement. A new treatment plan of cleanse with wound cleanser/normal saline, apply medical grade honey, Calcium Alginate to the wound bed and secure with boarded foam daily. The left heel unstageable pressure ulcer no concerns/changes to treatment. A new area of bilateral buttocks gluteal dermatosis (a common, underdiagnosed skin condition in the elderly, characterized by brownish, scaly, and thick (lichenified) plaques on the buttocks, (primarily caused by chronic pressure and friction from prolonged sitting) partial thickness measuring 4 cm by 2.5 cm by 0.1cm. Wound base 100 percent epithelial with peri wound intact and erythema. A treatment plan of cleanse with soap and water, apply Zinc Oxide, but prefer Triad paste (WCNP #1123 preferred the Triad paste) to the base of the wound and leave open to air every shift and as needed. Review of the physician orders dated 07/16/15 through 07/22/25 for Resident #72 revealed no treatment order for the bilateral buttocks gluteal dermatosis and no new treatment order for the left ischium unstageable pressure ulcer. (There was no order placed in the electronic medical record at all for the bilateral buttocks gluteal dermatosis). Review of the TAR for Resident #72 dated 07/16/25 through 07/22/25 revealed no treatment for the bilateral buttocks gluteal dermatosis and the incorrect treatment for the left ischium unstageable pressure ulcer. Review of care visit for Resident #72 dated 07/18/25 by FNP #1052 revealed will add an air mattress to her bed to help prevent further pressure ulcers and improve comfort. Review of the wound consult visit notes revealed Resident #72 was seen by WCNP #1055 on 07/23/25. The left ischium unstageable pressure ulcer worsened. it now measured 3.2 cm by 3 cm by 2.9 cm and had undermining from 6 o'clock to 12 o'clock at 3.2 cm. The wound bed description was 60 percent granulation and 40 percent slough with continued exposed muscle/fascia. Required debridement. A new treatment plan of cleanse with wound cleanser/normal saline, apply Calcium Alginate and Zinc Oxide to the base of the wound, secure with bordered foam daily. The left heel unstageable pressure ulcer no concerns/changes to treatment. The bilateral buttocks gluteal dermatosis partial thickness had worsened. It now measured 12 cm by 7 cm by 0.1 cm. Wound base 100 percent epithelial and peri wound intact, erythema and fragile with light amounts of serosanguineous exudate. A new treatment plan of cleanse with soap and water, apply medical grade honey, xeroform, Zinc Oxide to the peri wound to the base of the wound, secure with an abdominal dressing and change daily. Review of the physician order for Resident #72 dated 07/24/25 at 10:44 A.M. by LPN #1027 revealed for the bilateral buttocks gluteal dermatosis, cleanse with soap and water, apply medical grade honey, xeroform, Zinc Oxide to the peri wound, change daily. Start date of 07/25/25. Review of the physician orders for Resident #72 dated 07/24/25 through 07/29/25 revealed no new treatment order for the left ischium unstageable pressure ulcer.Review of the TAR for Resident #72 dated 07/24/25 through 07/29/25 revealed the incorrect treatment order for the left ischium unstageable pressure ulcer and no treatment completed for the bilateral buttock gluteal dermatosis on 07/24/25 and 07/25/25.Review of the wound consult visit notes revealed Resident #72 was seen by WCNP #1055 on 07/30/25. The left ischium unstageable pressure ulcer worsened and measured 4.2 cm by 3 cm by 3.5 cm with undermining from 6 o'clock to 12 o'clock at 3.2 cm. Wound base 40 percent epithelial and 60 percent slough with continued exposed muscle/fascia and now a mild odor after cleansing. Required debridement. A new treatment plan of cleanse with wound cleanser/normal saline, apply Santyl, Dakin's solution (no percent) moistened fluffed gauze to base of wound, secure with an abdominal dressing and change twice a day. The left heel has resolved. The bilateral buttocks gluteal dermatosis partial thickness worsened, measured 12 cm by 8 cm by 0.2 cm. Wound base 30 percent epithelial, 20 percent granulation, 50 percent slough and 20 percent eschar with mild odor after cleansing. Peri wound intact, erythema, fragile with moderate amount of serosanguinous exudate. A new treatment plan of cleanse with soap and water, apply medical grade honey, Calcium Alginate with Silver, Chamosyn to perilous to base of the wound, secure with abdominal dressing and change daily. A new facility acquired right ischium unstageable pressure ulcer measured 2.9 cm by 3.2 cm by 0.1 cm with wound base 20 percent epithelial and 80 percent eschar. Exposed tissues of the epithelium and dermis. A treatment plan of cleanse with soap and water, apply medical grade honey, Calcium Alginate with Silver to the base of the wound, secure with abdominal dressing and change daily. Review of the medical record for Resident #72 revealed no clarification/addendum with WCNP #1055 of the Dakin's Solution percent needed for the treatment of the left ischium unstageable pressure ulcer. Review of the physician order for Resident #72 dated 08/01/25 revealed a low air loss alternating pressure mattress to bed, check placement and function every shift. Review of the physician orders dated 08/01/25 at 12:38 A.M. by DON #2233 revealed no Dakin's Solution percent for the treatment of the left ischium unstageable pressure ulcer.Review of the physician orders for this resident dated 07/30/25 through 08/05/25 revealed no Dakin's Solution and Santyl ordered to come from the pharmacy. Review of the Medication Record Administration (MAR) and TAR dated 07/30/25 through 08/05/25 revealed the incorrect treatment completed for the left ischium unstageable pressure ulcer (due to no Santyl and Dakin's Solution). Review of the wound consult visit notes revealed Resident #72 was seen by WCNP #1055 on 08/06/25. The left ischium unstageable pressure ulcer measured 3.8 cm by 4.2 cm by 3.2 cm, undermining from 6 o'clock to 12 o'clock at 3.1 cm. Wound base 40 percent granulation and 60 percent slough with continued exposed muscle/fascia. Required debridement. A treatment plan to continue order from 07/30/25. The bilateral buttocks gluteal dermatosis full thickness measured 11.5 cm by 8.5 cm by 0.3 cm. Wound base 10 percent epithelial, 20 percent granulation, 50 percent slough, and 20 percent eschar. Peri wound intact, erythema, fragile with moderate amount of serosanguinous exudate. Required debridement. A new treatment plan of cleanse with wound cleanser, apply Santyl, Dakin's (no percent) solution moistened fluff gauze, nonstick contact layer to base of the wound, secure with abdominal dressing, change twice a day. The right ischium unstageable pressure ulcer measured 2.5 cm by 3 cm by 0.2 cm with the wound base 20 percent epithelial, 30 percent granulation, and 50 percent slough. Exposed tissues of the epithelium and dermis. Required debridement. A treatment plan to continue cleanse with soap and water, apply medical grade honey, Calcium Alginate with Silver to the base of the wound, secure with abdominal dressing and changed to twice a day. Review of the medical record for Resident #72 revealed no clarification/addendum with WCNP #1055 of the Dakin's Solution percent needed for the treatment of the left ischium unstageable pressure ulcer and bilateral buttocks gluteal dermatosis. Review of the physician order for Resident #72 dated 08/06/25 at 6:10 P.M. by LPN #1027 revealed no Dakin's Solution percent for the treatment of the left ischium unstageable pressure ulcer and the frequency was daily. Review of the physician order for this resident dated 08/06/25 at 6:15 P.M. by LPN #1027 revealed a treatment for the bilateral buttocks gluteal dermatosis to cleanse with wound cleanser, apply Dakin's Solution (no percent specified) moistened gauze, Santyl nickel thick and cover with abdominal dressing every day, on day shift. Review of the physician orders for this resident dated 08/06/25 through 08/12/25 revealed no Dakin's Solution and Santyl ordered to come from the pharmacy. Review of the MAR and TAR dated 08/07/25 through 08/12/25 revealed the incorrect treatment completed for the left ischium unstageable pressure ulcer and the bilateral buttocks gluteal dermatosis (this was due to no Santyl, Dakin's Solution, and incorrect frequency.) Review of the wound consult visit notes revealed Resident #72 was seen by WCNP #1055 on 08/13/25. The left ischium unstageable pressure ulcer worsened, measured 4 cm by 4 cm by 3.3 cm, undermining from 6 o'clock to 12 o'clock at 3.1 cm. wound base 20 percent granulation, 80 percent slough, with continued exposed muscle/fascia and malodorous after cleansing. Required debridement. The treatment plan was to continue from 08/06/25. The bilateral buttocks worsened to an unstageable pressure ulcer, measured 13.5 cm by 10.2 cm by 1.5 cm. Wound base 10 percent granulation, 60 percent slough, 30 percent eschar with exposed tissue now including subcutaneous. Moderate amount of serosanguineous and purulent exudate with malodorous odor after cleansing. Required debridement. A treatment plan to continue from 08/06/25. The right ischium measured 4 cm by 5 cm by 0.4 cm with wound base of 20 percent epithelial, 30 percent granulation, and 50 percent slough. Exposed tissue now includes subcutaneous. Required debridement. The treatment plan changed to cleanse with wound cleanser, apply Dakin's Solution (no percent specified) moistened fluffed gauze, Santyl to base of wound, secure with an abdominal dressing and change twice a day. Review of the medical record for Resident #72 revealed no clarification/addendum with WCNP #1055 of the Dakin's Solution percentage needed for the treatment of the left ischium, right ischium and bilateral buttocks unstageable pressure ulcers. Review of the physician order for this resident dated 08/15/25 at 9:04 A.M. by LPN #1010 revealed Santyl, apply per additional directions topically every shift for wound care. Continued review of the physician orders for this resident dated 08/13/25 through 08/20/25 revealed no Dakin's Solution ordered to come from the pharmacy. Review of the MAR and TAR dated 08/13/25 through 08/19/25 revealed the incorrect treatment completed for the left ischium, right ischium, and bilateral buttocks, unstageable pressure ulcers due to no Santyl for 2 days no Dakin's Solution and incorrect frequency of the left ischium and buttocks treatment. There was no documentation of any concerns of Resident #72 refusing any pressure ulcer treatments/interventions. Review of the wound consult visit notes revealed Resident #72 was seen by WCNP #1055 on 08/20/25. The left ischium unstageable pressure ulcer measured 4 cm by 3.8 cm by 3 cm with no documentation of assessment and description. Required debridement. A new treatment plan to cleanse with wound cleanser, apply medical grade honey, Collagen, and Calcium Alginate to wound bed, secure with abdominal dressing and change twice a day. The bilateral buttocks unstageable pressure ulcer measured 11 cm by 11 cm by 4.5 cm with no documentation of assessment and description. Required debridement. A treatment plan to continue from 08/06/25. The right ischium unstageable pressure ulcer had no documentation for measurements, assessments, descriptions and treatment plans. Review of the medical record for Resident #72 revealed no clarification/addendum with WCNP #1055 of the Dakin's Solution percent needed for the treatment of the bilateral buttocks unstageable pressure ulcer and for the right ischium pressure ulcer measurements, assessments, descriptions and treatment plan. Review of the physician orders for Resident #72 dated 08/20/25 through 08/27/25 revealed no Dakin's Solution ordered to come from the pharmacy. Review of the physician order for this resident dated 08/21/25 at 3:13 A.M. by LPN # 7777 revealed a CBC laboratory test for reported tarry stools. Review of the MAR and TAR dated 08/20/25 through 08/27/25 revealed the incorrect treatment completed for the right ischium, and bilateral buttocks unstageable pressure ulcers (no Dakin's Solution, and incorrect frequency of the buttocks treatment). Review of the complete blood count (CBC) laboratory results were received on 08/21/25 at 8:42 A.M. Resident #72's white blood cell (WBC) count was 14.9, which was high. Reported to facility on 08/21/25 at 12:58 P.M. Review of care visit for Resident #72 dated 08/21/25 by FNP #1052 revealed they were aware of WBC count of 14.9 with note of ongoing wound care for pressure ulcers. Review of the e-Care triage note for Resident #72 dated 08/24/25 at 12:23 P.M. by FNP #3333 revealed need to pain control for multiple pressure wounds as wounds are large and painful for dressing changes. Review of care visit for Resident #72 dated 08/25/25 by FNP #1052 revealed a follow up for pain of the sacrum pressure ulcer. Obtain another CBC laboratory test and obtain a sacrum (bilateral buttocks) wound culture. Review of the physician order for Resident #72 dated 08/25/25 at 4:01 P.M. by DON #2233 revealed a CBC laboratory test and a sacrum (bilateral buttocks) wound culture. Review of the CBC laboratory results for Resident #72 dated as received on 08/26/25 at 9:47 A.M. at 12:23 P.M. revealed a WBC count of 18.6, which was high. Reported to facility on 08/26/25 at 12:37 P.M. Review of the medical records for Resident #72 revealed no communication or notification of abnormal laboratory results reported to the FNP-BC #1052, Medical Director #1028 or the eCare triage center. Review of the progress note for Resident #72 dated 08/27/25 at 11:19 A.M. by LPN # 1010 revealed labs reviewed with resident, resident requesting to go to emergency room and transported at 11:15 A.M. Review of the hospital admission documentation dated 08/27/25 for Resident #72 revealed admission for sacrum (bilateral buttocks) pressure ulcer osteomyelitis requiring intravenous antibiotics throughout stay. The resident was also assessed to have left and right ischium pressure ulcers. Review of the medical record from 09/01/25 through 01/30/26 revealed Resident #72 was totally dependent for bed mobility, at risk for pressure ulcers and continued to have a left ischium, right ischium and sacrum stage IV pressure ulcers. Review of the physician orders through that time period revealed delayed and incorrect treatment orders and plans of care and revealed interventions were not specific to Resident #72. Review the after-visit summary dated 01/31/26 for Resident #72 revealed wound care treatment for the sacrum and left ischium of cleanse with wound cleanser, apply Calcium Alginate, cover with dry gauze and secure with tape, change every other day and as needed. For the right ischium, apply Zinc Oxide daily and as needed. Follow up with Adena Wound Clinic for follow up care. Review of the progress note dated 01/31/26 at 6:28 P.M. for Resident #72 revealed returned to the facility from a hospital stay unrelated to the pressure ulcers. Review of the admission evaluation dated 01/31/26 at 10:30 P.M. for Resident #72 re-vealed the resident was alert and oriented to person, place and time, mobility to be very limited with the ability to change and control body position, a left buttock pressure ulcer area with no measurement and assessment and a Braden Scale for Predicting Pressure Sore Risk score of 14 indicated moderate risk on a scale of 6 (high risk) to 23 (no risk). Review of the physician orders for Resident #72 dated 01/31/26 and 02/01/26 revealed no treatments orders for the sacrum, left ischium and right ischium pressure ulcers. Review of the MAR/TAR dated 01/31/26 and 02/01/26 for Resident #72 revealed no treat-ments completed for the sacrum, left ischium and right ischium pressure ulcers. Review of the wound evaluation for Resident #72 dated 02/01/26 at 9:31 A.M. by LPN # 1077 revealed a left ischium stage IV pressure ulcer measured 2.5 cm by 3 cm by 1.5 cm. Review of the wound evaluation for this resident dated 02/01/26 at 9:38 A.M. by LPN #1077 revealed a right ischium stage IV pressure ulcer measured 0.5 cm by 0.7 cm by 0.2 cm. Review of the wound evaluation for this resident dated 02/01/26 at 9:46 A.M.

Based on observations, interviews, and review of facility policy, the facility failed to ensure foods were stored in a sanitary manner. This had the potential to affect all 74 residents residing in the facility who were identified as eating food prepared in the facility kitchen. The facility census was 74.Findings include:Observation on 02/09/26 at 6:34 P.M. revealed a large amount of flour was lying in the bottom of a plastic bin located on the second shelf inside the dry storage room. Three bags of open corn flakes were lying on a shelf and did not contain a date they had been opened. Soft taco shells were being stored inside plastic storage bags and were not labeled with a date opened. Interview with Dietary Employee #1201 at the time of the observation confirmed all opened foods were to labeled with the date opened and confirmed the plastic bin with flour in the bottom of it needed to be cleaned out. Observation inside the walk-in refrigerator on 02/09/26 revealed a large bag of shredded mozzarella cheese was lying on the shelf. The bag had been opened at the top corner and had not been closed or sealed after being opened. The bag was not labeled with the date opened and had a moderate amount of a light red substance located on the bag around the opening. A bag of salad mix had been opened and was not closed or sealed after being opened. Some of the lettuce inside the bag of the salad mix was light brown in color and was wilted and slimy in appearance. An open package of sliced hickory-smoked turkey breast was stored in a plastic storage bag and was dated as being opened on 12/29/25, 42 days prior. An open package of thick-sliced bologna was stored in a plastic storage bag and was dated as being opened on 12/25/25, 47 days prior. Two plastic storage bags containing boiled eggs with the shells removed and sliced ham which was yellow in color and contained a large amount of a slimy substance on the slices had not been labeled with dates opened or prepared. The bags of boiled eggs and sliced ham were lying in the bottom of a metal pan which an unknown red, thick liquid in the bottom of it. A plastic beverage pitcher was sitting on the top shelf and contained a brown, thick substance. The pitcher was not labeled with a date prepared or the substance inside it. A small plastic cup with a white plastic lid contained thin fluid which was white and clear. The plastic cup was not labeled with a date or the substance inside it. Interview with Dietary Employee #1205 at the time of the observation confirmed foods should be labeled with the date opened or prepared. Dietary Employee confirmed the package of thick-sliced bologna dated 12/25/25 and the package of sliced hickory-smoked turkey breast dated 12/29/25 were likely expired and should have been thrown out. Dietary Employee #1205 confirmed the plastic cup with the white and clear liquid appeared to be spoiled milk which had separated. Dietary Employee #1205 confirmed the metal pan with red, thick liquid in the bottom of it needed cleaned and food should not have been lying inside it. Dietary Employee #1205 confirmed food packages should be closed or sealed properly once opened to prevent spoiling of the food inside. Review of the facility policy titled Food Storage, dated 11/2025, revealed food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination and cross-contamination. Food should be dated as it is placed on the shelves if required by state regulation. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days. All goods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen, or discarded. This deficiency represents non-compliance investigated under Complaint Number 2707280.

Based on record review, staff interview, and facility policy review, the facility failed to implement and maintain a comprehensive Quality Assurance Improvement Program (QAPI) program and plan to address care issues and/or concerns in the facility. This had the potential to affect all 74 residents who reside in the facility. The facility census was 74.Findings include:Review of the Quality Assurance (QA) committee attendance records for the previous eight months revealed QA meetings were held every month. Review of falls, pressure ulcers for residents that are healing, not healing, present on admission and or are in-house acquired, antibiotic use and weight loss are some of the areas discussed.The findings for the annual survey, dated 02/09/26 revealed noncompliance in the area of pressure ulcer care, which included prevention and treatments, resulting in substandard quality of care with an Immediate Jeopardy beginning on 08/27/25 for Resident #72 and an Actual Harm, beginning on 01/12/26 for Resident #6.Interview on 02/19/26 at 10:00 A.M. with the Administrator revealed the QAPI meetings are held monthly. He has attended the last two QAPI meetings since becoming the Administrator, which were December 2025 and January 2026 and will need to review the other six months of QAPI meetings that he was not in attendance. Verified at those two QAPI meetings, no residents were identified as ongoing issues and care for their pressure ulcers.Interview on 02/19/26 at 10:40 A.M. with the Administrator revealed no identification of ongoing issues and care for pressure ulcers at the facility for the previous six months of QAPI meetings prior to him (May 2025 through November 2025).Review of the facility policy titled Quality Assurance Performance Improvement dated November 2025 revealed Quality Assurance is a continuous process towards management where interventions are analyzed and targeted key performance improvement steps are identified. The Quality Assurance Committee has the overall responsibility and authority to conduct a confidential and privileged review of resident care and service trends to identify opportunities for performance improvement, identify quality issues and develop plans of action. Quality Assurance Performance Improvement is an ongoing process and reviews facility trends from data collection which includes quality of care with pressure ulcers.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure insulin and eye drops were labeled with the date opened and failed to ensure insulin glargine was discarded timely after being opened. This affected six residents (#9, #10, #24, #47, #55 and #60) whose medications were observed during the medication storage task. The facility census was 74.Findings include:Record review for Resident #9 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included senile degeneration of the brain, type two diabetes mellitus, and Alzheimer's disease. Review of the physicians order for Resident #9, dated 01/14/26, revealed 10 units of insulin glargine was to be administered subcutaneously at bedtime related to type two diabetes mellitus. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included chronic obstructive pulmonary disease, type two diabetes mellitus, and subluxation of the lens of the left eye. Review of the physicians order for Resident #10, dated 09/10/25, revealed one drop of 0.2 percent Brimonidine Tartrate Ophthalmic Solution was to be administered in the left eye three times a day related to subluxation of the lens of the left eye. Record review for Resident #24 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included metabolic encephalopathy, type two diabetes mellitus, and heart failure. Review of the physicians order for Resident #24, dated 02/14/26, revealed 20 units of insulin glargine was to be administered subcutaneously at bedtime for type two diabetes mellitus. Record review for Resident #47 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included chronic obstructive pulmonary disease, respiratory conditions due to smoke inhalation, and vascular dementia. Review of the physicians order for Resident #47, dated 11/25/25, revealed two puffs of Budesonide-Formoterol Fumarate Dihydrate 80-4.5 micrograms per actuation was to be inhaled by mouth twice a day for chronic obstructive pulmonary disease. Record review for Resident #55 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included acute kidney failure, bipolar disorder, and primary open-angle glaucoma. Review of the physicians order for Resident #55, dated 05/20/25, revealed one drop of 0.005 percent Latanoprost Ophthalmic Solution was to be administered in each eye at bedtime related to primary open-angle glaucoma. Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included type two diabetes mellitus, cerebral infarction, and vascular dementia. Review of the physicians order for Resident #60, dated 12/08/24, revealed 40 units of Lantus was to be administered subcutaneously at bedtime for diabetes mellitus. Observation of the C-Hall medication cart on 02/19/26 at 8:38 A.M. with Licensed Practical Nurse (LPN) #1037 revealed Resident #24's insulin glargine was open and was not labeled with the date it had been opened, Resident #55's Latanoprost eye drops were open and were not labeled with the date opened, and Resident #10's Brimonidine eye drops were open and were not labeled with the date opened. Interview with LPN #1037 at the time of the observation confirmed resident eye drops and insulin were to be labeled with the date when opened by the nurse. Observation of the B-Hall medication cart on 02/19/26 at 8:46 A.M. with LPN #1094 revealed a vial of insulin glargine had been pulled from the emergency drug box and was placed in the medication cart for Resident #60 but was not labeled with the date the bottle was opened. The Budesonide-Formoterol Fumarate Dihydrate inhaler for Resident #47 was open and was not labeled with the date opened. Insulin glargine for Resident #9 was in the medication cart and was dated as being opened on 01/16/26, 34 days prior. Interview with LPN #1094 at the time of the observation confirmed residents insulin and inhalers were to be labeled with date when opened by the nurse. LPN #1094 confirmed Resident #9's insulin glargine was dated as being opened on 01/16/26, 34 days prior to the observation. Review of the facility policy titled Storage of Medications, dated 11/2025, revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Insulin glargine expires 28 days after first use or removal from the refrigerator, whichever comes first.

Based on record review, policy review, and staff interview, the facility failed to implement the antibiotic stewardship policy to ensure antibiotics were prescribed appropriately. This affected three of three residents reviewed for antibiotic use (Residents #2, #5, and #33). The facility census was 74. Findings include: 1. Review of the record for Resident #5 revealed an admission date of 08/26/25 with diagnoses including malignant neoplasm of the urethra, chronic kidney disease, and obstructive and reflux uropathy. The resident had an indwelling catheter. Review of physician progress notes on 02/11/26 revealed the resident was transferred to the emergency room this morning after her catheter was found dislodged in her bed with the balloon still inflated. She reports that the catheter was likely accidentally pulled out. The facility staff are not permitted to replace the catheter due to her cancer diagnosis, so she went to the emergency room for replacement. The catheter was successfully replaced. A urinalysis showed large amounts of blood and leukocytes and she was diagnosed with a urinary tract infection (UTI). She was discharged back to the facility on Cefuroxime (antibiotic) 250 milligrams two tablets every 12 hours for seven days. She reports pain only when the catheter was being manipulated but otherwise feels fine. Review of a physician progress note on 02/13/26 revealed the resident continued on the antibiotic and denied dysuria, fever, flank pain, chest pain, or dyspnea. The note stated the urine culture and sensitivity results were pending. Will adjust antibiotic treatment if necessary based on culture results. Review of urine culture results obtained on 02/14/26 revealed 50,000-100,000 CFU/ML of pseudomonas aeruginosa and 10,000-50,000 CFU/ML pseudomonas aeruginosa. The results did not list Cefuroxime as an antibiotic effective against the bacteria. Review of an antibiotic stewardship evaluation completed by the facility 02/12/26 revealed the UTI did not meet the McGeer's criteria. ( to meet McGeers criteria, must be symptomatic and have a urine culture with > 10 to the fifth power (>100,000)CFU/ML of any organisms). However, the antibiotic was continued. Physician response for use of treatment stated: due to her medical condition of bladder cancer, not treating current symptoms would risk further complications. It did not indicate what physician gave the response or what the symptoms were that would risk further complications. Interview with Regional Director of Clinical Services #1050 on 02/17/26 at 1:09 P.M. confirmed the antibiotic Resident #5 was receiving was not listed on the urine culture sensitivity to indicate if the the bacteria was sensitive to that medication. She confirmed the urine culture did not show > 100,000 bacteria as required by the McGeers criteria. She confirmed the antibiotic stewardship evaluation completed 02/12/26 did not indicate what physician gave a response or what symptoms were present. 2. Review of the medical record for Resident #2 revealed an admission date of 02/07/26 and diagnoses including diabetes and chronic kidney disease. He had an indwelling catheter. He had a physician's order upon admission [DATE] for an antibiotic (Keflex) 500 milligrams every six hours for 10 days for UTI. On 02/07/26 an antibiotic stewardship evaluation was completed by the facility which stated he had a UTI with onset date of 02/07/26. Not experiencing pain related to the infection. No other urinary symptoms were documented. It further stated he had repeated oral temperature of 99 degrees Fahrenheit. It stated he met the McGeers criteria due to the fevers and a urine culture with at least 10 to the fifth power of any organism. Review of the urine culture results dated 02/09/26 revealed > 100,000 CFU/ML of proteus mirabilis. The sensitivity report did not include Keflex to determine if the bacteria was sensitive to that antibiotic. The facility provided documentation that stated that the effectiveness of Keflex is not guaranteed against UTI's and depends heavily on local resistance patterns. It stated urine culture and sensitivity testing is crucial before prescribing. Recent guidelines often favor alternative antibiotics over Keflex due to variable efficacy and resistance concerns. The Keflex was given until 02/14/26 (7 days out of 10) when it was discontinued due to the resident having diarrhea. He was then started on a different antibiotic (Doxycycline) due to chest xray results indicating pneumonia. On 02/15/26 at 5:19 A.M. nursing progress notes stated he returned from the emergency room where he was diagnosed again with a UTI. He was started on an antibiotic (Bactrim DS) 800-160 mg twice daily for five days. Interview with the Director of Nursing on 02/19/26 at 8:00 A.M. revealed she marked the antibiotic stewardship evaluation in error as Resident #2 did not have repeated oral temperatures of 99 degrees. She stated he had one temperature of 99.5 degrees on 02/07/26 but no other elevated temperatures. She confirmed there was no evidence the physician reviewed the use of Keflex when it was not listed on the urine culture sensitivity as effective against the bacteria. 3. Review of the medical record for Resident #33 revealed an admission date of 01/08/26 and diagnoses including diabetes and hypertension. On 01/15/26 the resident was sent to the emergency room. Hospital records on 01/15/26 stated the resident had decreased urinary output with concerns for kidney injury. States burning urinary pain. Has catheter. However the notes further stated denies abdominal or flank discomfort, fevers, chills, hematuria, or dysuria. The resident was started on an antibiotic (Macrobid) 100 milligrams twice daily for five days for UTI. The medication was given for five days as ordered. A physician progress note on 01/15/26 stated will continue Macrobid as prescribed. Follow up on urine culture results to ensure appropriate antibiotic coverage. Review of urine culture results on 01/19/25 indicated 10,000-50,000 CFU/ML of pseudomonas aeruginosa and escherichia coli. (not > 100,000 as required to meet McGeers criteria). Interview with the Director of Nursing on 02/19/26 at 8:00 A.M. revealed an antibiotic stewardship evaluation was not completed for the use of Macrobid on 01/15/26. She further confirmed there was no evidence of follow up by the physician on the use of the Macrobid when urine culture results did not support the use of an antibiotic. Review of the facility policy on Infection Prevention and Control Program dated October 2025 revealed McGeer criteria is used for infection surveillance. Review of the Antibiotic Stewardship policy dated October 2025 revealed the purpose of the the antibiotic stewardship program was to monitor the use of antibiotics. It stated when a culture and sensitivity is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on observations, record review, policy review, and staff interview, the facility failed to ensure the smoking policy was implemented to ensure the environment was free from hazards, and failed to implement assistive devices to prevent falls. This affected two residents (#39, #41) of three residents reviewed for accidents. The facility census was 74. Findings include: 1. The facility identified 15 residents as smokers, including Resident #39. Nine of the residents were identified as independent with smoking and six were identified as supervised with smoking. Resident #39 was identified as an independent smoker. Review of the record for Resident #39 revealed an admission date of 08/19/25 and diagnoses including cerebral vascular accident with hemiplegia and hemiparesis, diabetes, and hypertension. A Minimum Data Set assessment completed 01/19/26 documented a brief interview for mental status score of 15 (intact cognition). A smoking evaluation conducted 11/26/25 and 02/10/26 stated the resident may smoke independently. Review of the plan of care for Resident #39 dated 6/6/25 revealed the resident is a smoker. The goal was for the resident to follow the facility rules for designated smoking areas and smoking materials. An intervention included informing the resident of the storage of smoking materials. Observations on 02/10/26 at 3:20 P.M. revealed Resident #39 to have his cigarettes and lighter stored in his coat pocket in his room. Resident #39 stated it was permissible for him to store the items in his room. Review of the facility undated smoking policy revealed residents will smoke in designated areas only. Resident smoking materials will be retained and distributed by the facility staff to the residents during designated smoking times and/or when independent residents choose to smoke. Interview with the Administrator on 02/10/26 at 3:30 P.M. revealed residents are not to keep cigarettes and lighters in their rooms. He stated independent smokers are to lock their cigarettes and lighter in a box by the exit door to the smoking area after they are done smoking. The cigarettes and lighter are to be stored in the locked box until they smoke again. Interview with the Administrator on 02/12/26 at 8:48 A.M. revealed the social worker did verify that Resident #39 had his cigarettes and lighter in his room after the surveyor notified the Administrator on 02/10/26. He further confirmed that the facility smoking policy did not address that independent smokers were keeping their cigarettes in a locked box by the exit door. He stated independent smokers have keys and started using the locked boxes around October 2025. 2.Review of the medical record for Resident #41 revealed an admit to the facility date of 10/07/25 with diagnoses including but not limited to dementia, chronic obstructive pulmonary disease, schizoaffective disorder, polyneuropathy, and muscle weakness. Review of the Medicare Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/13/25 for Resident #41, revealed a Brief Interview for Mental Status (BIMS) of 15. This resident required supervision or touching assistance with toileting, lying to sitting, sitting to lying, sitting to stand and rolling with partial assistance with bathing/showering. This resident was also assessed to have had one fall since admission with no injury. Review of the plan of care dated 10/08/25 for Resident #41 revealed at risk for falls related to generalized weakness with interventions in place. Review of progress note dated 11/30/25 at 12:40 A.M. for Resident #41 revealed the resident had fallen asleep while sitting, then lying on the side of the bed and ended up sliding off the bed. No injuries were noted. Review of the plan of care revised on 11/30/25 revealed at risk for falls related to generalized weakness and intervention including but not limited to educate and encourage resident to position themselves in the middle of the bed upon lying down. Review of progress notes dated 12/01/25 for Resident #41 revealed a follow up occurrence note with fall intervention of resident being educated and encouraged to position themselves in the middle of the bed upon lying down. Review of fall risk assessment dated [DATE] for Resident #41 revealed a score of 65 indicated at high risk. Review of progress note dated 01/03/26 at 12:30 A.M. for Resident #41 revealed resident was found lying on the floor next to bed after sliding off the edge while sleeping. No injuries were noted. Review of plan of care revised on 01/03/26 for Resident #41 revealed at risk for falls related to generalized weakness with an added intervention of a perimeter mattress. Review of progress notes dated 01/04/26 and 01/06/26 for Resident #41 revealed a follow up occurrence noted with intervention noted for perimeter mattress added to bed. Review of the plan of care revised on 02/10/26 for Resident #41 revealed at risk for falls related to generalized weakness with the intervention of a perimeter mattress resolved with no added intervention in its place. Review of Restraint Enabler Decision Tree dated 02/11/26 for Resident #41 revealed assist rails bilaterally to bed to promote participation in mobility and repositioning. Review of the medical record for Resident #41 from 01/04/26 through 02/10/26 revealed no falls while in bed. Review of the Therapy Screening form dated 02/09/26 for Resident #41 completed by Physical Therapy Assistant (PTA) #1026 revealed an evaluation for grab bars in place of a perimeter mattress as this resident was in occupational therapy for upper extremity strengthening. No documentation on assessment of her bed mobility with a perimeter mattress noted. Interview and observation with the Director of Nursing (DON) on 02/12/26 at 8:19 A.M. revealed no perimeter mattress for Resident #41, but that it had been resolved due to physical therapy recommending handrails as a better alternative to prevent falls. Interview with Resident #41 on 02/12/26 at 8:41 A.M. revealed no recollection of whether the mattress had been changed. Stated there was no discussion or education on bed rails being added to the bed and they were just there one day. Interview on 02/12/26 at 8:49 A.M. with the DON revealed for Resident #41, it was discussed with physical therapy in their morning meeting, that the perimeter mattress might be affecting her mobility, so grab bars were initiated. Verified the resident had no falls since the perimeter mattress was placed and the resident had two falls due to being in bed asleep. Also verified no documentation in the resident's record indicating the perimeter mattress was affecting her mobility and the Restraint Enabler Decision Tree completed with the resident was not inclusive for fall prevention. Also confirmed the plan of care for at risk for falls for this resident had the perimeter mattress resolved with the grab bars placed as an intervention under the plan of care for mobility and not for fall prevention. Interview on 02/12/26 at 8:51 A.M. with Physical Therapy Assistant #1026 revealed she completed the therapy screening on 02/09/26 for Resident #41 for mobility and not for fall prevention. Also verified Resident #41 had been receiving occupational therapy which includes bed mobility and there were no concerns with the perimeter mattress affecting her mobility. In her professional opinion, grab bars are for resident mobility and can be for fall prevention, but this resident is falling out of bed while asleep, therefore, the grab bars are for mobility and not fall prevention.

Based on record reviews, interviews and facility policy review, the facility failed to document non pressure areas upon admission and initiate treatments for Residents #6, #22, #34. The facility also failed to ensure new and/or ongoing non pressure areas treatments were accurate. This affected Resident #2 and Resident #6. This affected four residents (#2, #6, #22, and #34) of the six residents reviewed for non-pressure skin alterations. The facility census was 74.Findings include:1. Review of the medical record for Resident #2, revealed an admission date of 02/07/26 Diagnoses included but were not limited to other reduced mobility, need for assistance with personal care, muscle weakness and unspecified severe protein calorie malnutrition . Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed in progress at the time of this survey. Review of the plan of care dated 02/10/26 for Resident #2 revealed at risk for impaired skin integrity related to poor nutritional intake and confined to bed all or most of the time with an intervention including but not limited to encourage/assist as needed to elevate heels off mattress as tolerated and treatments per physician/CNP orders. Review of the admission assessment for Resident #2 dated 02/07/26 at 2:25 P.M. revealed alert and oriented to person, place and time, 1-person assistance for transfers, and bed mobility with skin impairments that included left heel open area with black scabbing surrounding. Review of the wound evaluation dated 02/07/26 for Resident #2 revealed a left heel open wound measured 2.6 cm by 1.8 cm by 0.4 cm. Review of the physician order dated 02/08/26 revealed a treatment for the left heel open wound of cleanse with wound cleanser, apply medihoney, cover with apply nonstick dressing, wrap with kerlix and ace wrap daily. Review of the wound consult visit notes revealed Resident #2 was seen by Wound Consultant Nurse Practitioner (WCNP) #1054 on 02/10/26. The left heel is a diabetic foot ulcer measured 0.5 cm by 0.5 cm by 0.3 cm. A treatment plan to cleanse with wound cleanser, apply medical grade honey to the base of the wound, secure with abdominal dressing, rolled gauze and change daily. recommendations to float heels while in bed. Review of the physician orders for Resident #2 dated 02/10/26 through 2/17/26 revealed treatment order for the left heel was continued from 02/08/26. Review of the Treatment Administration Record (TAR) for Resident #2 dated 02/10/26 through 02/17/26 revealed the incorrect treatment completed for the left heel. Observation and interview on 02/11/26 at 7:38 A.M. with Resident #2 revealed him in bed with heels not elevated. Interview and observation on 02/17/26 at 10:30 A.M with CNA #1095 confirmed Resident #2 in bed with heels not elevated off bed. Interview on 02/18/26 at 2:14 P.M. with RDCS #1050 verified treatment order for the left heel was not ordered per the WCNP #1054 on 02/10/26 and resident received the wrong treatment for 02/10/26 through 02/17/26. 2 Review of the medical record for Resident #6, revealed an admission date of 01/03/26. Diagnoses included but were not limited to type 2 diabetes mellitus with diabetic neuropathy, moderate protein-calorie malnutrition, chronic kidney disease stage 3 and personal history of other diseases of the circulatory system. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with shower/bathe self, bed mobility, and total dependence with toilet hygiene and transfers. Review of the Adena hospital stay from admission on [DATE] through discharge to the facility on [DATE] for Resident #6 revealed vascular wounds of the left lower anterior and distal leg, unclear etiology wound of the left calf and unclear etiology wounds to the right calf. Treatment to cleanse wounds to BLEs with wound cleanser and pat dry. Apply double layer of Xeroform to wound beds, cover with 4x4 gauze, then wrap with Kerlix and ACE wraps, from base of toes to Tibial Tuberosity with both. Change every other day and as needed if dressing becomes soiled. Review of the admission assessment for Resident #6 dated 01/03/26 at 5:00 P.M. revealed alert and oriented to person and place and a skin impairment of a skin tear observed. Review of the plan of care initiated on 01/06/26 for Resident #6 revealed impaired skin integrity with interventions including but not limited to complete wound evaluation to monitor the progress of the resident's skin condition and treatments per physician/CNP orders. Review of the physician order dated 01/05/26 with a start date of 01/06/26 for Resident #6 revealed a treatment order for the bilateral lower extremities, cleanse with wound cleanser and pat dry. Apply double layer of Xeroform to wound beds, cover with 4x4 gauze, then wrap with Kerlix and ACE wraps, from base of toes to Tibial Tuberosity with both. Change every other day and as needed if dressing becomes soiled. Review of the TAR for Resident #6 dated 01/03/26 through 01/05/26 revealed no treatment completed for the bilateral lower extremities wounds. Review of the medical record for Resident #6 dated 01/03/26 through 01/11/26 revealed no assessments and measurements of the skin tear and the bilateral lower extremities. Review of the wound consult visit notes revealed Resident #6 was seen by WCNP #1055 on 01/12/26. The left shin venous ulcer assessed and a treatment plan of cleanse with wound cleanser, apply Collagen, Xeroform to base of the wound, secure with abdominal dressing, kerlix, ace wrap and change daily. The right elbow skin tear was assessed and a treatment plan of cleanse with wound cleanser, apply Collagen Hydrogel, nonstick contact layer to base of the wound, secure with bordered foam and change every other day. Review of the physician order dated 01/14/26 to start on 01/15/26 for Resident #6 revealed a treatment order for the left shin venous ulcer of wash with wound cleanser, apply Collagen, Xeroform to base of the wound, secure with abdominal dressing, kerlix, ace wrap and change daily. Further review of the physician order for this resident dated 01/14/26 to start on 01/15/26 revealed a treatment order for the right elbow skin tear to was with wound cleanser, apply Collagen Hydrogel, nonstick contact layer to base of the wound, secure with bordered foam and change every other day. Review of the TAR for Resident #6 dated 01/12/26 through 01/15/26 revealed no treatment completed for the left skin venous ulcer. Further review of the TAR for this resident dated 01/12/26 through 01/18/26 revealed no treatment completed for the right elbow skin tear. Review of the wound consult visit notes revealed Resident #6 was seen by WCNP #1055 on 01/19/26. The left shin venous ulcer assessed and continue treatment as 01/12/26 and the right elbow skin tear healed out. Review of the wound consult visit notes revealed Resident #6 was seen by WCNP #1055 on 01/27/26. The left shin venous ulcer healed out. A new area of a right shin skin tear assessed and a treatment plan of cleanse with wound cleanser, apply Collagen, xeroform, nonstick contact layer to base of the wound, secure with an abdominal dressing, kerlix and change daily. Review of the physician order dated 01/27/26 for Resident #6 revealed cleanse with wound cleanser, apply Collagen, xeroform, nonstick contact layer to base of the wound, secure with an abdominal dressing, kerlix and change daily. no site indicated. Review of the TAR dated 01/27/26 through 01/29/26 for Resident #6 revealed no treatment for the right shin skin tear completed. Review of the physician order dated 01/30/26 for Resident #6 revealed for the right shin a treatment of cleanse with wound cleanser, apply Collagen, xeroform, nonstick contact layer to base of the wound, secure with an abdominal dressing, kerlix and change daily. Review of the wound consult visit notes revealed Resident #6 was seen by WCNP #1054 on 02/10/26. The right shin skin tear was assessed and continue treatment from 01/27/26. Interview on 02/18/26 at 2:16 P.M. with the RDCS #1050 verified for Resident #6 from admission to 01/30/26, no assessments and measurements for areas identified on admission until 1/12/26 with order and admission skin assessment and treatment orders not followed as ordered and/or not initiated timely resulting in not documented treatments for non-pressure wounds during that time frame. 3.Review of the medical record for Resident #22, revealed an admission date of 01/13/2026. Diagnoses included but were not limited to cellulitis of the left lower limb, Type 2 diabetes with diabetic neuropathy, hypertensive heart disease without heart failure, chronic kidney disease Stage 3, non-pressure chronic ulcer of other part of left foot limited to breakdown of skin, venous insufficiency and polyneuropathies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #22 revealed a Brief Interview for Mental Status (BIMS) of 15. The resident was assessed to require setup/cleanup assistance with toileting and personal hygiene, supervision with shower/bathing, and independent with sitting to lying/lying to sitting/sitting to stand and transferring. Review of the plan of care dated 01/25/2026 for Resident #22 revealed impaired metabolic status related to diabetes mellitus with interventions including but not limited to medications and treatments as indicated. Further review of the plan of care for this resident revealed impaired skin as evidenced by the right lateral plantar diabetic foot ulcer and left lateral plantar diabetic foot ulcer with an intervention including but not limited to complete wound evaluation to monitor the progress of the resident's skin condition. Review of the hospital Discharge summary dated [DATE] for Resident #22 revealed an order to cleanse bilateral lower extremities diabetic ulcers with 0.9 normal saline, pat dry, apply xeroform to all wound after applying Adaptec Calcium Alginate to the left plantar 5th metatarsal. Cover all with dry gauze, ABD, Kerlix, and Ace bandage daily. Review of the admission assessment dated [DATE] for Resident #22 revealed no skin impairments noted with reason for admission being cellulitis to the left foot. Review of the physician orders dated 01/13/26 through 01/16/26 for Resident #22 revealed no treatment orders for the bilateral lower extremities diabetic foot ulcer wounds. Review of the TAR for Resident #22 dated 01/13/26 through 01/16/26 revealed no treatments completed for the bilateral lower extremities diabetic foot ulcers. Review of the medical record for Resident #22 from 01/14/26 through 01/19/26 revealed no measurements and assessments of the left lateral plantar diabetic foot ulcer and right lateral plantar diabetic foot ulcer. Review of the progress note dated 01/17/2026 for Resident #22 revealed a telephone order for daily treatments for the bilateral lower diabetic foot ulcers and to contact outside wound care on Monday 1/19/26 by Nurse Practitioner (NP) #1052. Review of the physician orders dated 01/17/26 for Resident #22 revealed wound cleanser to bilateral lower extremity diabetic foot ulcers, pat dry, apply Xeroform to open areas and wrap with kerlix – daily and as needed. Review of the wound overview dated 01/20/26 for Resident #22 revealed the left lateral plantar diabetic foot ulcer was 1.5 cm by 1.7 cm by no depth and a right lateral plantar diabetic foot ulcer was 1.5 cm by 1.7 cm by no depth. Interview on 02/17/26 at 10:00 A.M. and 02/18/26 at 9:27 A.M. with the DON revealed no additional information regarding Resident #22's bilateral diabetic foot ulcers in regards to no wound assessment completed from admission until 01/20/26 as well as orders not being initiated upon admission for treatments until 01/17/26. 4.Review of the medical record for Resident #34, revealed an admission date of 01/02/26. Diagnoses included but were not limited to acute hematogenous osteomyelitis, acquired absence of the left leg below the knee, Type 2 diabetes, COPD, chronic kidney disease, peripheral vascular disease, MI, and hypertensive heart disease without heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #34 revealed a Brief Interview for Mental Status (BIMS) of 14. The resident was assessed to require setup/cleanup assistance with eating, moderate assistance with oral hygiene, and personal hygiene, maximal assistance with shower/bathing, dressing, rolling and sitting dependent on toileting, lying to sitting, sitting to stand and transfers. Review of the plan of care dated 01/04/2026 for Resident #34 revealed the resident with impaired metabolic status related to diabetes mellitus with an intervention including but not limited to treatments as indicated by physician orders. Further review of the plan of care for this resident revealed impaired skin integrity as evidenced by a right lateral 5th toe diabetic foot ulcer and left below knee amputation closed surgical wound with an intervention including but not limited to complete wound evaluation to monitor the progress of the resident's skin condition. Review of the medical record for Resident #34 revealed upon transfer to the hospital, the resident had skin impairments of a left below knee amputation surgical wound and right lateral 5th toe diabetic ulcer. Review of medical record for Resident #34 revealed a hospital stay unrelated to the non-pressure wounds from 01/19/26 through 01/23/26. Review of the hospital discharge instructions dated 01/24/26 revealed no non pressure wound care treatment orders. Review of the readmission assessment dated [DATE] on Resident #34 revealed a vascular skin impairment and surgical incision noted. No locations, assessments and measurements completed. Review of the physician orders dated 01/23/26 through 01/27/26 revealed no treatment orders for the left below knee amputation surgical wound and right lateral 5th toe diabetic ulcer. Review of the TAR for Resident #34 dated 01/23/26 through 01/27/26 revealed no treatments completed for the left below knee amputation surgical wound and right lateral 5th toe diabetic ulcer. Review of the medical record for Resident #34 from 01/23/26 through 01/27/26 revealed no assessments and measurements of the left below knee amputation surgical wound or right lateral 5th toe diabetic ulcer. Review of orders for 01/28/26 for Resident #34 revealed an order for the right lateral 5th toe diabetic foot ulcer stating to wash with wound cleanser, pat dry, apply skin prep and leave open to air twice a day. For the left below knee amputation surgical incision on Resident #34 dated 01/28/26 order to cleanse area with wound cleanser, pat dry, and apply sterile dressing daily. Review of the wound overview dated 01/27/26 for Resident #34 revealed a left below knee amputation surgical wound measuring 0.2 cm by 25.0 cm by 0.1 cm and a right lateral 5th toe diabetic ulcer measuring 0.8 cm by 0.4 cm by no depth. Interview on 02/17/26 at 10:00 A.M. and 02/18/26 at 9:27 A.M. with the DON revealed no additional information regarding Resident #34's left below knee amputation surgical wound and right lateral 5th toe diabetic ulcer in regards to no wound assessments completed from admission until 01/27/26 as well as no orders being initiated upon re admission until 01/27/26.

Based on resident record review and staff interview, the facility failed to ensure Level II Preadmission Screening and Resident Review (PASARR) recommendations were implemented timely and appropriately. This affected the one resident (#10) of one resident who was reviewed for PASARR recommendations. The facility census was 74.Findings include:Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included acute respiratory failure with hypoxia, bipolar disorder, schizoaffective disorder, personality disorder, anxiety disorder, obsessive compulsive disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/25, revealed the resident was assessed to have mildly impaired cognition. Review of the Notice of PASRR Level II Outcome, dated 08/25/25, revealed recommendations for 1:1 staffing due to a history of head banging and fire starting, self-injurious items should be placed out of reach to prevent injury, group therapy with a trained group therapist, a behavior management safety plan to decrease inappropriate behaviors and ensure safety, and ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms. Interview with Business Office Manager (BOM) #1059 on 02/12/26 at 9:29 A.M. confirmed the employee was in the position of Social Service Director at the time of the Level II PASARR recommendations for Resident #10. BOM #1069 confirmed the Level II PASARR recommendations for 1:1 staffing due to a history of head banging and fire starting, self-injurious items should be placed out of reach to prevent injury, group therapy with a trained group therapist, a behavior management safety plan to decrease inappropriate behaviors and ensure safety, and ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms had not been addressed or implemented as recommended. BOM #1059 confirmed Resident #10 had not exhibited any head banging, self-injurious behavior, or fire starting since admission to the facility.

Based on record review, policy review, and staff interview, the facility failed to provide and document sufficient preparation to ensure a safe and orderly transfer or discharge from the facility and ensure the discharge planning process addressed each residents discharge goals and needs. This affected two residents (#4, #32) of three residents reviewed for transfer or discharge from the facility. The facility census was 74.Findings include: 1. Review of the record for Resident #32 revealed an admission date of 01/13/26 and diagnoses including alcohol dependence in remission, chronic obstructive pulmonary disease, and rheumatoid arthritis. Review of a Minimum Data Set assessment completed 01/19/26 revealed a brief interview for mental status (BIMS) score of 14 (intact cognition). Review of nursing and physician progress notes from admission through 02/12/26 did not reveal any issues related to alcohol consumption. The plan of care dated 01/19/26 and revised 02/11/26 stated he had a history of substance abuse (alcohol and drugs). It further stated he will purchase alcohol and drink at the facility. Interventions included to monitor and report signs of misuse to the physician, and nurses to notify physician if resident consumes too much alcohol and there is a concern due to medications. A social service evaluation on 01/13/26 stated the resident was admitted for skilled services. Resident stated he would be discharging home to his daughters. Resident expressed he has been going from family to family since 2024. Stated he would like to get his own place at some time. Receives social security income. He expressed that he had lived in his jeep as well. Is alert and oriented. No concerns with mood or behaviors at this time. Further review of Resident #32's care plan dated 01/19/26 revealed the resident planned to discharge to community with his daughter. The goal was for him to have a safe transition back to the community. Interventions included encourage resident/family to participate in the discharge planning process, involve specialized home care agencies and appropriate community support services as needed for safe discharge, provide resident/family with written instructions upon discharge to ensure a safe return to the community. Review of nursing progress notes on 02/13/26 at 2:30 P.M. by Licensed Practical Nurse (LPN) #1010 revealed this nurse was notified by another staff member that Resident #32 had fallen in the hallway and hit his head on the medication cart. It stated the resident was under the influence of alcohol. It stated he had an abrasion to the left eyebrow. The note stated the nurse practitioner, resident representative, administrator and unit managers were notified. On 02/13/26 at 2:31 P.M. LPN #1010 documented the resident was alert and oriented x 4 and was refusing to go to the hospital for further evaluation. Resident admitting he had 1 beer today. Resident educated on the risk of bleeding and injury due to fall. Resident continued to refuse. Neuro check initiated. The next entry in the nursing progress notes by LPN #1010 on 02/13/26 at 4:27 P.M. (approximately 2 hours after the fall) revealed report was called to another nursing facility to notify the facility that the resident was being transported there. All medications being sent with resident to the facility. On 02/13/26 at 4:59 P.M. LPN #1010 documented an entry correction due to misunderstanding of the recall of events of the fall. This nurse was notified by another staff member that resident stated he fell outside on the sidewalk and hit his head and was witnessed by other residents, then had fallen into the medication cart and was caught by staff. A late entry in the nursing progress notes on 02/13/26 at 5:55 P.M. by [NAME] President of Clinical Services #1029 revealed Resident #32 was transferred to another nursing facility per his request. (Even though the resident was noted to be intoxicated at the time). Review of a discharge plan of care dated 02/13/26 stated Resident #32 was discharged to another nursing home. It stated a medication list was faxed to the new facility. The discharge plan provided no further documentation regarding how it came to be that he was transferred to another nursing facility. The following notes were entered into Resident #32's record by the facility he was transferred to: On 02/13/26 at 11:59 P.M. the nurse practitioner had entered triage notes that included details after the resident was transferred to the new facility. It included notes from 5:49 P.M. that stated new admit from sister facility. Do you still want meds to be held until tomorrow due to alcohol consumption. It stated the resident was agitated and exit seeking. Amount of alcohol consumed is unknown. The note also stated this resident has been consuming alcohol daily at the other facility. Is there specific precautions we need to or should put in place for him given he will have limited or no access to alcohol at our facility. Uncertain of how much he has been consuming daily. He also had a fall at the other facility prior to coming to ours. Details are limited related to the fall. The note then stated that at 9:02 P.M. he is now complaining of double vision. He has an abrasion above his left eyebrow. The details of the fall are unknown. He is requesting to go the emergency room. He states he is nauseated. The area above his left eyebrow is prominent. The note stated to send him to the emergency room. Interview with LPN #1010 on 02/17/26 at 11:20 A.M. revealed she was Resident #32's nurse on 02/13/26. She confirmed he fell around 2:30 P.M. She stated he had been outside smoking and other resident's saw him fall. She stated staff then saw him stumbling in the hall and he hit the medication cart and staff caught him. She stated he reeked of alcohol and appeared intoxicated. She stated he refused to go to the hospital for evaluation. She stated the Administrator then talked to the resident about his drinking, the fact that he had fallen, and where he preferred to go. She stated the resident still smelled of alcohol. She stated she did not know how the facility he was transferred to was decided upon as the place to send him. She stated he was then transported by the facility bus to the other nursing facility around 5:55 P.M. She stated he had never had exit seeking behavior at this facility as he was able to come and go as he wanted. She stated she did not know why the facility he was transferred to would be documenting that. She stated it could be because she thought the new facility was not close to any gas stations and he always walked there to get snacks, lottery tickets, and alcohol. Interview with the Administrator on 02/18/26 at 10:20 A.M. revealed the other nursing facility had just happened to call on 02/13/26 and asked the facility if they had any residents with behavior issues that would be better suited at their facility. He stated he was aware Resident #32 had fallen on 02/13/26 prior to his transfer but was not aware he had been drinking alcohol. He stated there had been one prior incident of the resident bringing alcohol into the facility and they had discussed about not being able to give him his medications if he was drinking. He stated he did not know if the transfer to the other facility had been discussed with the physician. He stated that the resident had stated that he preferred to move closer to another city (not where he was transferred) but the facility had not had the staffing to handle trying to find somewhere for him to move where he wanted. There was no further documentation in the record regarding the reason for the transfer to another nursing home or why the resident's previous discharge plan of discharging to family home was no longer his plan. There was no documentation to indicate how the new nursing facility was chosen or how it could meet the needs of the resident differently than the present facility. Review of the Alcohol use policy dated January 2026 revealed the facility recognizes the rights of residents to make personal choices regarding their lifestyle, including the consumption of alcoholic beverages, provided the consumption does not adversely affect the resident's health, safety, care plan, other residents, or facility operations. Alcohol consumption will be permitted in accordance with this policy. During the course of the investigation, multiple attempts to interview Resident #32 were unsuccessful. 2. Review of the closed medical record for Resident #4 revealed an admission date of 01/16/26 with diagnoses including respiratory failure, alcoholic cirrhosis of the liver, diabetes, alcohol abuse, viral hepatitis, post traumatic stress disorder, and bipolar disorder. A Minimum Data Set assessment completed 01/22/26 documented a BIMS score of 15 (intact cognition). Review of a physician progress note on 01/19/26 revealed Resident #4 was admitted after a hospital stay for alcohol detoxification and hypoxia. She reports heavy alcohol consumption since Christmas, escalating from a pint daily to approximately 1.5 fifths daily. Has a history of alcohol withdrawal seizures and completed alcohol withdrawal treatment during this admission. admitted here for rehab. Wishes to return to VA when a bed comes available. Lives with husband. Review of social service note by Business Office Manager #1059 on 01/30/26 at 3:44 P.M. revealed the resident was accepted for inpatient rehab program at the VA tentatively scheduled for transfer to VA on 02/05/26. The next nursing progress note on 01/31/26 at 8:09 A.M. stated the resident came to the facility, picked up her belongings and her ordered medications. Educated resident on her discharge and follow up visit at VA. There was no further documentation regarding the reason for the discharge. Interview with Business Office Manager #1059 on 02/18/26 at 9:44 A.M. revealed she was helping with social services at the time of Resident #4's discharge. She stated the resident had authorization from the VA to stay at the facility for 30 days. She was then to be transferred to the VA on 02/05/26 to an inpatient alcohol rehab program. She stated the resident did go out of the facility daily after she received her therapy for the day. She stated when she (Business Office Manager #1059) left for the day on 01/31/26 the plan was for the resident to stay at the facility until the transfer to the VA on 02/05/26. She stated the discharge was done in the evening by the nurse and she was not informed prior to the resident discharging home. She stated a discharge would require a physician's order. If there was not a physician's order to discharge, then it would be against medical advice. She stated this discharge was not handled as an against medical advice discharge. Interview with Resident #4 by telephone on 02/18/26 at 9:07 A.M. revealed she left the faciity on [DATE] and went home. She stated she was then admitted to the VA on 02/05/26 and remained at the VA at this time. When asked why she went home on [DATE] instead of staying at the facility until 02/05/26 as planned, she stated that someone at the facility talked to her about her leaving the facility everyday to go home after therapy. She stated that after that conversation, she decided to discharge home. Interview with the Director of Nursing on 2/18/26 at 10:31 A.M. confirmed there was not a physician's order to discharge the resident and there was no evidence the physician was aware of the discharge home. She stated if the physician did not agree to the discharge home, then the discharge should have been done as against medical advice, and was not. Review of a discharge plan of care dated 01/31/26 revealed Resident #4 was discharged home. There was no evidence the physician was aware of the discharge and there was no physician's order to discharge. There was no further documentation to indicate why the resident was discharged home instead of transferring to the VA on 02/05/26 as planned. Review of the facility policy date November 2025 titled Discharge Summary and Plan revealed when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Every resident will be evaluated for his or her discharge needs. The post discharge plan will be developed by the interdisciplinary team with the assistance of the resident and his or her family. Residents will be asked about their interest in returning to the community. If the resident indicates an interest, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. Residents transferring to another skilled nursing facility will be assisted in selecting a provider that is relevant and applicable to the residents goals of care and treatment preferences.

Based on resident record reviews, review of hospital discharge records, interviews, and review of facility policy, the facility failed to ensure advance directives were ordered and implemented timely upon admission or readmission to the facility. This affected two residents (#72 and #92) out of the two residents reviewed for advance directives. The facility census was 74.Findings include:1. Record review for Resident #92 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertensive emergency, acute pulmonary edema, and Sjorgen syndrome. Review of the hospital Discharge summary, dated [DATE], revealed the resident code status was Do Not Resuscitate - Comfort Care Arrest (DNRCCA). Review of the physician orders for Resident #92 revealed an order for advance directives had not been initiated until 02/10/26 and listed the resident as Full Code status. Review of the DNRCCA paperwork, signed by the physician on 02/05/26, revealed the paperwork was uploaded into the resident's electronic health record on 02/11/26. Interview with Regional Director of Clinical Services (RCDS) #1050 on 02/10/26 at 2:30 P.M. confirmed Resident #92 was admitted to the facility on [DATE] and physician orders for code status were not implemented until 02/10/26. RCDS #1050 confirmed the hospital discharge summary listed the resident as being DNRCCA code status but the facility had not obtained signed DNR paperwork so the resident had to be Full Code status until the paperwork was obtained. Interview with [NAME] President of Clinical Services (VPCS) #1029 on 02/12/26 at 11:18 A.M. confirmed the signed DNRCCA paperwork for Resident #92 had been signed by the physician on 02/05/26 and uploaded into the residents electronic health record on 02/11/26. VPCS #1029 confirmed the physicians order for code status for Resident #92 remained Full Code status on 02/12/26 but would be updated. Review of the facility policy titled Advance Directives Guidance, dated 01/2026, revealed upon admission a nurse will question the resident about advance directives. All residents without advance directives will be treated as a full code. The Ohio Advance Directive form will need to be fully executed by the resident physician or physician extender: next a nurse will obtain a physician order following the advanced directive wishes of the resident. The advanced directive order will be entered into the resident's electronic health record. 2. Review of the medical record for Resident #72, revealed an admission date of 07/03/25. Diagnoses included but were not limited to left buttock stage 4 pressure ulcer, paraplegia, generalized anxiety disorder, major depressive disorder, neuromuscular dysfunction of bladder. Review of the DNRCCA paperwork for Resident #72, signed by the physician on 01/27/26, revealed the paperwork was uploaded into the resident's electronic medical record on 01/06/26. Review of the physician orders for Resident #72 dated 01/31/26 through 02/10/26 revealed no order for their code status entered into the electronic medical record. Interview on 02/10/26 at 2:35 P.M. with director of nursing (DON) #1057 confirmed upon readmission from a hospital stay on 01/31/26, a DNRCCA physician order was not placed in the electronic medical record, and it will be added. Review of the facility policy titled Advance Directives Guidance, dated 01/2026, revealed The Ohio Advance Directive form will need to be fully executed by the resident physician or physician extender: next a nurse will obtain a physician order following the advanced directive wishes of the resident. The advanced directive order will be entered into the resident's electronic health record.

Based on observation, record review, interviews and facility policy review, the facility failed to assess, develop and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection for Resident #43 and #49. Actual harm occurred on 02/05/25 when Resident #43 was readmitted to the facility following an acute care hospital stay, was determined to be at high risk for skin breakdown, dependent on staff for bed mobility and with known pressure ulcers that were found not to have a comprehensive assessment of the known pressure ulcers upon readmission to the facility. Additionally, the resident's physician ordered treatments for pressure ulcers that were not provided as ordered. Furthermore, the resident was sent to the local acute care hospital on 02/13/25 following a physical examination of stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer to the sacrum for suspected infection in need of surgical intervention, non-staged pressure ulcer to the right outer ankle and a new unidentified wound to the right outer fifth digit to the right foot. Additionally, Actual Harm occurred on 01/10/25 when Resident #49, who was cognitively impaired, was at high risk for pressure ulcer development, dependent on staff for bed mobility and had known pressure ulcers and was found to have a stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) pressure ulcer to the left ischium without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. Furthermore, the resident readmitted to the facility on [DATE] with no readmission assessment and no physician ordered treatments to the unstageable, known but not stageable due to coverage of wound bed by slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed), and/or eschar (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound), pressure ulcer to the sacrum/coccyx, left ischium and stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also be present as an intact or open/ruptured blister.) pressure ulcer to the left heel. This affected two (Resident #43 and #49) of three residents reviewed for pressure ulcers. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #43 revealed an initial admitted [DATE] with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the resident's admission evaluation dated 01/22/25 revealed the resident was admitted from an acute care hospital for wounds and weakness. The assessment indicated the resident had edema to bilateral lower extremities. The resident had an indwelling urinary catheter on admission. The assessment indicated the resident had a skin impairment of a blister. Review of the Braden scale contained within the assessment revealed a score of 15 indicating the resident was at high risk for skin breakdown. Review of the wound evaluation dated 01/22/25 revealed the resident had an unstageable pressure ulcer to his left gluteal fold measuring 4.0 centimeters (cm) by 8.0 cm by 0.1 cm. The wound was described as 20% granulation tissue with scant sanguineous exudate and 80% slough. The peri-wound was described as pink. Review of the wound evaluation dated 01/22/25 revealed the resident had an unstageable pressure ulcer to his right gluteal fold measuring 7.0 cm by 6.25 cm by 0.1 cm. The wound was described as 20% granulation tissue with scant sanguineous exudate and 80% slough. The peri-wound was pink. Review of the wound evaluation dated 01/23/25 revealed the resident had an unstageable pressure ulcer to his coccyx measuring 13/5 cm by 9.5 cm by 0.1 cm and the wound was described as 90% slough with a scant amount of serosanguineous exudate. The peri-wound was pink. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent for bed mobility and toileting. The assessment indicated the resident had an indwelling urinary catheter and an ostomy. The assessment indicated the resident was at risk for skin breakdown and was admitted with one stage II and three stage III pressure ulcers. The assessment indicated the resident had an infection to his foot, other lesion to his foot and open lesions. The facility implemented a pressure reducing device to bed, pressure ulcer/injury care, application of ointments/medications other than to feet and application of dressings to feet. Review of the progress note dated 01/25/25 at 9:33 A.M. revealed the resident was shaking all over stating that he was freezing. The resident requested to be sent to the emergency room (ER) for an evaluation. Review of the progress note dated 01/25/25 at 5:50 P.M. revealed the resident was admitted to the hospital for the diagnoses of influenza A, dehydration and cough. Review of the progress note dated 02/05/25 at 6:10 P.M. revealed the resident was readmitted to the facility at 6:00 P.M. Review of the medical record revealed a comprehensive readmission assessment was not completed until 02/07/25. Further review revealed the assessment was still in progress. The resident was admitted from the hospital for wound care. The resident had an ostomy as well as an indwelling urinary catheter. The assessment indicated the resident was admitted with pressure ulcer and blisters. The Braden scale contained within the evaluation revealed a score of 14 indicating the resident was at risk moderate for skin breakdown. Review of the medical record revealed no documented comprehensive assessment of the resident's pressure ulcers to the sacrum, left gluteus, right gluteus, right out ankle and surgical wound to left shin. Review of the resident's monthly physician orders for February 2024 identified orders dated 01/22/25 encourage and assist with frequent offloading, heel medic boots bilaterally to assist with offloading, cleanse wound to sacrococcygeal region with wound cleanser, pat dry, apply barrier cream daily and as needed, 01/23/25 enabler bars to enhance bed mobility, bilateral ischial tuberosities-cleanse wounds with wound cleanser, pat dry, apply calcium alginate to wound bed and cover with comfort foam border dressing daily and 01/24/25 cleanse wounds to bilateral lower legs and feet with wound cleanser, pat dry, apply Xeroform to wounds wrap with Kerlix starting at base of toes working up the knee and secure with tape, change daily and as needed. On 02/11/25 at 1:34 P.M., observation of Licensed Practical Nurse (LPN) #180 provide the physician ordered treatment to the resident's wounds revealed the LPN donned a gown and gloves for enhanced barrier precautions (EBP). The LPN placed a barrier on the bedside table consisting of a clear trash bag. She then set up the required supplies on the barrier. The dressings to the bilateral lower extremities (BLE) were dated 02/09/25. LPN #180 verified the dressing changes were physician ordered as daily and had not been changed since 02/09/25. The LPN removed the soiled dressing to the resident's left lower extremity (LLE) then removed the soiled dressing to the right outer ankle using the same gloves. The LPN placed the soiled dressings on the clear trash bag used as a barrier on the bedside table next to the clean treatment supplies. The LPN then cleansed the wounds to his LLE and right outer ankle. The LPN then washed her hands and donned a pair of gloves. The LPN then removed a piece of gauze used to cleanse the wound to the left lower extremity and placed a piece of Xeroform to the wound. She then placed multiple 4 X 4 on the Xeroform and wrapped the resident's left lower extremity with Kerlix. Using the same gloves the LPN placed a piece of Xeroform to the pressure ulcer on the right outer ankle, covered with a 4 X 4 and wrapped with Kerlix. The LPN removed the barrier from the bedside table and EBP to obtain the supplies to provide treatment to the left and right ischium wounds and the sacral wound. The LPN set-up the required supplies on the bedside table with no barrier. The resident was assisted onto his right side by a Certified Nursing Assistant (CAN) with difficulty due to the parameter mattress being too small for the resident's size. The dressing to the resident's sacrum was dated 02/08/25. The dressing was saturated with blood-tinged drainage and a foul odor was noted. LPN #180 verified the dressing changes were daily and had not been changed since 02/08/25. The LPN removed the soiled dressings to the left ischium, right ischium and sacrum using the same gloves. The LPN then cleansed all three wounds using wound cleanser and 4 X 4. The LPN then washed her hands, donned a pair of gloves and placed calcium alginate to all wound beds and covered with multiple 4 x 4. The LPN then covered all three wounds with two ABD pads and secured with tape. On 02/11/25 at 2:00 P.M., an interview with LPN #180 confirmed the resident's bed was too small limiting the resident's ability to turn and reposition to achieve off-loading to the pressure ulcers and would require a bariatric bed. The LPN confirmed the resident was not provided with an air mattress despite the stage IV pressure ulcer to the sacrum. On 02/11/15 at 3:25 P.M., interview with the Licensed Nursing Home Administrator (LNHA) and the Regional Nurse revealed the contracted wound company was supposed to start in March 2025. The LNHA and Regional Nurse was made aware of no admission assessment, no comprehensive assessment of the resident's wounds, the resident's left and right ischium wounds and sacral/coccyx wound treatments had not been completed since 02/08/25 and 02/09/25. The LNHA and Regional Nurse was made aware of the resident's bed was not large enough to accommodate his size to off-load pressure to the wounds. On 02/13/25 at 9:05 A.M., an interview with the resident's primary care physician (PCP) #200 revealed he was scheduled to see Resident #43. The resident's PCP was unaware the facility had no contracted wound company, and the resident was not referred to a wound clinic, the physician ordered treatments were not being rendered as ordered and the resident was not on a specialized mattress. Review PCP #200's progress note dated 02/13/25 revealed the resident was being seen for evaluation of multiple wound and recent hospitalization for influenza A. On 01/30/25 the resident underwent surgical incision and drainage of a left calf abscess a right ankle wound, a sacral wound and ischial wounds. An examination revealed a deep stage IV pressure wound to the coccyx with significant slough and some odor indicative of an underlying infection. The wounds needed immediate debridement which could not be delayed for the wound physician's visit in the next six days. The physician's plan was to send to the hospital for further evaluation, management and treatment. The physician documented the risk of osteomyelitis was high and required surgical intervention. Review of the progress note dated 02/13/25 at 4:12 P.M. revealed the resident was admitted to the local acute care hospital for the evaluation and treatment of wounds. The facility failed to provide any documented evidence that the readmission assessment, comprehensive wound assessment and the physician ordered treatments were completed. 2. Review of the medical record for Resident #49 revealed an initial admitted [DATE] with the latest readmission of 02/11/25 with the diagnoses including but not limited to cerebrovascular accident with right sided hemiplegia, respiratory failure, asthma, chronic respiratory failure with hypoxia, severe protein calorie malnutrition, systemic lupus, dysphagia, dysphonia, neuromuscular dysfunction of bladder, gastrostomy status, cardiomyopathy, anemia, anxiety disorder, gastro-esophageal reflux disease, hyperlipidemia, hypertension, fibromyalgia and major depressive disorder. Review of the admission evaluation dated 12/27/24 revealed the resident was admitted with an indwelling urinary catheter and was incontinent of bowel. The assessment indicated the resident was a two person assist with toileting and bed mobility. The assessment indicated the resident was admitted to the facility with pressure to the sacrum/coccyx being described as a large open deep wound with tunneling, measuring 6.0 centimeters (cm) by 7.2 cm by undefinable depth. The resident also had a wound to her right ischium measuring 1.3 cm x 1.5 cm by 0.3 cm. The assessment had no description of the tissue of the wounds. Review of the wound evaluation dated 12/27/24 revealed the resident had an open wound to the sacrum/coccyx measuring 8.0 cm by 12.0 cm by undefinable depth. The wound had tunneling at 12 o'clock, 3 o'clock and 9 o'clock. The wound was described as 60% slough with a heavy purulent exudate. The peri-wound was described as pink. Review of the plan of care dated 12/29/24 revealed the resident had impaired skin integrity. Interventions included assisting resident with turning and repositioning as needed, complete skin inspection every seven to 10 days and as needed, complete wound evaluation to monitor the progress of the resident's skin condition and treatments per physician orders. Review of the resident's readmission assessment dated [DATE] revealed the resident was admitted to the facility with an indwelling urinary catheter and was incontinent of bowel. The assessment indicated the resident was a two person assist with toileting and bed mobility. The assessment indicated the resident was readmitted to the facility with pressure ulcers. The assessment contained no location, staging or description of the pressure ulcers. Review of the skin inspection dated 01/10/25 revealed the resident had skin issues as follows and were present on admission: Sacrum/coccyx wound measured 0.8 centimeters (cm) by 12.0 cm by undefinable depth with bone involvement. The wound was described as 60% tan slough with 40% granulation tissue, bone was visible at the center of the wound. The wound also had tunneling/undermining present at 3 o'clock, 6 o'clock and 9 o'clock with heavy malodorous brown wound drainage. The wound edges were uneven, and the peri-wound was pink. Right Ischium open wound measured 0.3 cm with a 0.1 cm depth. The wound bed was not described and had no drainage. The peri-wound was described as dark purple-maroonish. The left ischium open area was from shearing measuring 0.3 cm by 0.8 cm by 0.1 cm with no description of the wound bed. The wound edges were uneven, and the peri-wound was pink. Left heel open wound measured 1.5 cm by 3.0 cm by 0.1 cm with no description of the wound bed. The wound edges were uneven, and the peri-wound was dark purple maroonish in color. Review of the wound evaluation dated 01/11/25 revealed the resident was readmitted to the facility with an unstageable pressure ulcer to her sacrum/coccyx measuring 8.0 cm by 12.0 cm by undefinable. The wound had tunneling and/or undermining at 3 o'clock, 6 o'clock and 9 o'clock. The wound was described as 30% epithelial tissue, 10% granulation and 60% slough with a heavy serous exudate. The peri-wound was described as pink. Review of the wound evaluation dated 01/16/25 revealed the resident stage IV pressure ulcer to the coccyx measured 12 cm by 7.0 cm by 1.3 cm. The wound was described as 70% granulation tissue and 30% slough with a moderate amount of serosanguineous exudate. The peri-wound was described as pink, and the facility determined the wound had remained unchanged. Review of the wound evaluation dated 01/16/25 revealed the shearing wound was now a stage III pressure ulcer to the left ischium measuring 6.0 cm by 3.0 cm by 0.1 cm and described as 70% granulation and 30% slough with a small amount of serosanguineous exudate. The assessment indicated the resident was admitted with stage III pressure ulcer. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident was dependent on staff for toileting. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and was admitted with one stage II pressure ulcer, one stage III pressure ulcer and one stage IV pressure ulcer. The facility implemented pressure reducing devices to bed/chair, turning/repositioning program, nutrition or hydration intervention to manage skin problems and pressure ulcer/injury care. Review of the wound evaluation dated 01/22/25 revealed the resident stage IV pressure ulcer to the coccyx measured 10 cm by 6.5 cm by 1.3 cm. The wound was described as 70% granulation tissue and 30% slough with a moderate amount of sanguineous exudate. The peri-wound was described as pink, and the facility determined the wound had remained unchanged. Review of the wound evaluation dated 01/22/25 revealed the resident had a stage III pressure ulcer to the left ischium measuring 6.0 cm by 3.0 cm by 0.1 cm and described as 70% granulation and 30% slough with a small amount of sanguineous exudate. The assessment indicated the resident was admitted with stage III pressure ulcer. Review of the medical record revealed no documented evidence the wounds to the right ischium and the left heel were assessed every seven days as required. Review of the residents' January 2025 Treatment Administration Record (TAR) revealed a treatment was not implemented for the wound to the resident's left heel, left ischium until 01/17/25. The physician ordered treatment was not provided for the left ischium wound on 01/19/25 and 01/30/25. Further review revealed the physician ordered treatment to the sacral/coccyx wound was not provided as ordered on 01/16/25, 01/19/25 and 01/30/25. Additionally, the air mattress was not implemented until 01/28/25. Review of the progress note dated 02/01/25 at 9:05 A.M. revealed the resident was displaying an altered mental status. The resident was sent to the local emergency room (ER) for an evaluation. Review of the progress note dated 02/01/25 at 11:01 P.M. revealed the resident was admitted to the acute care hospital for altered mental status, possible urinary tract infection (UTI) and acute metabolic encephalopathy. Review of the progress note dated 02/11/25 at 8:27 P.M. revealed the resident was readmitted to the facility. Review of the medical record revealed no documented evidence a readmission assessment or wound assessment was completed. Review of the resident's monthly physician orders for February 2025 identified orders dated 02/12/25 enhanced barrier precautions (EBP) related to wound, tube feeding and tracheostomy. Further review revealed no orders for the treatment of the sacral/coccyx wound, left ischium wound, the right ischium wound and the left heel wound. Review of the first documented wound evaluation following survey request revealed on 02/13/25 the unstageable pressure ulcer to the sacral/coccyx measured 10.0 cm by 6.5 cm by 1.3 cm and described as 30% slough and 70% granulation tissue. The wound had a heavy amount of serosanguineous exudate. The peri-wound was described as pink. Review of the first documented wound evaluation following survey request revealed on 02/13/25 the unstageable pressure ulcer to the left ischium measured 6.0 cm by 1.3 cm by 0.1 cm and described as 30% slough and 70% granulation tissue with a small amount of serosanguineous exudate. The peri-wound was described as pink. Review of the first documented wound evaluation following survey request revealed on 02/13/25 the stage III pressure ulcer measuring 6.0 cm by 1.3 cm by 0.1 cm with the wound being described as 30% slough and 70% granulation tissue with a small amount of serosanguineous exudate. The peri-wound was described as pink. Review of the resident's February 2024 Treatment Administration Record (TAR) revealed a treatment to the unstageable pressure ulcer to the sacrum/coccyx and left ischium and the stage II pressure ulcer to the left heel was not implemented until 02/13/24. On 02/13/25 at 9:05 A.M., an interview with the resident's PCP #200 revealed he was scheduled to see Resident #49 and revealed he was unaware the resident had no treatment in place for the multiple pressure ulcers. On 02/13/25 at 2:45 P.M., an interview with the Director of Nursing (DON) verified the resident had no readmission assessment, readmission wound assessments and treatments for the multiple pressure ulcers. Review of the facility policy titled, Wound Care, dated 09/21 revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Verify there is a physician's order for the procedure. Review of the facility policy titled, Pressure Reducing and Relieving Devices, not dated revealed the purpose of the procedure was to provide guidelines for the assessment of the appropriate reducing and relieving devices for residents at risk of skin breakdown. Redistributing support surfaces are to promote for bed or chairbound residents to prevent skin breakdown, promote circulation and provide pressure relief or reduction. Mattresses are chosen for the residents based on Braden scale pressure ulcer risk. Residents at risk for developing pressure ulcers should be placed on a redistribution support surface such as foam, gel, static, air, alternating air or air loss or gel when lying in bed. This deficiency represents noncompliance investigated under Complaint Number OH00162365.

Based on observation, interview and facility policy review, the facility failed to ensure staffing to meet residents needs. This affected two (Resident #50 and #72) residents and had the potential to affect all 67 residents residing in the facility. The census was 67. Finding Include: 1. On 02/11/25 at 11:15 A.M., observation of Licensed Practical Nurse (LPN) #168 administer Resident #50 morning medication due at 6:00 A.M. via his peg-tube revealed the resident's medication was being administered late. On 02/11/25 at 11:30 A.M., interview with LPN #168 confirmed Resident #50's morning medication was administered outside of the allotted timeframe. LPN #168 revealed the the facility only had three nurses on duty so she had half of another hallway and had three residents who she had to administer morning medications yet. 2. Review of the closed medical record for Resident #72 revealed an initial admitted [DATE] with the diagnoses including but not limited to acute respiratory failure with hypoxia, multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, right bundle branch block, urinary tract infection, pneumonitis due to inhalation of food and vomit, dysphagia, other disorders of lung, history of falling, pain, slow transit constipation, migraine, vitamin D deficiency, intervertebral disc displacement lumbar region, neuromuscular dysfunction of bladder, slurred speech, osteoarthritis, dependence on supplemental oxygen, anxiety disorder and functional quadriplegia. The resident was discharged to another local skilled nursing facility (SNF) on 02/07/25. Review of the resident's admission evaluation dated 01/24/25 revealed the resident preferred bathing at bedtime. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for personal hygiene, toileting, bathing, bed mobility and substantial/maximal assistance with dressing. Review of the resident's medical record revealed the resident was scheduled for routine showers every Monday and Thursday. Review of the medical record revealed no evidence the resident was provided the scheduled shower on 01/27/25, 01/30/25, 02/03/25 and 02/06/25. On 02/12/25 at 12:27 P.M., interview with Certified Nursing Assistant (CNA) #149 revealed facility staff had been an issue and showers are not done when staffing is not adequate. Review of the facility policy titled, Staffing, dated 09/21 revealed the facility provides staffing to needed care and services for the resident population. This deficiency represents non-compliance investigated under Master Complaint Number OH00162558 and Complaint Number OH00162365.

Based on observation, record review and interviews, the facility failed to maintain a complete and accurate record for one resident (#43) in the area of physician ordered treatments. This affected one (Resident #43) of three residents reviewed for pressure ulcers. The facility census was 67. Findings Include: Review of the medical record for Resident #43 revealed an initial admitted [DATE] with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the medical record revealed a comprehensive readmission assessment was not completed until 02/07/25. Further review revealed the assessment was still in progress. The resident was admitted from the hospital for wound care. The resident had an ostomy as well as an indwelling urinary catheter. The assessment indicated the resident was admitted with pressure ulcer and blisters. The Braden scale contained within the evaluation revealed a score of 14 indicating the resident was at risk moderate for skin breakdown. Review of the medical record revealed no documented comprehensive assessment of the resident's pressure ulcers to the sacrum, left gluteus, right gluteus, right out ankle and surgical wound to left shin. Review of the resident's monthly physician orders for February 2024 identified orders dated 01/22/25 encourage and assist with frequent offloading, heel medic boots bilaterally to assist with offloading, cleanse wound to sacrococcygeal region with wound cleanser, pat dry, apply barrier cream daily and as needed, 01/23/25 enabler bars to enhance bed mobility, bilateral ischial tuberosities-cleanse wounds with wound cleanser, pat dry, apply calcium alginate to wound bed and cover with comfort foam border dressing daily and 01/24/25 cleanse wounds to bilateral lower legs and feet with wound cleanser, pat dry, apply Xeroform to wounds wrap with Kerlix starting at base of toes working up the knee and secure with tape, change daily and as needed. Review of the resident's monthly Treatment Administration Record (TAR) for February 2025 revealed the physician ordered treatments to the residents' sacrum/coccyx pressure ulcer was initialed by a staff nurse indicating the treatment was completed on 02/09/25 and 02/10/25. Further review revealed the treatment to the resident's bilateral lower extremities was initialed by a staff nurse indicating the treatment was completed on 02/10/25. On 02/11/25 at 1:34 P.M., observation of Licensed Practical Nurse (LPN) #180 provide the physician ordered treatment to the resident's wounds revealed the LPN donned a gown and gloves for enhanced barrier precautions (EBP). The LPN placed a barrier on the bedside table consisting of a clear trash bag. She then set up the required supplies on the barrier. The dressings to the bilateral lower extremities (BLE) were dated 02/09/25. LPN #180 verified the dressing changes were physician ordered as daily and had not been changed since 02/09/25. The resident was assisted onto his right side by a certified nursing assistant with difficulty due to the parameter mattress being too small for the resident's size. The dressing to the resident's sacrum was dated 02/08/25. The dressing was saturated with blood-tinged drainage and a foul odor was noted. LPN #180 verified the dressing changes were daily and had not been changed since 02/08/25. This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on record review, interview and facility policy review, the facility failed to ensure one resident (#72) was provided the physician ordered chest vest (help clear patients ' airways. It dislodges mucus from the bronchial walls, and helps move secretions and mucus from smaller to larger airways, where it can be coughed or suctioned out.) for chest physiotherapy. This affected one (Resident #72) of one resident reviewed for chest vest use. The facility census was 67. Findings Include: Review of the closed medical record for Resident #72 revealed an initial admitted [DATE] with the diagnoses including but not limited to acute respiratory failure with hypoxia, multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, right bundle branch block, urinary tract infection, pneumonitis due to inhalation of food and vomit, dysphagia, other disorders of lung, history of falling, pain, slow transit constipation, migraine, vitamin D deficiency, intervertebral disc displacement lumbar region, neuromuscular dysfunction of bladder, slurred speech, osteoarthritis, dependence on supplemental oxygen, anxiety disorder and functional quadriplegia. The resident was discharged to another local skilled nursing facility (SNF) on 02/07/25. Review of the resident's admission evaluation dated 01/24/25 revealed the resident was admitted to the facility from an acute care hospital stay for MS, increased weakness and post-op debridement of pressure ulcers. The assessment did not address the use of the chest vest for chest physiotherapy. Review of the medical record revealed no baseline plan of care addressing the resident's respiratory status and the use of the chest vest for chest physiotherapy. Review of the resident's discharge physician orders identified an order dated 01/25/25 chest physiotherapy via chest vest three times a day. Review of the progress note dated 01/25/25 at 7:21 P.M. revealed the resident arrived at the facility without the chest vest for chest physiotherapy. Review of the progress note dated 01/30/25 at 12:42 P.M. revealed the percussion wrap arrived to the facility and placed in resident room for percussion therapy. On 02/12/25 at 8:50 A.M., interview with the Regional Nurse #210 verified the chest vest for chest physiotherapy had not arrived in a timely manner. This deficiency represents non-compliance investigated under Complaint Number OH00162365.

Based on observation, record review and interview, the facility failed to maintain two residents (#50, #72) enteral feeding tube in proper working order. This affected two (Resident #50 and #72) of three residents reviewed for enteral feedings. The facility census was 67. Findings Include: 1. Review of the closed medical record for Resident #72 revealed an initial admitted [DATE] with the diagnoses including but not limited to acute respiratory failure with hypoxia, multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, right bundle branch block, urinary tract infection, pneumonitis due to inhalation of food and vomit, dysphagia, other disorders of lung, history of falling, pain, slow transit constipation, migraine, vitamin D deficiency, intervertebral disc displacement lumbar region, neuromuscular dysfunction of bladder, slurred speech, osteoarthritis, dependence on supplemental oxygen, anxiety disorder and functional quadriplegia. The resident was discharged to another local skilled nursing facility (SNF) on 02/07/25. Review of the resident's plan of care dated 02/03/25 last revised on 02/11/25 revealed the resident had nutritional problem or potential nutritional problem related to peg-tube placement 12/23/24, enteral feedings, skin impairment, body mass index (BMI) low end of normal, dysphagia, MS, aspiration pneumonia, chewing/swallowing difficulties, broken/missing teeth, appetite stimulant and abnormal labs. Interventions included monitor/document/report as needed any signs/symptoms of dysphagia, monitor/record/report to physician as needed signs/symptoms of malnutrition, provide and serve diet as ordered, Registered Dietician (RD) to evaluate and make diet change recommendations as needed and speech therapy to screen and provide recommendations for feeding as needed. Review of the resident's discharged physician ordered identified orders dated 01/25/25 nothing by mouth (NPO), enteral feeding of Pivot 1.5 at 45 milliliters (ml) per hour with 100 ml water flush every four hours via peg-tube, check residuals every eight hours, if greater than 100 ml, hold feeding and recheck in one hour, if not resolved call the physician, check peg-tube placement before feeding, flush and medications, flush peg-tube with minimum of 30 ml of water before giving medications, flush with at least 5 ml between medications and flush with minimum of 30 ml after all medications given, monitor for tube feeding complications and 01/28/25 change feeding administration set with each new bottle, label the formula container, syringe and administration set with resident's name, date, time and the nurse's initials. On 02/11/25 at 11:30 A.M., interview with Licensed Practical Nurse (LPN) #168 verified she worked with Resident #72 and his peg-tube leaked due to the connector had a crack. The LPN revealed the facility did not have a replacement connector so they wrapped the connection in a towel to soak up the enteral feeding leaking out. On 02/12/25 at 12:27 P.M., interview with Certified Nursing Assistant (CNA) #149 verified she cared for Resident #72 and his peg-tube leaked the entire time he was a the facility. She revealed she wrapped his peg-tube in a towel to catch the leaking formula and changed the towel frequently. 2. Review of the medical record for Resident #50 revealed an initial admitted [DATE] with the diagnoses including but not limited to acute respiratory failure with hypoxia, diabetes mellitus, cardiac arrest due to other underlying condition, moderate protein calorie malnutrition, intracranial injury with loss of consciousness, dysphagia, atrial fibrillation, obstructive sleep apnea, hyperlipidemia, hypertension, gastro-esophageal reflux disease, insomnia, obesity, major depressive disorder, anemia, hearing loss, mood disorder, osteoarthritis, polyneuropathy and atypical atrial flutter. Review of the plan of care dated 01/31/25 revealed the resident was at risk for altered nutritional status related to diabetes mellitus, protein calorie malnutrition, dysphagia, hyperlipidemia, hypertension, peg-tube placement 11/06/24, abnormal labs, diarrhea, swallowing difficulties, significant weight loss and appetite stimulant. Interventions included administer medication and/or vitamin/mineral supplement per physician order, encourage/provide intake of fluids throughout the day, if not contraindicated, notify RD, family, and physician of any signs / symptoms of dehydration, obtain labs per physicians orders associated with nutritional status and report results to the physician and ensure dietician is aware, therapy referral/evaluation/treatment as needed, periodically obtain resident's weight, evaluate, and report to RD, physician, and family of significant weight changes, Provide feeding/dining assistance as needed, Provide meals/snacks/fluids based on resident food preferences and physician orders, provide nutritional supplements as ordered by physician, administer enteral nutrition per physician orders, notify physician of complications observed with enteral nutrition, review with resident and/or family any issues or concerns about the enteral nutrition, flush feeding tube per physician orders, treatment to tube site per physician orders, Monitor and report to physician any abdominal pain, distension, tenderness at tube site, nausea/vomiting and check for tube placement and residual as indicated. Review of the resident's physician orders for February 2025 identified orders dated 01/31/25 flush peg tube every shift with 100 ml of water every 4 hours via peg-tube, Peptide 1.5-55 ml/hour continuously, change syringe daily daily on night shift, check and record residuals every shift, contact physician if residual exceeds 100 ml, check tube placement before initiation of formula, medication administration, and flushing tube or at least every eight hours, continuous feed, check every four to six hours, prior to irrigation and as needed, closed system container, change feeding administration set with each new bottle/bag; label the formula container, syringe and administration set with resident's name, date, time, and nurse's initials, elevate head of bed 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped, 02/01/25 cleanse peg-tube site with normal saline and pat dry, apply split sponge and secure with tape daily, and 02/03/25 NPO diet, Enhanced Barrier Precautions related to g-tube every shift. On 02/11/25 at 11:15 A.M., observation of Licensed Practical Nurse (LPN) #168 administer Resident #50 morning medication via his peg-tube revealed the crushed all of the resident's medications and opened the capsules and placed in a clear plastic medication cup together. The LPN checked placement of the peg-tube with 10 ml of air and aspiration for residual enteral formula. The LPN then placed a syringe onto the peg-tube and filled the syringe with approximately 30 ml of water. The peg-tube was clogged so the LPN pushed the water resulting in the water spraying onto the resident's clothing. The LPN obtained another syringe and attempted to administer the resident's morning medication with the syringe with the part of the medication leaking out onto the resident. Interview with LPN #168 at the time of the observation revealed the facility did not have any piston type syringes in stock for the resident's peg-tube. The LPN donned no enhanced barrier precaution (EBP) equipment (gown and gloves) during the procedure. Review of the facility policy titled, Administering Medications Through an Enteral Tube, dated 09/21 revealed the purpose of the procedure was to provide guidelines for the safe administration of medications through an enteral tube. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately. This deficiency represents non-compliance investigated under Complaint Number OH00162365.

Based on observation, record review and interview, the facility failed to ensure an indwelling urinary catheter was changed as physician ordered for Resident #43. Additionally, the facility failed to ensure one resident (#73) received routine indwelling catheter care. This affected two (Resident #43 and #73) of three residents reviewed for indwelling urinary catheter. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #43 revealed an initial admitted [DATE] with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the resident's admission evaluation dated 01/22/25 revealed the resident was admitted from an acute care hospital for wounds and weakness. The resident had an indwelling urinary catheter on admission. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent for bed mobility and toileting. The assessment indicated the resident had an indwelling urinary catheter and an ostomy. Review of the resident's monthly physician orders for February 2024 identified orders dated 02/10/25 change Foley catheter and Foley bag every month every day shift starting on the tenth and ending on the tenth every month, change Foley every 30 days starting in 2/10/25. Review of the medical record revealed no evidence the resident's indwelling urinary catheter was changed as physician ordered on 02/10/25. On 02/11/25 at 11:47 A.M., interview with Resident #43 revealed his indwelling urinary catheter was supposed to be changed on 02/10/25, however it was not changed. Observation of the resident revealed the indwelling urinary catheter collection bag was not in a privacy bag and the clear yellow urine was visible from the hallway. On 02/11/25 at 2:15 P.M., interview with Licensed Practical Nurse (LPN) #180 confirmed the resident's indwelling urinary catheter was not changed as physician ordered on 02/10/25. 2. Review of the closed medical record for Resident #73 revealed an initial admitted [DATE] with the latest readmission of 11/21/24 with the diagnoses including but not limited to sepsis, severe sepsis with shock, urinary tract infection (UTI), adult failure to thrive, retention of urine, chronic atrial fibrillation, cystitis with hematuria, hypertension, osteoarthritis, pain, anemia, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, edema, malignant neoplasm of prostate, presence of urogenital implants, bladder neck obstruction, cerebral ischemia and hyperlipidemia. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident was dependent on staff for toileting and transfers. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of the resident's Foley catheter justification dated 12/17/24 revealed the assessment was blank. Review of the resident's discharged physician orders identified an order dated 12/19/24 record Foley catheter output every shift. Review of the medical record revealed no physician orders or documented evidence the resident's indwelling urinary catheter was provided care. On 02/13/25 at 3:45 P.M., interview with the Director of Nursing (DON) confirmed the the resident had no physician orders or documented evidence the resident's indwelling urinary catheter was provided care. This deficiency represents non-compliance investigated under Complaint Number OH00162180.

Based on record review, interview and facility policy review, the facility failed to ensure one resident (#72) who was dependent on staff received routine bathing. This affected one (Resident #72) of three residents reviewed for bathing. The facility census was 67. Findings Include: Review of the closed medical record for Resident #72 revealed an initial admitted [DATE] with the diagnoses including but not limited to acute respiratory failure with hypoxia, multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, right bundle branch block, urinary tract infection, pneumonitis due to inhalation of food and vomit, dysphagia, other disorders of lung, history of falling, pain, slow transit constipation, migraine, vitamin D deficiency, intervertebral disc displacement lumbar region, neuromuscular dysfunction of bladder, slurred speech, osteoarthritis, dependence on supplemental oxygen, anxiety disorder and functional quadriplegia. The resident was discharged to another local skilled nursing facility (SNF) on 02/07/25. Review of the resident's admission evaluation dated 01/24/25 revealed the resident preferred bathing at bedtime. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for personal hygiene, toileting, bathing, bed mobility and substantial/maximal assistance with dressing. Review of the resident's medical record revealed the resident was scheduled for routine showers every Monday and Thursday. Review of the medical record revealed no evidence the resident was provided the scheduled shower on 01/27/25, 01/30/25, 02/03/25 and 02/06/25. On 02/12/25 at 8:30 A.M., an interview with Regional Nurse #210 confirmed the facility had no documented evidence the resident received routine bathing. Review of the facility policy titled, Shower/Tub Bath, dated 09/21 revealed the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. This deficiency represents non-compliance investigated under Master Complaint Number OH00162558 and Complaint Number OH00162365.

Based on record review and staff interview, the facility failed to complete a comprehensive admission assessment on admission for two residents (#43, #49). This affected two (Resident #43 and #49) of three residents reviewed for pressure ulcers. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #43 revealed an initial admitted [DATE] with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the progress note dated 02/05/25 at 6:10 P.M. revealed the resident was readmitted to the facility at 6:00 P.M. Review of the medical record revealed a comprehensive readmission assessment was not completed until 02/07/25. Further review revealed the assessment was still in progress. On 02/11/25 at 3:25 P.M., interview with Regional Nurse #210 confirmed the readmission assessment was not completed in a timely manner. 2. Review of the medical record for Resident #49 revealed an initial admitted [DATE] with the latest readmission of 02/11/25 with the diagnoses including but not limited to cerebrovascular accident with right sided hemiplegia, respiratory failure, asthma, chronic respiratory failure with hypoxia, severe protein calorie malnutrition, systemic lupus, dysphagia, dysphonia, neuromuscular dysfunction of bladder, gastrostomy status, cardiomyopathy, anemia, anxiety disorder, gastro-esophageal reflux disease, hyperlipidemia, hypertension, fibromyalgia and major depressive disorder. Review of the progress note dated 02/11/25 at 8:27 P.M. revealed the resident was readmitted to the facility. On 02/13/25 at 2:45 P.M., an interview with the Director of Nursing (DON) verified the resident had no readmission assessment, readmission wound assessments were not completed. This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on observation, record review and interview, the facility failed to ensure one resident's (#43) bed accommodated his size and had physician ordered enabler bars to enhance bed mobility. This affected one (Resident #43) of three residents reviewed for pressure ulcers. The facility census was 67. Findings Include: Review of the medical record for Resident #43 revealed an initial admitted [DATE] with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the resident's monthly physician orders for February 2024 identified an order dated 01/23/25 enabler bars to enhance bed mobility. On 02/11/25 at 1:34 P.M., observation of resident during wound care revealed the resident's bed was a regular bed with a parameter mattress in place. The resident had no enabler bars in place on the bed to assist with bed mobility. Further observation revealed when the resident was assisted onto his right side his legs fell from the bed due to the bed not being large enough for his size. On 02/11/25 at 2:00 P.M., an interview with Licensed Practical Nurse (LPN) #180 confirmed the resident's bed was too small limiting the resident's ability to turn and reposition to achieve off-loading to the pressure ulcers and would require a bariatric bed. The LPN confirmed the resident was not provided with an air mattress despite the pressure ulcer. The LPN also verified the resident had no enabler bars on the bed as physician ordered. This deficiency represents non-compliance investigated under Complaint Number OH00162365.

Based on observation, record review, interview and facility policy review, the facility failed to ensure residents were treated in a dignified manner. This affected three residents (#43, #48, #49) of three residents reviewed for indwelling urinary catheter. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #43 revealed an initial admitted [DATE] with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the resident's admission evaluation dated 01/22/25 revealed the resident was admitted from an acute care hospital for wounds and weakness. The resident had an indwelling urinary catheter on admission. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent for bed mobility and toileting. The assessment indicated the resident had an indwelling urinary catheter and an ostomy. Review of the resident's monthly physician orders for February 2024 identified orders dated 01/22/25 record Foley catheter output every shift, catheter care every shift, Foley catheter 16 FR with 5 milliliter (ml) balloon to gravity drainage every shift, Foley catheter to remain covered every shift for privacy, ostomy site care daily and as needed, empty ostomy bag every shift and as needed, and 02/10/25 change Foley catheter and Foley bag every month every day shift starting on the tenth and ending on the tenth every month, change Foley every 30 days starting on 02/10/25. On 02/11/25 at 11:47 A.M., interview with Resident #43 revealed his indwelling urinary catheter was supposed to be changed on 02/10/25, however it was not changed. Observation of the resident revealed the indwelling urinary catheter collection bag was not in a privacy bag and the clear yellow urine was visible from the hallway. On 02/12/24 at 2:15 P.M., interview with Licensed Practical Nurse (LPN) #180 confirmed the resident's indwelling urinary catheter collection bag was not in a privacy bag as physician ordered. 2. Review of the medical record for Resident #49 revealed an initial admitted [DATE] with the latest readmission of 02/11/25 with the diagnoses including but not limited to cerebrovascular accident with right sided hemiplegia, respiratory failure, asthma, chronic respiratory failure with hypoxia, severe protein calorie malnutrition, systemic lupus, dysphagia, dysphonia, neuromuscular dysfunction of bladder, gastrostomy status, cardiomyopathy, anemia, anxiety disorder, gastro-esophageal reflux disease, hyperlipidemia, hypertension, fibromyalgia and major depressive disorder. Review of the admission evaluation dated 12/27/24 revealed the resident was admitted with an indwelling urinary catheter and was incontinent of bowel. The assessment indicated the resident was a two person assist with toileting and bed mobility. Review of the plan of care dated 12/29/24 revealed the resident had a need for an indwelling urinary catheter. Interventions included monitor for signs and symptoms of urinary tract infection and report to the physician, report signs of peri-area redness, irritation, skin excoriation/breakdown to physician, document output, catheter bag to be emptied every shift, review with resident/family of the risks of catheterization, securement device to be applied to securely anchor catheter tubing, provide peri-care prior to application and after removal of external catheter, change catheter and drainage system as indicated per physician orders, keep tubing free of kinks and twists, maintain drainage bag below the bladder level, privacy cover to drainage bag, provide catheter care every shift and as needed and provide prophylactic interventions per physicians orders. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident was dependent on staff for toileting. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of the resident's monthly physician orders for February 2025 identified orders dated 02/12/25 urinary catheter care every shift, change urinary catheter anchor weekly on Monday, change urinary catheter drainage bag every four weeks on Monday and record urinary catheter output every shift. On 02/12/25 at 8:48 A.M., observation of Resident #49 revealed the indwelling urinary catheter collection bag as not contained in a privacy bag allowing the clear yellow urine to be visible from the hallway. On 02/12/25 at 10:07 A.M., interview with Licensed Practical Nurse (LPN) #130 confirmed the resident's indwelling urinary catheter was not contained in a privacy bag allowing the resident's urine to be visible from the hallway. 3. Review of the medical record for Resident #48 revealed an initial admitted [DATE] with the latest readmission of 01/28/25 with the diagnoses including but not limited to sepsis, obstructive and reflux uropathy, hydronephrosis with renal and urethral calculous obstruction, hypertension and atrial fibrillation. Review of the plan of care dated 02/11/25 revealed the resident had an indwelling urinary catheter related to obstructive uropathy. Interventions included monitor for signs and symptoms of urinary tract infection (UTI) and report to the physician, report signs of peri-area redness, irritation, skin excoriation/breakdown to physician, documents output, catheter bag to be emptied every shift, securement device to be applied to securely anchor catheter tubing, provide peri-care prior to application and after removal of external catheter, change catheter and drainage system as indicated per physician orders, keep tubing free of kinks and twists, maintain drainage bag below the bladder level, privacy cover to drainage bag and provide catheter care every shift and as needed. Review of the resident's February 2025 monthly physician orders identified the only order related to the resident's indwelling urinary catheter dated 02/12/25 record output every shift. On 02/11/25 at 11:45 A.M., observation of Resident #48 revealed the resident's indwelling urinary catheter bag was laying on the floor with clear amber urine visible from the hallway. On 02/11/25 at 2:50 P.M., observation of Resident #48 revealed he was ambulating in the hallway with his walker. Further observation revealed the resident's indwelling urinary catheter collection bag was hanging on the walker with clear amber urine being visible. On 02/11/25 at 10:05 A.M., interview with LPN #130 confirmed the resident's indwelling urinary catheter collection bag was not contained in a privacy bag. Review of the facility policy titled, Dignity, not dated revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. This deficiency represents non-compliance investigated under Complaint Number OH00162558.

Based on medical record review, review of hospital progress notes, staff interview, observation, resident interview, and review of the facility policy, the facility failed to ensure a resident received medication timely and as ordered by the physician. Actual Harm occurred when the facility failed to administer two scheduled doses of Suboxone (a medication used for opioid withdrawal) resulting in Resident #52 experiencing nausea, diaphoresis (sweating), and discomfort and resulted in the resident being transported to the hospital and admitted for opioid withdrawal symptoms. This affected one (Resident #52) of three residents reviewed for medication administration. The facility census was 72 residents. Findings include: Review of the medical record for Resident #52 revealed the resident was admitted on [DATE] with diagnoses including a history of intravenous (IV) drug use. Review of the physician's orders for Resident #52 revealed an order dated 09/12/24 for eight milligrams (mg) of Suboxone every twelve hours for opioid dependence. Review of the Medication Administration Record (MAR) for Resident #52 dated 09/12/24 revealed the staff documented the resident was not administered the evening dose of Suboxone as ordered by the physician. There was no documentation in Resident #52's record regarding the rationale for omission of the evening dose of Suboxone nor was there documentation of physician notification of the missed dose. Review of the MAR for Resident #52 dated 09/13/24 revealed the staff documented the resident was not administered the morning dose of Suboxone as ordered by the physician. There was no documentation in Resident #52's record regarding the rationale for omission of the morning dose of Suboxone nor was there documentation of physician notification of the missed dose. Review of the hospital progress note for Resident #52 dated 09/13/24 revealed the resident presented to the emergency room complaining of withdrawal symptoms due to not receiving scheduled doses of Suboxone at the facility and was admitted to the hospital. The resident was documented to have been receiving Suboxone since May of 2024 for the treatment of substance abuse. Interview with Licensed Practical Nurse (LPN) #200 on 09/13/24 confirmed Resident #52 was admitted during the afternoon on 09/12/24 and had not received scheduled doses of Suboxone on the evening of 09/12/24 or the morning of 09/13/24 due to the medication not being available. Observation on 09/13/24 at 12:40 P.M. of Resident #52 revealed the resident was lying on her left side and was curled into a ball. The resident was sweating and appeared to be uncomfortable. Interview on 09/13/24 at 12:40 P.M. with Resident #52 confirmed she was sweating, nauseous, and very uncomfortable. Resident #52 confirmed she had not received the scheduled doses of Suboxone ordered by the doctor since being admitted to the facility the day prior. The resident stated she had received the last dose of Suboxone in the hospital at 8:00 A.M. on 09/12/24 and did not receive scheduled doses the evening of 09/12/24 or the morning of 09/13/24. The resident stated she believed she was beginning to experience withdrawal symptoms due to missing scheduled medication doses. Telephone interview on 09/13/24 at 1:46 P.M. with Nurse Practitioner (NP) #500 confirmed Resident #52 was likely experiencing withdrawal symptoms due to not receiving scheduled doses of Suboxone on 09/12/24 and 09/13/24. NP #500 confirmed staff should have notified the physician or NP of the medication not being available for administration. Interview on 09/13/24 at 2:05 P.M. with Licensed Practical Nurse (LPN) #20 confirmed Resident #52 had been transferred to the hospital for evaluation due to complaints of nausea, sweating, and not feeling well due to missing scheduled doses of Suboxone. Review of the facility policy titled Medication Administration dated September 2018 revealed medications were to be administered in accordance with written orders of the prescriber. This deficiency represents noncompliance investigated under Complaint Number OH00156868.

Based on record review, staff interview and facility policy review, the facility failed to implement a residents care planned fall interventions to prevent falls. This resulted in actual harm when Resident #23's fall interventions were not in place and the resident fell , sustaining injuries including a subarachnoid hemorrhage (bleeding around the brain), cephalohematoma (a collection of blood on the head) and an operation/procedure to evacuate or remove the hematoma requiring hospitalization . This affected one (Resident #23) of three residents reviewed for accidents. The facility census was 92. Findings include: Review of Resident #23's medical record revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of Resident #23's care plan dated 04/16/18 revealed the resident was at risk for falls related to a recent [MEDICAL CONDITION] with left sided [MEDICAL CONDITION], the resident would attempt to transfer self without assistance, and had poor safety awareness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was moderately cognitively impaired. He required extensive assistance of two people for bed mobility, and transfers. He required extensive assistance of one person for locomotion on and off the unit, and personal hygiene. The residents assessment indicated walking in room and the corridor did not occur during the prior seven days. The resident's balance during transition and walking was not steady, only able to stabilize with staff assistance for moving from seated to standing and surface to surface transfer. He utilized a walker and wheelchair to aid in mobility. Review of hospital records dated 05/04/18 revealed the Resident #23 had a fall with a head injury and a scalp hematoma. Review of Resident #23's nursing note dated 05/05/18 at 3:31 A.M., revealed the Resident had a fall on 05/04/18 and returned to facility at 9:00 P.M. Resident #23 was sent out to the emergency room after a fall due to hitting his head. The Resident had a negative Computerized Tomography (CT) scan and received a tetanus shot. The physician and resident's family were notified. Review of Resident #23's fall risk evaluation assessment dated [DATE] revealed the resident was a high risk for falls with a score of 16. A score of over 10 was considered to be at risk. Further review of Resident #23's care plan revealed on 05/07/19, an updated intervention was added to include a pressure alarm to the residents bed and chair at all times. Review of a progress note dated 05/30/18 revealed at 3:00 P.M., an State tested Nurse Aide (STNA) heard Resident #23 make a noise, the STNA turned around and he was on the floor in the hallway outside the door to his room. The resident was face down on the floor, with a hematoma to the right forehead above the eye, a skin tear to the right elbow and altered mental status. The Resident was sent to emergency room at the local hospital and then transferred to another hospital. Review of hospital notes dated 05/30/18 revealed Resident #23 sustained a subarachnoid hemorrhage, cephalohematoma, and an operation/procedure was done to evacuate or remove the hematoma and closure over a drain. The resident was hospitalized from [DATE] until 06/04/18. Review of the facility's fall investigation dated 05/30/18 for Resident #23 revealed he had a fall with major injury on 05/30/18 and the Resident had an order for [REDACTED]. Observation on 01/29/19 at 9:24 A.M., revealed Resident #23 was in bed in his room with care planned fall interventions in place. Interview with Licensed Practical Nurse (LPN) #17 on 01/30/19 at 12:10 P.M., revealed she completed the investigation for Resident #23's fall on 05/30/18. LPN #17 verified the fall alarm mat was on the Residents chair and it should had been on the bed as the Resident was on his bed on the phone prior to the fall. LPN #17 revealed there was no alarm going off. Observation on 01/30/19 at 4:30 P.M., revealed Resident #23 was in bed in his room with care planned fall interventions in place. Interview with STNA #52 on 01/30/19 at 4:37 P.M., revealed Resident #23 would frequently try to get out of bed looking for his truck or fried chicken. STNA #52 stated the resident would usually not try to get out of the bed or chair when the alarms were in place and sounding. Interview with LPN #65 on 01/31/19 10:51 A.M., verified that she was present on 05/30/19 when Resident #23 fell . LPN #65 verified there was no alarm sounding when the Resident fell . LPN #65 stated the Resident was forgetful and he would forgets he could not walk so that was why he had an alarm. Review of the facility fall policy (revised 08/16/18) revealed the facility would provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. All resident would have a comprehensive fall risk assessment and appropriate care plan interventions would be implemented and evaluated as indicated by assessment. The comprehensive care plan would be implemented with individual goals and interventions.

Based on medical record review, review of personnel files, review of a facility Self-Reported Incident (SRI), review of a local law enforcement report, social media documentation review, review of the facility's abuse policy and procedure, review of the facility's employee handbook, and interviews with staff and residents, the facility failed to ensure a resident was free from sexual abuse by a staff member. This resulted in Immediate Jeopardy and psychosocial harm for one resident (Resident #71), when Licensed Physical Therapy Assistant (LPTA) #93 kissed Resident #71 during a physical therapy session, digitally penetrated her vagina and exchanged inappropriate messages via a social media messenger that were sexual in nature. This affected one (Resident #71) of four residents reviewed for sexual abuse. The facility census was 91. On 03/29/18 at 4:00 P.M., the Administrator, Director of Nursing (DON) and the Regional Care Consultant (RCC) #92 were notified that Immediate Jeopardy began on 03/09/18 at 9:10 A.M., when LPTA #93 was providing a 50 minute massage therapy session which included kissing the resident on the mouth and the resident reported digital penetrated of her vagina. During the therapy session, Resident #62 overheard Resident #71 telling LPTA #93 to stop and declining his offer to go into the bathroom. At 12:39 P.M., LPTA #93 began messaging Resident #71 via a social media messenger. LPTA #93 sent multiple messages pursuing Resident #71 including when can I see you again, asking her if she would like a more intense massage, and did she want to go to the bathroom with him for more privacy. When recounting the incident, Resident #71 became tearful stating she felt scared and intimidated by LPTA #93 who was a large man. The Immediate Jeopardy was removed on 03/30/18 when the facility implemented the following corrective actions: · On 03/14/18 at 12:30 P.M., LPTA #93 was suspended by Rehabilitation Service Manager (RSM) #97 · On 03/14/18 at 12:30 P.M., an investigation was initiated by the Administrator, DON, Licensed Practical Nurse (LPN) #95, Social Service Director (SSD) #96 and RSM #97 upon initial report of the sexual abuse allegation for Resident #71. At 2:30 P.M., the DON submitted an SRI to the State Agency regarding the sexual abuse allegation. · On 03/14/18 at 1:00 P.M., LPN #98 assessed Resident #71 for any signs and symptoms of abuse, with no concerns or abnormal results. The physician assistant (PA) #99 was notified of Resident #71's allegation of sexual abuse by LPN #98. · On 03/14/18 at 1:00 P.M., the Administrator, DON, LPN #95, SSD #96 and RSM #97 obtained written witness statements including Resident #62, State tested Nursing Assistant (STNA) #9, LPN #95, LPTA #128, SSD #96, Resident #71, LPTA #93, and LPTA #114. · On 03/14/18 at 1:15 P.M., resident interviews were obtained utilizing the investigation questions for resident interview form for alert and oriented residents to include whether or not LPTA #93 provided therapy services to them. These interviews were completed by RNs #101 and #103, and LPN #102. All alert and oriented residents were interviewed by 03/15/18 at 12:00 P.M. including Residents #3, #20, #38, #67, #69, #72, #76, #78, #79, #82, #85 and #90 who received therapy services from LPTA #93. There were no negative findings. · On 03/14/18 at 1:15 P.M., RN #103, LPN #98 and LPN #189 initiated skin checks on all residents residing in the facility. These skin checks were completed on 03/15/18 at 12:00 P.M. No evidence of abuse was identified for any of these residents. · On 03/14/18 at 2:32 P.M., the DON made notification to local law enforcement, the brother of Resident #71, and the Medical Doctor (MD) #100 of the allegation of sexual abuse. · On 03/14/18 at 2:32 P.M., the Abuse policy, Social Media policy and Professional Boundaries from the employee handbook was reviewed per the ad hoc quality assurance and performance improvement (QAPI) meeting by the Interdisciplinary team (IDT) which consisted of MD #100, the DON, the Administrator, LPN #95, RSM #97, RN #197, RN #103, SSD #96 and LPN #102. · On 03/14/18 at 6:36 P.M., Resident #71 was transported to the local hospital for evaluation. · On 03/14/18, 03/15/18 and 03/16/18, SSD #96 assessed Resident #71 for possible psychosocial issues. No negative outcomes were noted. · On 03/14/18 at 3:00 P.M., the minimum data set (MDS) Care Plan Coordinator #197 reviewed Resident #71's plan of care with no updates. · On 03/14/18 at 1:15 P.M., all facility staff re-education began on Abuse, Neglect and Misappropriation policy and procedure, use of Social Media, and Professional Boundaries of conduct. This training was completed by Staff Developer RN #101 and completed on 03/30/18 at 12:00 P.M. · On 03/15/18, the ombudsman was contacted regarding the allegation by the Administrator. · On 03/23/18 at 1:45 P.M., the facility terminated LPTA #93. · On 03/28/18 at 4:00 P.M., a monthly QAPI meeting was held and reviewed completed SRIs and investigations. Those in attendance included the Administrator, DON, Business office Manager (BOM) #172, Admissions #182, Dietary Manager #199, LPN #102, Activity Director #179, SSD #96 and RN #101. · On 03/29/18 at 1:30 P.M., 2:15 P.M., and again on 03/30/18 at 6:15 A.M., scheduled staff meetings were held by the Administrator regarding Abuse Policy and Procedures, Social Media Policy and Procedures and Professional Boundaries. Staff in attendance included STNA #107, #108, #109, #119, #123, #130, #148, #157, #175, #187 and #193, Plant Staff #167, Central Supply #198, RN #101, Activity Director #179, Dietary Manager #199, Laundry Supervisor #223 and Laundry #222. · On 03/29/18 from 4:40 P.M., to 5:30 P.M., interviews with RNs #103 and #101, LPNs #102, #95, #104 and #105, Chaplain #106, STNAs #107, #108, #109 and Certified Occupational therapy assistants (COTA) #110, #111 and #112 and RSM #97 verified they had received education on the abuse policy, social media and professional boundaries. They all were knowledgeable and knew who to report to. · On 03/30/18 at 7:00 A.M., the Administrator updated the Resident Interview Tool with Questions related to Social Media. · On 03/30/18 at 12:25 P.M., LPN #102, Medical Records #181, LPN #95, RN #103 and RN #197 re-interviewed and educated alert and oriented residents on staff member engagement on social media. During the interview/education, one resident (Resident #62) indicated she had friended two LPNs (LPN #98 and LPN #165) on social media to look at photos of their families. She indicated there was no allegation of abuse. Both nurses were provided with coaching and counseling on the social media policy. · Beginning on 03/30/18, the facility will utilize the Resident Interview tool with Questions concerning Abuse and Social Media policy and procedure to conduct random interviews with five residents three times a week for four weeks, random interviews with five residents one time a week for eight weeks to be completed by the Administrator or designee. 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 continued compliance. Findings include: Review of the medical record for Resident #71 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 02/23/18, revealed the resident had intact cognition. The resident required limited assistance of one staff for bed mobility, transfers, ambulation. Review of behavior and mood assessment revealed no behaviors. Review of the nurse progress notes dated 02/16/18 to 03/29/18 revealed no pertinent information related to abuse, mood, or behaviors concerns. Review of the computerized plan of care dated 02/17/18 revealed Resident #71 had impaired coping related to life style changes and lack of support system, resident was overly concerned with things at times. Interventions included orient to surroundings, introduce her to other residents, establish trust relationships, allow to discuss feelings of fear and anxiety, discuss loss of independence, offer positive praise for appropriate behavior and provide quality listening Review of the physical therapy (PT) notes dated 03/09/18 revealed LPTA #93 provided therapy services to Resident #71 for a total 50 minute session. Review of the SRI dated 03/14/18 at 2:31 P.M., revealed on 03/14/18 at approximately 12:30 P.M., Resident #71 reported to STNA #94 that LPTA #93 had kissed her on the mouth and had been messaging back and forth on social media with her. She asked STNA #94 not to say anything because she did not want LPTA #93 to lose his job. Multiple interviews were conducted with Resident #71 and different versions of the incident were obtained with more allegations. She reported while he was giving her a massage, his hands were near her vagina and peri area and when he rolled her over he kissed her on the lips. She reported Resident #62 had seen the kiss. The facility reported a therapist had entered the room and saw the privacy curtain was pulled and LPTA #93 was sitting in the room providing therapy services. It was also revealed LPTA #93 had given $20.00 dollars to Resident #71 and had conversations on social media messenger. Resident #71 provided visualization of the messages on her phone of interaction between Resident #71 and LPTA #93. Information of the contact on social media messenger revealed LPTA #93 initiated contact with Resident #71 on 02/20/18 at 3:15 P.M., and on 03/09/18 at 12:39 P.M., after the said massage session consensual phone messaging began between Resident #71 and LPTA #93. They had conversation on 03/09/18, 03/10/18 and 03/13/18. Resident #71 had not reported it before now because she had not spoken with her brother about it until 03/13/18. Her brother told Resident #71 it was not right and she needed to report it. At 5:45 P.M., Resident #71 made a gesture with her index finger in an upward motion and when asked what this meant she reported LPTA #93 had his finger in her VJJ (a slang term for vagina). A head to toe assessment was completed and she was sent to the local emergency room due to this further allegation. Review of social media messages dated from 02/20/18 at 5:15 P.M., to 03/14/18 at 9:49 A.M., revealed LPTA #93 initiated contact and requested to become friends and with Resident #71 on 02/20/18. On 03/09/18, LPTA #93 and Resident #71 became friends on social media facebook messenger. On 03/09/18 at 12:39 P.M., LPTA #93 was waving at Resident #71. At 2:05 P.M., Resident #71 responded back with hi sorry I took a nap after my wonderful massage session. The message also had a grin emoticon (defined as a representation of a facial expression, formed by various combinations of keyboard characters and used in electronic communications to convey the writer's feelings or intended tone.) At 2:20 P.M., LPTA #93 responded back with So glad u liked it. If I have time, would u like another one? Cuz im not sure when I'll be back. This message had a sad face emoticon. Resident #71 responded, Yes, to which LPTA #93 replied, Can u behave urself?? With a winky tongue out emoticon used. Resident #71 responded back with yes I believe I can. The question is can you? At 2:23 P.M., LPTA #93 replied with Actually, i'm not gonna promise u at all. Im horrible at temptations. Resident #71 responded back with Lol now ya must behave LPTA #93 replied, Ill try. I might have to help u go into the bathroom. They say it's a little more private in there. There was a heart eyes emoticon used for this message. Resident #71 responded, Lol to toilet is yuk, LPTA #93 replied, Well we might have to go in there so u can show me. What do you think? Resident #71 responded, I think slow down so we don't get caught. LPTA #93 replied, Oh we wouldn't my dear, but if that's what u want. There was also the use of a crying emoticon for this message. LPTA #93 sent emoticons of a flower then at 4:46 P.M., OMG!!!! Resident #71 responded, Lol. LPTA #93 replied, What did u think, I know!!!!!, Tease! Ha! Resident #71 responded, No Not Me. LPTA #93 responded, Ha! Uh Huh!! I bet Resident #71 responded, with a wink face emoticon. LPTA #93 replied, I have a feeling you & i r gonna get along GREAT! There was also the use of the heart eyes emoticon. Resident #71 responded, We shall see, but I think so. LPTA #93 replied, I have NO doubt!! Resident #71 responded,Awe sweet. LPTA #93 replied, I may not want to return u and utilized the heart eye emoticon. Resident #71 responded Awe. LPTA #93 responded with Every little bit counts and used the heart eyed emoticon. Resident #71 responded, Awe you don't have to do that Thank you. LPTA #93 responded, I want to. Plus uve helped so many people over the years. You're welcome! LPTA #93 also stated, Doesnt she EVER leave the room?? Ha! Resident #71 replied, NO. NEVER. LPTA #93 responded, Such a shame. Depending on our time id like to find a place for me to give u a better, more intense massage. Im talking after the movie Resident #71 responded with a thumbs up emoticon. LPTA #93 responded,Any ideas where we could go? How does Tuesday sound to you? At 6:48 P.M., LPTA #93 responded, I just left. I'll talk to u later. At 11:20 P.M., LPTA #93 stated, Hi. On 03/10/18 at 1:36 P.M., LPTA #93 responded, R u mad at me? And also used a crying face emoticon. At 3:07 P.M., Resident #71 responded, No hun my phone is so messed up. Its like it's being hit by lighting. It makes strange noise and goes blank. Then won't work for a while. At 3:18 P.M., LPTA #93 responded, Good! R u interested in this Tuesday? On 03/11/18 at 11:19 P.M., LPTA #93 responded, U awake?' Resident #71 responded, Yes kinda Where ya work tomm. LPTA #93 replied, Im off tomorrow. Resident #71 responded, Tired went to brothers. LPTA #93 replied, When r u going to brothers Resident #71 responded, I went today. LPTA #93 responded, Oh wish i would known. Resident #71 responded, We had a family thing. LPTA #93 responded , How bout Thursday? Resident #71 responded, Really no big deal, my brother is going to be out of town going to pick up daughter. Sorry. LPTA #93 responded, No worries. Would u like to see me again? Resident #71 responded, Yes. Not here though. LPTA #93 responded Oh no. Any ideas? Resident #71 responded, Hard when I have to depend on ride from here. LPTA #93 responded, I know. I wish there was some way i could pick u up. Resident #71 replied with a thumbs up emoticon and I'm falling asleep can ya text me on morning. LPTA #93 responded, Yes mam. Sweet dreams. Get some rest. Emoticons were sent back and forth for good night. On 03/13/18 at 3:50 P.M., LPTA #93 responded, Hi! How are you today? On 03/14/18 at 9:49 A.M., LPTA #93 responded, I'm working there tomorrow. This was the end of the documented conversation. Review of the local hospital record dated 03/14/18 revealed the resident was seen for possible sexual assault. Resident #71 stated she was digitally penetrated by LPTA #93 on 03/09/18 at the long-term care facility where she resided. The Sexual Assault Nurse Examiner (SANE) on call reported they would not be collecting evidence due to the length of time since the alleged incident. Adult Protective Service (APS) were called and were at the bedside with Resident #71. Review of Resident #62's witness statement dated 03/14/18 revealed she saw LPTA #93 in the room giving a massage to Resident #71. Resident #62 stated LPTA #93 touched Resident #71's breast one time and she saw Resident #71 be kissed by him one time. Review of the local law enforcement report dated 03/14/18 at 2:32 P.M., revealed Officer #113 was dispatched to the long-term care facility for a possible sexual assault. The officer spoke to Resident #71 who reported LPTA #93 came in and began to massage her left hip as she laid on her right side. Resident #71 reported LPTA #93's body was very close to hers, he pulled her pants down around her hip to massage the hip area better and then he kept moving his hands closer to the inside thigh. Resident #71 then stated LPTA #93 touched her chu-chu and slid what she believed was his finger inside of her vagina. Resident #71 stated she immediately pulled away and jerked his hand out of her. She stated when the LPTA #93 pulled his hands back LPTA #93 apologized stating Oh I'm sorry, then he told her to roll to the other hip and while turning over he leaned in and kissed her, sticking his tongue in her mouth. Resident #71 said she did not know what to do and continued to roll over. It was documented she stated LPTA #93 asked her to go into the bathroom but Resident #71 refused and he finished the massage. When she sat up, he kissed her again and told her to add him on social media. Resident #71 said she looked at her phone and saw a friend request from the LPTA #93 and felt obligated to accept him as he was staring at her. She said shortly after the session, LPTA #93 returned to her room with a folded piece of paper with a twenty-dollar bill inside. LPTA #93 insisted she keep the money. LPTA #93 had messaged her on 02/28/18 but did not add him until 03/09/18. Resident #71 showed the officer her phone of their discussions and she tried to tell LPTA #93 to slow down before we get caught, because she was worried about his job, she said she lied on 03/10/18 and 03/11/18 so LPTA #93 would leave her alone as the messages appeared they were friends. Resident #71 stated she was not friends with LPTA #93 and did not mean for it to sound like they were. She stated LPTA #93 tried to get her to have her brother take her to a restaurant so they could go on a date on Tuesday 03/13/18 to see a movie Fifty Shades of Grey. She further stated she had not reported it until LPTA #93 said he was coming back and she got worried something worse would happen. Resident #62 was contacted and stated she was in the room during the incident. She called LPTA #93 a different name but had seen him often in the facility and he came to do Resident #71's massage. Resident #62 reported LPTA #93 was pressing his body firm against the bed while he was giving the massage, she stated she could not hear everything but saw LPTA #93 massaging lower than her hip area. She stated she saw LPTA #93 kiss Resident #71 and touch her breast. Resident #71 said stop and when he asked her to go to the bathroom with him, Resident #71 refused to go. Review of the LPTA #93's witness statement dated 03/15/18 at 12:15 P.M., revealed LPTA #93 was documented as stating he and Resident #71 hit it off and had a good relationship. The statement further revealed he had given her twenty dollars and she asked him to add her on social media so he did. He said he asked her out to dinner but he was assuming this would be as friends. He stated he commented about doing the massage in the bathroom as a joke. He further stated he had gotten too emotionally involved with Resident #71 and could see that was not a good idea. He denied kissing the resident or touching her in anyway outside of the hip and leg massage. Review the personnel file for LPTA #93 revealed he was hired by the former company on 02/14/14 and the current ownership took over on 08/01/14. He had a bureau of criminal investigation (BCI) and federal bureau of investigation (FBI) completed on 02/07/18 with no concerns. However, there was no evidence of reference checks being completed upon hire. LPTA #93 was terminated on 03/23/18 for violation of the facility Conduct and Behavior policy 2.01. Telephone interview on 03/29/18 at 10:21 A.M., with LPTA #93 revealed he provided therapy services and gave money to Resident #71 out of the goodness of his heart. When questioned about the social media messaging he would not respond and deferred to his Attorney #116. He stated he absolutely, positively had not ever had any sexual contact with Resident #71. Interview on 03/29/18 at 10:56 A.M., Resident #71 revealed she arrived to the facility on [DATE]. On 02/20/18, he reached out to her on Facebook instant messaging, she did not acknowledge him as she did not know who he was. On 03/09/18, he entered the room to give her a massage She stated some of the therapists give a massage so that was not uncommon. Resident #71 stated she let LPTA #93 start and then he started talking about weird things. She stated said she froze because it was similar to experiences she had as a child from five years old to 16 from her biological father. She stated she was instantly scared and was frozen, she was saying no and stop and he was a very big man. She stated Resident #62 was in the room. Resident #71 stated LPTA #93 was massaging and his ungloved finger was massaging her bottom and went into her vagina. She stated LPTA #93 said oops sorry. She stated he held her down and kissed her and that day he made them become friends on Facebook. She did not know what to do, he began messaging her so she thought she would play along, he had mentioned another massage and trying to get her to go into the bathroom but she did not. He came back with a 20 dollar bill, he said he wanted to help her and she deserved the money. She said she was scared because he was scheduled to come back so she reported this to STNA #94. Resident #71 stated the facility called her a liar and was not nice. She felt like she was being interrogated and at the end of the day the facility wanted to talk to her again and said they were the same age and she flirted with him. Resident #71 became tearful during the interview and stated she felt intimidated and scared by LPTA #93 who was a large man and this was why she reported the incident. She stated she felt the facility kept telling her she flirted with him in the messages and it was consensual since they were the same age. Resident #71 stated it was not consensual. Interview on 03/29/18 at 12:35 P.M., Licensed Physical Therapy Assistant (LPTA) #114 stated earlier in the morning of 03/09/18, he was looking for the stimulation machine. He stated he approached Resident #71's room and saw the machine not in use at the foot of the bed. He stated Resident #71 and LPTA #93 were behind the drawn privacy curtain. LPTA #93 was sitting in the middle of the room facing Resident #71 and his back would have been to the roommate side of the room. He did not see Resident #62 but assumed she was in there because she very rarely left her room. He stated they both greeted him and he asked if he could use the machine and LPTA #93 said yes. LPTA #114 stated he was in the room only long enough to roll up the cord and take the machine out of the room. He said after the incident was reported, he began to get several text messages from LPTA #93 asking him to write a witness statement for him. He stated he responded by saying he could not speak about the investigation. LPTA #93 kept texting him maybe three times. LPTA #114 finally called LPTA #93 and told him he did not know what he was going through but did not know how his 15 seconds in the room was going to help him. Interview on 03/29/18 at 12:56 P.M., with Resident #62 (who was assessed as having intact cognition), stated LPTA #93 came in the room to provide therapy massage to Resident #71. She stated LPTA #93 was close to the bed and she could not see his hands but could see his elbows move toward her bottom area. She stated Resident #71 jumped up and this was when LPTA #93 kissed her on the mouth. She also heard LPTA #93 ask Resident #71 to go to the bathroom and she refused and also heard Resident #71 stay stop several times. Resident #62 stated she never reported it because after he left the room, Resident #71 did not say anything about what had happened so she figured it was none of her business. Interview on 03/29/18 at 2:39 P.M., with the Administrator and RCC #92 verified there was an inappropriate relationship with social media messages between Resident #71 and LPTA #93. They completed an SRI but did not substantiate the SRI because they felt Resident #71 and Resident #62 were being manipulative. The Administrator also stated the facility felt like it was a consensual relationship. They verified LPTA #93 should not have sent Resident #71 messages on social media and should not have given her money. The Administrator also verified this interaction was against their policy. An interview was conducted on 03/29/18 at 5:00 P.M., with LPN #95 who interviewed Resident #71 during the investigation into the incident with LPTA #93. LPN #95 stated Resident #71 never once said the contact was consensual. She stated Resident #71 said he had her pants down and he rolled her over and kissed her. Interview on 04/02/18 at 10:53 A.M., with STNA #94 revealed on 03/09/18 she went into Resident #71's room to answer the light. She said on her way out Resident #71 said she wanted to tell her something and she could not tell anyone. STNA #94 said if it was something bad she would have to report it. She then proceeded to tell her LPTA #93 had kissed her and they were messaging back and forth and he wanted to hook up with her. Resident #71 scrolled through her phone and showed her the messages however she did not read them she just saw it was LPTA #93's name and picture. She then reported the situation immediately. STNA #94 also stated she had not known Resident #71 to exhibit manipulative behaviors. Review of the facility Conduct and Behavior policy 2.01 updated 12/01/09 revealed types of conduct and behavior that are considered inappropriate include but are not limited to the follow; sexual or any other type of harassment or unlawful discrimination or any conduct that is determined by the company to be detrimental to the health and welfare, dignity, safety of the residents, visitors, fell ow stakeholders or the company. Review of the policy titled Abuse, Neglect and Misappropriation or Property dated 11/16/17 revealed sexual abuse included sexual harassment, sexual coercion, or sexual assault. Sexual abuse includes, but is not limited to, any physical contact with a resident's body that is not reasonably related to appropriate provision of ordered care or services; sexually oriented comments or jokes. Review of the Stakeholder Handbook (undated) revealed the employee needed to be careful about posting on social media and prevent the misuse of social media. Inappropriate postings including discriminatory remarks, harassment, defamation, bullying and threats of violence or similar inappropriate or unlawful conduct will not be tolerated and may subject staff to disciplinary action up to and including termination. Sexual harassment may include a range of subtle and not so subtle behaviors and may involve individuals of the same or different gender. Depending on the circumstances, these behaviors may include but are not limited to: unwanted sexual advances or requests for sexual favors; sexual jokes and innuendo; verbal abuse of a sexual nature; commentary about an individual's body, sexual prowess or sexual deficiencies; leering, [MEDICATION NAME] or touching; insulting or obscene comments or gestures; and other physical, verbal or visual conduct of a sexual nature. This deficiency substantiates allegations contained in Complaint Master Control Number OH 941 and Complaint Number OH 940.

Based on medical record review, review of personnel files, review of a facility Self-Reported Incident (SRI), review of local law enforcement report, social media documentation review, review of the facility's abuse policy and procedure, review of the facility's employee handbook, and interviews with staff and residents, the facility failed to implement their abuse policy to ensure residents were free from sexual abuse by a staff member. This resulted in Immediate Jeopardy and psychosocial harm for one resident (Resident #71), when Licensed Physical Therapy Assistant (LPTA) #93 kissed Resident #71 during a physical therapy session digitally penetrated her vagina, and exchanged inappropriate messages via a social media messenger that were sexual in nature. This affected one (Resident #71) of four residents reviewed for sexual abuse. The facility census was 91. On 03/29/18 at 4:00 P.M., the Administrator, Director of Nursing (DON) and the Regional Care Consultant (RCC) #92 were notified that Immediate Jeopardy began on 03/09/18 at 9:10 A.M., when LPTA #93 was providing a 50 minute massage therapy session which included kissing the resident on the mouth and the resident reported digital penetrated of her vagina. During the therapy session, Resident #62 overheard Resident #71 telling LPTA #93 to stop and declining his offer to go into the bathroom. At 12:39 P.M., LPTA #93 began messaging Resident #71 via a social media messenger. LPTA #93 sent multiple messages pursuing Resident #71 including when can I see you again, asking her if she would like a more intense massage, and did she want to go to the bathroom with him for more privacy. When recounting the incident, Resident #71 became tearful stating she felt scared and intimidated by LPTA #93 who was a large man. The Immediate Jeopardy was removed on 03/30/18 when the facility implemented the following corrective actions: · On 03/14/18 at 12:30 P.M., LPTA #93 was suspended by Rehabilitation Service Manager (RSM) #97. · On 03/14/18 at 12:30 P.M., an investigation was initiated by the Administrator, DON, Licensed Practical Nurse (LPN) #95, Social Service Director (SSD) #96 and RSM #97 upon initial report of the sexual abuse allegation for Resident #71. At 2:30 P.M., the DON submitted an SRI to the State Agency regarding the sexual abuse allegation · On 03/14/18 at 1:00 P.M., LPN #98 assessed Resident #71 for any signs and symptoms of abuse, with no concerns or abnormal results. The physician assistant (PA) #99 was notified of Resident #71's allegation of sexual abuse by LPN #98. · On 03/14/18 at 1:00 P.M., the Administrator, DON, LPN #95, SSD #96 and RSM #97 obtained written witness statements including Resident #62, State tested Nursing Assistant (STNA) #9, LPN #95, LPTA #128, SSD #96, Resident #71, LPTA #93, and LPTA #114. · On 03/14/18 at 1:15 P.M., resident interviews were obtained utilizing the investigation questions for resident interview form for alert and oriented residents to include whether or not LPTA #93 provided therapy services to them. These interviews were completed by RNs #101 and #103, and LPN #102. All alert and oriented residents were interviewed by 03/15/18 at 12:00 P.M. including Residents #3, #20, #38, #67, #69, #72, #76, #78, #79, #82, #85 and #90 who received therapy services from LPTA #93. There were no negative findings. · On 03/14/18 at 1:15 P.M., RN #103, LPN #98 and LPN #189 initiated skin checks on all residents residing in the facility. These skin checks were completed on 03/15/18 at 12:00 P.M. No evidence of abuse was identified for any of these residents. · On 03/14/18 at 2:32 P.M., the DON made notification to local law enforcement, the brother of Resident #71, and the Medical Doctor (MD) #100 of the allegation of sexual abuse. · On 03/14/18 at 2:32 P.M., the Abuse policy, Social Media policy and Professional Boundaries from the employee handbook was reviewed per the ad hoc quality assurance and performance improvement (QAPI) meeting by the Interdisciplinary team (IDT) which consisted of MD #100, the DON, the Administrator, LPN #95, RSM #97, RN #197, RN #103, SSD #96 and LPN #102. · On 03/14/18 at 6:36 P.M., Resident #71 was transported to the local hospital for evaluation. · On 03/14/18, 03/15/18 and 03/16/18, SSD #96 assessed Resident #71 for possible psychosocial issues. No negative outcomes were noted. · On 03/14/18 at 3:00 P.M., the minimum data set (MDS) Care Plan Coordinator #197 reviewed Resident #71's plan of care with no updates. · On 03/14/18 at 1:15 P.M., all facility staff re-education began on Abuse, Neglect and Misappropriation policy and procedure, use of Social Media, and Professional Boundaries of conduct. This training was completed by Staff Developer RN #101 and completed on 03/30/18 at 12:00 P.M. · On 03/15/18, the ombudsman was contacted regarding the allegation by the Administrator. · On 03/23/18 at 1:45 P.M., the facility terminated LPTA #93. · On 03/28/18 at 4:00 P.M., a monthly QAPI meeting was held and reviewed completed SRIs and investigations. Those in attendance included the Administrator, DON, Business office Manager (BOM) #172, Admissions #182, Dietary Manager #199, LPN #102, Activity Director #179, SSD #96 and RN #101. · On 03/29/18 at 1:30 P.M., 2:15 P.M., and again on 03/30/18 at 6:15 A.M., scheduled staff meetings were held by the Administrator regarding Abuse Policy and Procedures, Social Media Policy and Procedures and Professional Boundaries. Staff in attendance included STNA #107, #108, #109, #119, #123, #130, #148, #157, #175, #187 and #193, Plant Staff #167, Central Supply #198, RN #101, Activity Director #179, Dietary Manager #199, Laundry Supervisor #223 and Laundry #222. · On 03/29/18 from 4:40 P.M., to 5:30 P.M., interviews with RNs #103 and #101, LPNs #102, #95, #104 and #105, Chaplain #106, STNAs #107, #108, #109 and Certified Occupational therapy assistants (COTA) #110, #111 and #112 and RSM #97 verified they had received education on the abuse policy, social media and professional boundaries. They all were knowledgeable and knew who to report to. · On 03/30/18 at 7:00 A.M., the Administrator updated the Resident Interview Tool with Questions related to Social Media. · On 03/30/18 at 12:25 P.M., LPN #102, Medical Records #181, LPN #95, RN #103 and RN #197 re-interviewed and educated alert and oriented residents on staff member engagement on social media. During the interview/education, one resident (Resident #62) indicated she had friended two LPNs (LPN #98 and LPN #165) on social media to look at photos of their families. She indicated there was no allegation of abuse. Both nurses were provided with coaching and counseling on the social media policy. · Beginning on 03/30/18, the facility will utilize the Resident Interview tool with Questions concerning Abuse and Social Media policy and procedure to conduct random interviews with five residents three times a week for four weeks, random interviews with five residents one time a week for eight weeks to be completed by the Administrator or designee. 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 continued compliance. Findings include: Review of the medical record for Resident #71 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 02/23/18, revealed the resident had intact cognition. The resident required limited assistance of one staff for bed mobility, transfers, ambulation. Review of behavior and mood assessment revealed no behaviors. Review of the nurse progress notes dated 02/16/18 to 03/29/18 revealed no pertinent information related to abuse, mood, or behaviors concerns. Review of the computerized plan of care dated 02/17/18 revealed Resident #71 had impaired coping related to life style changes and lack of support system, resident was overly concerned with things at times. Interventions included orient to surroundings, introduce her to other residents, establish trust relationships, allow to discuss feelings of fear and anxiety, discuss loss of independence, offer positive praise for appropriate behavior and provide quality listening Review of the physical therapy (PT) notes dated 03/09/18 revealed LPTA #93 provided therapy services to Resident #71 for a total 50 minute session. Review of the SRI dated 03/14/18 at 2:31 P.M., revealed on 03/14/18 at approximately 12:30 P.M., Resident #71 reported to STNA #94 that LPTA #93 had kissed her on the mouth and had been messaging back and forth on social media with her. She asked STNA #94 not to say anything because she did not want LPTA #93 to lose his job. Multiple interviews were conducted with Resident #71 and different versions of the incident were obtained with more allegations. She reported while he was giving her a massage, his hands were near her vagina and peri area and when he rolled her over he kissed her on the lips. She reported Resident #62 had seen the kiss. The facility reported a therapist had entered the room and saw the privacy curtain was pulled and LPTA #93 was sitting in the room providing therapy services. It was also revealed LPTA #93 had given $20.00 dollars to Resident #71 and had conversations on social media messenger. Resident #71 provided visualization of the messages on her phone of interaction between Resident #71 and LPTA #93. Information of the contact on social media messenger revealed LPTA #93 initiated contact with Resident #71 on 02/20/18 at 3:15 P.M., and on 03/09/18 at 12:39 P.M., after the said massage session consensual phone messaging began between Resident #71 and LPTA #93. They had conversation on 03/09/18, 03/10/18 and 03/13/18. Resident #71 had not reported it before now because she had not spoken with her brother about it until 03/13/18. Her brother told Resident #71 it was not right and she needed to report it. At 5:45 P.M., Resident #71 made a gesture with her index finger in an upward motion and when asked what this meant she reported LPTA #93 had his finger in her VJJ (a slang term for vagina). A head to toe assessment was completed and she was sent to the local emergency room due to this further allegation. Review of social media messages dated from 02/20/18 at 5:15 P.M., to 03/14/18 at 9:49 A.M., revealed LPTA #93 initiated contact and requested to become friends and with Resident #71 on 02/20/18. On 03/09/18, LPTA #93 and Resident #71 became friends on social media facebook messenger. On 03/09/18 at 12:39 P.M., LPTA #93 was waving at Resident #71. At 2:05 P.M., Resident #71 responded back with hi sorry I took a nap after my wonderful massage session. The message also had a grin emoticon (defined as a representation of a facial expression, formed by various combinations of keyboard characters and used in electronic communications to convey the writer's feelings or intended tone.) At 2:20 P.M., LPTA #93 responded back with So glad u liked it. If I have time, would u like another one? Cuz im not sure when I'll be back. This message had a sad face emoticon. Resident #71 responded, Yes, to which LPTA #93 replied, Can u behave urself?? With a winky tongue out emoticon used. Resident #71 responded back with yes I believe I can. The question is can you? At 2:23 P.M., LPTA #93 replied with Actually, i'm not gonna promise u at all. Im horrible at temptations. Resident #71 responded back with Lol now ya must behave LPTA #93 replied, Ill try. I might have to help u go into the bathroom. They say it's a little more private in there. There was a heart eyes emoticon used for this message. Resident #71 responded, Lol to toilet is yuk, LPTA #93 replied, Well we might have to go in there so u can show me. What do you think? Resident #71 responded, I think slow down so we don't get caught. LPTA #93 replied, Oh we wouldn't my dear, but if that's what u want. There was also the use of a crying emoticon for this message. LPTA #93 sent emoticons of a flower then at 4:46 P.M., OMG!!!! Resident #71 responded, Lol. LPTA #93 replied, What did u think, I know!!!!!, Tease! Ha! Resident #71 responded, No Not Me. LPTA #93 responded, Ha! Uh Huh!! I bet Resident #71 responded, with a wink face emoticon. LPTA #93 replied, I have a feeling you & i r gonna get along GREAT! There was also the use of the heart eyes emoticon. Resident #71 responded, We shall see, but I think so. LPTA #93 replied, I have NO doubt!! Resident #71 responded,Awe sweet. LPTA #93 replied, I may not want to return u and utilized the heart eye emoticon. Resident #71 responded Awe. LPTA #93 responded with Every little bit counts and used the heart eyed emoticon. Resident #71 responded, Awe you don't have to do that Thank you. LPTA #93 responded, I want to. Plus uve helped so many people over the years. You're welcome! LPTA #93 also stated, Doesnt she EVER leave the room?? Ha! Resident #71 replied, NO. NEVER. LPTA #93 responded, Such a shame. Depending on our time id like to find a place for me to give u a better, more intense massage. Im talking after the movie Resident #71 responded with a thumbs up emoticon. LPTA #93 responded,Any ideas where we could go? How does Tuesday sound to you? At 6:48 P.M., LPTA #93 responded, I just left. I'll talk to u later. At 11:20 P.M., LPTA #93 stated, Hi. On 03/10/18 at 1:36 P.M., LPTA #93 responded, R u mad at me? And also used a crying face emoticon. At 3:07 P.M., Resident #71 responded, No hun my phone is so messed up. Its like it's being hit by lighting. It makes strange noise and goes blank. Then won't work for a while. At 3:18 P.M., LPTA #93 responded, Good! R u interested in this Tuesday? On 03/11/18 at 11:19 P.M., LPTA #93 responded, U awake?' Resident #71 responded, Yes kinda Where ya work tomm. LPTA #93 replied, Im off tomorrow. Resident #71 responded, Tired went to brothers. LPTA #93 replied, When r u going to brothers Resident #71 responded, I went today. LPTA #93 responded, Oh wish i would known. Resident #71 responded, We had a family thing. LPTA #93 responded, How bout Thursday? Resident #71 responded, Really no big deal, my brother is going to be out of town going to pick up daughter. Sorry. LPTA #93 responded, No worries. Would u like to see me again? Resident #71 responded, Yes. Not here though. LPTA #93 responded Oh no. Any ideas? Resident #71 responded, Hard when I have to depend on ride from here. LPTA #93 responded, I know. I wish there was some way i could pick u up. Resident #71 replied with a thumbs up emoticon and I'm falling asleep can ya text me on morning. LPTA #93 responded, Yes mam. Sweet dreams. Get some rest. Emoticons were sent back and forth for good night. On 03/13/18 at 3:50 P.M., LPTA #93 responded, Hi! How are you today? On 03/14/18 at 9:49 A.M., LPTA #93 responded, I'm working there tomorrow. This was the end of the documented conversation. Review of the local hospital record dated 03/14/18 revealed the resident was seen for possible sexual assault. Resident #71 stated she was digitally penetrated by LPTA #93 on 03/09/18 at the long-term care facility where she resided. The Sexual Assault Nurse Examiner (SANE) on call reported they would not be collecting evidence due to the length of time since the alleged incident. Adult Protective Service (APS) were called and were at the bedside with Resident #71. Review of Resident #62's witness statement dated 03/14/18 revealed she saw LPTA #93 in the room giving a massage to Resident #71. Resident #62 stated LPTA #93 touched Resident #71's breast one time and she saw Resident #71 be kissed by him one time. Review of the local law enforcement report dated 03/14/18 at 2:32 P.M., revealed Officer #113 was dispatched to the long-term care facility for a possible sexual assault. The officer spoke to Resident #71 who reported LPTA #93 came in and began to massage her left hip as she laid on her right side. Resident #71 reported LPTA #93's body was very close to hers, he pulled her pants down around her hip to massage the hip area better and then he kept moving his hands closer to the inside thigh. Resident #71 then stated LPTA #93 touched her chu-chu and slid what she believed was his finger inside of her vagina. Resident #71 stated she immediately pulled away and jerked his hand out of her. She stated when the LPTA #93 pulled his hands back LPTA #93 apologized stating Oh I'm sorry, then he told her to roll to the other hip and while turning over he leaned in and kissed her, sticking his tongue in her mouth. Resident #71 said she did not know what to do and continued to roll over. It was documented she stated LPTA #93 asked her to go into the bathroom but Resident #71 refused and he finished the massage. When she sat up, he kissed her again and told her to add him on social media. Resident #71 said she looked at her phone and saw a friend request from the LPTA #93 and felt obligated to accept him as he was staring at her. She said shortly after the session, LPTA #93 returned to her room with a folded piece of paper with a twenty-dollar bill inside. LPTA #93 insisted she keep the money. LPTA #93 had messaged her on 02/28/18 but did not add him until 03/09/18. Resident #71 showed the officer her phone of their discussions and she tried to tell LPTA #93 to slow down before we get caught, because she was worried about his job, she said she lied on 03/10/18 and 03/11/18 so LPTA #93 would leave her alone as the messages appeared they were friends. Resident #71 stated she was not friends with LPTA #93 and did not mean for it to sound like they were. She stated LPTA #93 tried to get her to have her brother take her to a restaurant so they could go on a date on Tuesday 03/13/18 to see a movie Fifty Shades of Grey. She further stated she had not reported it until LPTA #93 said he was coming back and she got worried something worse would happen. Resident #62 was contacted and stated she was in the room during the incident. She called LPTA #93 a different name but had seen him often in the facility and he came to do Resident #71's massage. Resident #62 reported LPTA #93 was pressing his body firm against the bed while he was giving the massage, she stated she could not hear everything but saw LPTA #93 massaging lower than her hip area. She stated she saw LPTA #93 kiss Resident #71 and touch her breast. Resident #71 said stop and when he asked her to go to the bathroom with him, Resident #71 refused to go. Review of the LPTA #93's witness statement dated 03/15/18 at 12:15 P.M., revealed LPTA #93 was documented as stating he and Resident #71 hit it off and had a good relationship. The statement further revealed he had given her twenty dollars and she asked him to add her on social media so he did. He said he asked her out to dinner but he was assuming this would be as friends. He stated he commented about doing the massage in the bathroom as a joke. He further stated he had gotten too emotionally involved with Resident #71 and could see that was not a good idea. He denied kissing the resident or touching her in anyway outside of the hip and leg massage. Review the personnel file for LPTA #93 revealed he was hired by the former company on 02/14/14 and the current ownership took over on 08/01/14. He had a bureau of criminal investigation (BCI) and federal bureau of investigation (FBI) completed on 02/07/18 with no concerns. However, there was no evidence of reference checks being completed upon hire. LPTA #93 was terminated on 03/23/18 for violation of the facility Conduct and Behavior policy 2.01. Telephone interview on 03/29/18 at 10:21 A.M., with LPTA #93 revealed he provided therapy services and gave money to Resident #71 out of the goodness of his heart. When questioned about the social media messaging he would not respond and deferred to his Attorney #116. He stated he absolutely, positively had not ever had any sexual contact with Resident #71. Interview on 03/29/18 at 10:56 A.M., Resident #71 revealed she arrived to the facility on [DATE]. On 02/20/18, he reached out to her on Facebook instant messaging, she did not acknowledge him as she did not know who he was. On 03/09/18, he entered the room to give her a massage She stated some of the therapists give a massage so that was not uncommon. Resident #71 stated she let LPTA #93 start and then he started talking about weird things. She stated said she froze because it was similar to experiences she had as a child from five years old to 16 from her biological father. She stated she was instantly scared and was frozen, she was saying no and stop and he was a very big man. She stated Resident #62 was in the room. Resident #71 stated LPTA #93 was massaging and his ungloved finger was massaging her bottom and went into her vagina. She stated LPTA #93 said oops sorry. She stated he held her down and kissed her and that day he made them become friends on Facebook. She did not know what to do, he began messaging her so she thought she would play along, he had mentioned another massage and trying to get her to go into the bathroom but she did not. He came back with a 20 dollar bill, he said he wanted to help her and she deserved the money. She said she was scared because he was scheduled to come back so she reported this to STNA #94. Resident #71 stated the facility called her a liar and was not nice. She felt like she was being interrogated and at the end of the day the facility wanted to talk to her again and said they were the same age and she flirted with him. Resident #71 became tearful during the interview and stated she felt intimidated and scared by LPTA #93 who was a large man and this was why she reported the incident. She stated she felt the facility kept telling her she flirted with him in the messages and it was consensual since they were the same age. Resident #71 stated it was not consensual. Interview on 03/29/18 at 12:35 P.M., Licensed Physical Therapy Assistant (LPTA) #114 stated earlier in the morning of 03/09/18, he was looking for the stimulation machine. He stated he approached Resident #71's room and saw the machine not in use at the foot of the bed. He stated Resident #71 and LPTA #93 were behind the drawn privacy curtain. LPTA #93 was sitting in the middle of the room facing Resident #71 and his back would have been to the roommate side of the room. He did not see Resident #62 but assumed she was in there because she very rarely left her room. He stated they both greeted him and he asked if he could use the machine and LPTA #93 said yes. LPTA #114 stated he was in the room only long enough to roll up the cord and take the machine out of the room. He said after the incident was reported, he began to get several text messages from LPTA #93 asking him to write a witness statement for him. He stated he responded by saying he could not speak about the investigation. LPTA #93 kept texting him maybe three times. LPTA #114 finally called LPTA #93 and told him he did not know what he was going through but did not know how his 15 seconds in the room was going to help him. Interview on 03/29/18 at 12:56 P.M., with Resident #62 (who was assessed as having intact cognition), stated LPTA #93 came in the room to provide therapy massage to Resident #71. She stated LPTA #93 was close to the bed and she could not see his hands but could see his elbows move toward her bottom area. She stated Resident #71 jumped up and this was when LPTA #93 kissed her on the mouth. She also heard LPTA #93 ask Resident #71 to go to the bathroom and she refused and also heard Resident #71 stay stop several times. Resident #62 stated she never reported it because after he left the room, Resident #71 did not say anything about what had happened so she figured it was none of her business. Interview on 03/29/18 at 2:39 P.M., with the Administrator and RCC #92 verified there was an inappropriate relationship with social media messages between Resident #71 and LPTA #93. They completed an SRI but did not substantiate the SRI because they felt Resident #71 and Resident #62 were being manipulative. The Administrator also stated the facility felt like it was a consensual relationship. They verified LPTA #93 should not have sent Resident #71 messages on social media and should not have given her money. The Administrator also verified this interaction was against their policy. An interview was conducted on 03/29/18 at 5:00 P.M., with LPN #95 who interviewed Resident #71 during the investigation into the incident with LPTA #93. LPN #95 stated Resident #71 never once said the contact was consensual. She stated Resident #71 said he had her pants down and he rolled her over and kissed her. Interview on 04/02/18 at 10:53 A.M., with STNA #94 revealed on 03/09/18 she went into Resident #71's room to answer the light. She said on her way out Resident #71 said she wanted to tell her something and she could not tell anyone. STNA #94 said if it was something bad she would have to report it. She then proceeded to tell her LPTA #93 had kissed her and they were messaging back and forth and he wanted to hook up with her. Resident #71 scrolled through her phone and showed her the messages however she did not read them she just saw it was LPTA #93's name and picture. She then reported the situation immediately. STNA #94 also stated she had not known Resident #71 to exhibit manipulative behaviors. Review of the facility Conduct and Behavior policy 2.01 updated 12/01/09 revealed types of conduct and behavior that are considered inappropriate include but are not limited to the follow; sexual or any other type of harassment or unlawful discrimination or any conduct that is determined by the company to be detrimental to the health and welfare, dignity, safety of the residents, visitors, fell ow stakeholders or the company. Review of the policy titled Abuse, Neglect and Misappropriation or Property dated 11/16/17 revealed sexual abuse included sexual harassment, sexual coercion, or sexual assault. Sexual abuse includes, but is not limited to, any physical contact with a resident's body that is not reasonably related to appropriate provision of ordered care or services; sexually oriented comments or jokes. Review of the Stakeholder Handbook (undated) revealed the employee needed to be careful about posting on social media and prevent the misuse of social media. Inappropriate postings including discriminatory remarks, harassment, defamation, bullying and threats of violence or similar inappropriate or unlawful conduct will not be tolerated and may subject staff to disciplinary action up to and including termination. Sexual harassment may include a range of subtle and not so subtle behaviors and may involve individuals of the same or different gender. Depending on the circumstances, these behaviors may include but are not limited to: unwanted sexual advances or requests for sexual favors; sexual jokes and innuendo; verbal abuse of a sexual nature; commentary about an individual's body, sexual prowess or sexual deficiencies; leering, [MEDICATION NAME] or touching; insulting or obscene comments or gestures; and other physical, verbal or visual conduct of a sexual nature. This deficiency substantiates Complaint Master Control Number OH 941 and Complaint Number OH 940.

Based on clinical record review, review of hospital records and ambulance reports, staff interviews, surgeon interview and review of facility's policy regarding Gastrostomy (Balloon) Feeding Tube Insertion/Replacement, the facility failed to provide services to one (#92) of three sampled residents according to professional standards of quality. Licensed Practical Nurse (LPN) #10 was not knowledgeable about the facility's policy and current standards of practice when she failed to send the resident to the hospital and have a newly placed [DEVICE] re-inserted and proper placement verified prior to administration of fluid or flushes. The resident developed peritonitis and a collapsed bowel after receiving intermittent tube feedings and flushes through the [DEVICE]. Findings include: Record review revealed Resident #92 was admitted to the facility on [DATE] from a local hospital after having a [DEVICE] surgically placed on 10/09/10. Review of the accumulative [DIAGNOSES REDACTED]. The record revealed the resident was alert and oriented to self and had some confusion. Review of physician's orders [REDACTED]. The orders further revealed the resident was to receive one can of Ensure (240 cubic centimeters) three times a day via his [DEVICE], at 12:00 A.M., 10:00 A.M. and 8:00 P.M. Review of Resident #92's progress notes dated 10/11/10 revealed the resident arrived at the facility at 7:30 P.M. His [DEVICE] site was clean and dry. On 10/12/10 at 2:50 A.M., the resident's [DEVICE] was patent and placement was verified per air [MEDICATION NAME]/auscultation. At 12:20 P.M., LPN #10 documented in the progress note the resident pulled out his [DEVICE]; no bleeding was noted. The note further documented the surgeon who placed the [DEVICE] was notified and an order was received to re-insert the [DEVICE]. LPN #10 replaced the [DEVICE] and verified it's placement using an air [MEDICATION NAME] and auscultation. There was no evidence an x-ray was performed to verify the [DEVICE] was properly placed in the stomach. Review of the Treatment and Medication Records revealed Resident #92 received a can of Ensure with 100 ml's of water on 10/12/10 at 8:00 P.M. after the [DEVICE] was re-inserted. The treatment record documented 60 cc of residual fluid was obtained prior to administering the tube feeding. The Resident received another can of ensure with 100 mil's of water at 12:00 A.M. and 10:00 A.M. on 10/13/10 for a total of 1020 cc's of fluid after the tube was re-inserted. The treatment record documented 50 cc's of residual was returned with the 12:00 A.M. feeding and greater than 600 cc's of residual with the 10:00 A.M. feeding. Review of Resident Progress Note dated 10/13/10 at 8:45 A.M. revealed the resident's skin was clammy, he was diaphoretic (sweating) over his entire upper body and he was pale. When his [DEVICE] placement was checked, greater than 600 cc's of residual fluid was found and there was fluid draining from around the [DEVICE] site. The facility's physician was notified and a message was left on the answering machine of the resident's spouse. The resident was sent to the emergency room for an evaluation. Review of the emergency room 's "Patient Visit Information" revealed Resident #92 was mildly dehydrated and additional instructions were to monitor his [DEVICE] site. The resident was sent back to the facility and, according to the Resident Progress Notes, arrived back at the facility at 2:05 P.M. with no new orders. Resident Progress Notes documented at 4:10 P.M., the resident went unresponsive while having a bowel movement. Staff could not obtain a blood pressure or oxygen saturation level. His respirations were 28 per minute. The resident did not respond to any stimuli. An ambulance was available in the facility and the resident was sent to the emergency room at 4:25 P.M. after the facility's physician and family were notified of the resident's change in condition. Review of the hospital's Computed Tomography (CT xray) dated 10/13/10 revealed Resident #92 had a malpositioned [MEDICATION NAME] tube. A large amount of fluid was seen in the abdomen and pelvis. The descending and sigmoid colon were collapsed. The resident was taken to the operating room on 10/13/10 where a large amount of purulent material was removed from the resident's abdomen. The resident's [DEVICE] was noted in the abdominal space and not in the lumen of the stomach. After surgery the resident was transferred to the critical care unit and remained intubated. A post-operative consultation report dated 10/14/10 revealed Resident #92 was in septic shock and unresponsive. He was not breathing without the ventilator. Interview with Licensed Practical Nurse (LPN) #10 on 11/22/10 at 3:20 P.M. confirmed she was the nurse who re-inserted Resident #92's [DEVICE] on 10/12/10. LPN #10 stated when Speech Therapist #50 reported to her the resident's [DEVICE] had been pulled out, LPN #10 stated she called the surgeon who had placed the [DEVICE]. She received an order to re-insert the [DEVICE]. She confirmed she replaced the [DEVICE] and only verified it's placement using a [MEDICATION NAME] of air and auscultation. When interviewed on 11/23/10 at 1:45 P.M., Resident #92's surgeon denied the facility ever contacted him and advised him the resident's [DEVICE] had been pulled out or the resident had been sent to the emergency room after pulling the tube out. The surgeon stated he did not give an order for [REDACTED]. No feedings or flushes should be given until placement is verified. The surgeon stated Resident #92's misfortune could have been avoided if the facility would have just sent the resident to the emergency room when he pulled the tube out on 10/12/10. Review of facility's policy titled, Gastrostomy (Balloon) Feeding Tube insertion/Replacement, dated 10/31/09 states, do NOT attempt re-insertion if the dislodged [DEVICE] is less than six weeks old. The re-insertion must be performed by a physician or a registered nurse with specific competency in the procedure. Feeding may NOT begin until proper placement is confirmed by x-ray or radiological dye studies or a physician has examined the resident and documented the placement is correct. Interview with the facility's Corporate Nurse on 11/23/10 at 2:00 P.M. confirmed the facility's policy was not followed when LPN #10 replaced the [DEVICE] that was less than six weeks old. Interview with the facility's Medical Director on 11/24/10 at 10:25 A.M. confirmed Resident #92's [DEVICE] should not have been replaced by the facility. He stated the resident's tube should have been replaced by a physician. The Medical Director further stated his specific orders are staff should not replace a [DEVICE] that is less than seven days old. According to the Ohio Revised Code (ORC) Chapter 4723-4-04 (B), standards relating to competent practice as a licensed practical nurse, a licensed practical nurse shall maintain current knowledge of the duties, responsibilities and accountabilities for safe nursing practice. The ORC further requires a licensed practical nurse shall, in a timely manner: implement any order or direction for a client unless the licensed practical nurse believes, or should have reason to believe the order or direction is: inaccurate, not properly authorized, not current or valid, harmful, or potentially harmful to a client. There was no evidence in the medical record that LPN #10 questioned the physician's orders [REDACTED]. Instead, she implemented the physician's orders [REDACTED]. After she replaced the [DEVICE] and did not verify placement with x-ray, three [MEDICATION NAME] tube feedings and flushes were given. The resident developed peritonitis and a collapsed bowel. This is an incidental defiiency found during the investigation of Complaint Control Number OH 307.

Based on clinical record review, review of hospital records and ambulance reports, staff interviews, surgeon interview and review of facility's policy regarding Gastrostomy (Balloon) Feeding Tube Insertion/Replacement, the facility failed to ensure one (#92) of three sampled residents received services to prevent complications from having a newly placed [DEVICE] re-inserted after the resident pulled the [DEVICE] out of place. The resident developed peritonitis and a collapsed bowel after the two day old [DEVICE] was re-inserted and correct placement was not verified prior to the resident receiving intermittent tube feedings and flushes through the [DEVICE]. Findings include: Record review revealed Resident #92 was admitted to the facility on [DATE] from a local hospital after having a [DEVICE] surgically placed on 10/09/10. Review of the accumulative [DIAGNOSES REDACTED]. The record revealed the resident was alert and oriented to self and had some confusion. Review of physician's orders [REDACTED]. The orders further revealed the resident was to receive one can of Ensure (240 cubic centimeters) three times a day via his [DEVICE], at 12:00 A.M., 10:00 A.M. and 8:00 P.M. Review of Resident #92's progress notes dated 10/11/10 revealed the resident arrived at the facility at 7:30 P.M. His [DEVICE] site was clean and dry. On 10/12/10 at 2:50 A.M., the resident's [DEVICE] was patent and placement was verified per air [MEDICATION NAME]/ausculation. At 12:20 P.M., LPN #10 documented in the progress note the resident pulled out his [DEVICE]; no bleeding was noted. The note further documented the surgeon who placed the [DEVICE] was notified and an order was received to re-insert the [DEVICE]. LPN #10 replaced the [DEVICE] and verified it's placement using an air [MEDICATION NAME] and ausculation. There was no evidence an x-ray was performed to verify the [DEVICE] was properly placed in the stomach. Review of the Treatment and Medication Records revealed Resident #92 received a can of Ensure with 100 ml's of water on 10/12/10 at 8:00 P.M. after the [DEVICE] was re-inserted. The treatment record documented 60 cc of residual fluid was obtained prior to administering the tube feeding. The Resident received another can of ensure with 100 mil's of water at 12:00 A.M.and 10:00 A.M. on 10/13/10 for a total of 1020 cc's of fluid after the tube was re-inserted. The treatment record documented 50 cc's of residual was returned with the 12:00 A.M. feeding and greater than 600 cc's of residual with the 10:00 A.M. feeding. Review of Resident Progress Note dated 10/13/10 at 8:45 A.M. revealed the resident's skin was clammy, he was diaphoretic (sweating) over his entire upper body and he was pale. When his [DEVICE] placement was checked, greater than 600 cc's of residual fluid was found and there was fluid draining from around the [DEVICE] site. The facility's physician was notified and a message was left on the answering machine of the resident's spouse. The resident was sent to the emergency room for an evaluation. Review of the emergency room 's "Patient Visit Information" revealed Resident #92 was mildly dehydrated and additional instructions were to monitor his [DEVICE] site. The resident was sent back to the facility and, according to the Resident Progress Notes, arrived back at the facility at 2:05 P.M. with no new orders. Resident Progress Notes documented at 4:10 P.M., the resident went unresponsive while having a bowel movement. Staff could not obtain a blood pressure or oxygen saturation level but his respirations were 28 per minute. The resident did not respond to any stimuli. An ambulance was available in the facility and the resident left for the emergency room at 4:25 P.M. after the facility's physician and family were notified of the resident's change in condition. Review of the hospital's Computed Tomography (CT xray) dated 10/13/10 revealed Resident #92 had a malpositioned [MEDICATION NAME] tube. A large amount of fluid was seen in the abdomen and pelvis. The descending and sigmoid colon were collapsed. The resident was taken to the operating room on 10/13/10 where a large amount of purulent material was removed from the resident's abdomen. The resident's [DEVICE] was noted in the abdominal space and not in the lumen of the stomach. After surgery the resident was transferred to the critical care unit and remained intubated. A post-operative consultation report dated 10/14/10 revealed Resident #92 was in septic shock and unresponsive. He was not breathing without the ventilator. Interview with Licensed Practical Nurse (LPN) #10 on 11/22/10 at 3:20 P.M. confirmed she was the nurse who re-inserted Resident #92's [DEVICE] on 10/12/10. LPN #10 stated when Speech Therapist #50 reported to her the resident's [DEVICE] had been pulled out, LPN #10 stated she called the surgeon who had placed the [DEVICE]. She received an order to re-insert the [DEVICE]. She stated she replaced the [DEVICE] and verified it's placement using a [MEDICATION NAME] of air and auscultation. When interviewed on 11/23/10 at 1:45 P.M., Resident #92's surgeon denied the facility ever contacted him and advised him the resident's [DEVICE] had been pulled out or the resident had been sent to the emergency room after pulling the tube out. The surgeon stated he did not give an order for [REDACTED]. No feedings or flushes should be given until placement is verified. The surgeon stated Resident #92's misfortune could have been avoided if the facility would have just sent the resident to the emergency room when he pulled the tube out on 10/12/10. Review of facility's policy titled, Gastrostomy (Balloon) Feeding Tube insertion/Replacement, dated 10/31/09 states, do NOT attempt re-insertion if the dislodged [DEVICE] is less than six weeks old. The re-insertion must be performed by a physician or a registered nurse with specific competency in the procedure. Feeding may NOT begin until proper placement is confirmed by x-ray or radiological dye studies or a physician has examined the resident and documented the placement is correct. Interview with the facility's Corporate Nurse on 11/23/10 at 2:00 P.M. confirmed the facility's policy was not followed when LPN #10 replaced the [DEVICE] that was less than six weeks old. Interview with the facility's Medical Director on 11/24/10 at 10:25 A.M. confirmed Resident #92's [DEVICE] should not have been replaced by the facility. He stated the resident's tube should have been replaced by a physician. The Medical Director further stated his specific orders are staff should not replace a [DEVICE] that is less than seven days old.