Every finding on record at Indianspring of Oakley

Based on medical record review, review of staff witness statements, review of hospital records, review of facility Interdisciplinary Team (IDT) fall follow-up notes, staff interview, review of online clinical resources per Medline Plus Medical Encyclopedia, and review of the facility policy, the facility staff failed to safely and properly position a resident in bed during incontinence care. Actual Harm occurred on 05/30/25 when Certified Nursing Assistant (CNA) #521 rolled Resident #108 who was in a raised bed away from the aide and onto the floor, resulting in a right nondisplaced intertrochanteric hip fracture which required a hospital admission and subsequent surgical repair of the right hip fracture on 06/02/25. This affected one (Resident #108) of three residents reviewed for falls. The facility census was 123 residents. Findings include: Review of the medical record for Resident #108 revealed an admission date of 01/09/25 with diagnoses including end stage renal disease, left below the knee amputation (BKA), diabetes mellitus, and intellectual disabilities. Review of the occupational therapy (OT) evaluation for Resident #108 dated 01/11/25 revealed attempts to assist with rolling the resident at bed level required two sets of hands to maintain safety. Review of the fall risk assessment for Resident #108 dated 04/26/25 revealed the resident was at high risk for falls. Review of the care plan for Resident #108 dated 05/02/25 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to impaired mobility, impaired balance, and left BKA. Interventions included resident was totally dependent for bed mobility with the assistance of two staff. Review of the x-ray report for Resident #108 dated 05/31/25 revealed the resident had a nondisplaced right intertrochanteric (hip) fracture. Review of the Minimum Data Set (MDS) assessment for Resident #108 dated 06/01/25 revealed the resident was moderately cognitively impaired and section GG revealed the resident was dependent with rolling right to left (the ability to roll right to left and back and return to lying back on bed). Dependent was defined in the MDS as helper does all of the effort, and resident does none of the activity, or the assistance of two or more helpers is required to complete the activity. Review of a witness statement regarding Resident #108 dated 06/01/25 per Licensed Practical Nurse (LPN) #419 revealed on 05/30/25 the nurse was in the hallway near the resident's room and was conducting medication administration when she heard a loud noise. CNA #521 told the nurse the resident had fallen out of bed while the aide was providing care. CNA #521 told the nurse while the resident was lying flat, he was coughing and had fallen out of bed. Upon LPN #419's arrival to Resident #108's room, the resident was lying on a floor mat with his right side extended straight out. The nurse assessed the resident who denied pain and/or hitting his head. Review of a witness statement regarding Resident #108 dated 06/02/25 per CNA #521 revealed on 05/30/25 at approximately 8:00 P.M. to 8:15 P.M. the aide went into Resident #108's room to change the resident's incontinence brief. CNA #521 paused the resident's tube feeding, removed his soiled brief, rolled him onto his right side, and then used the draw sheet to position him in the center of the bed. CNA #521 was standing on the left side of the bed (if looking at bed from the foot of the bed). The bed was positioned at the waist height of the aide. As CNA #521 was cleaning the resident's buttocks, Resident #108 began coughing uncontrollably. CNA #521 immediately stopped providing care and the resident continued to cough very roughly and then fell off the bed and onto the fall mat located on the right side of the bed. CNA #521 immediately notified Resident #108's nurse of the fall. LPN #419 assessed Resident #108 and lowered the bed to put the resident back to bed with the assistance of another aide. Resident #108 started coughing so hard it had caused him to vomit. Resident #108 was sitting up in his bed at this time and complained of pain in his right hip but refused to go to the hospital. LPN #419 offered Resident #108 pain medication. CNA #521 frequently checked on Resident #108 throughout the night and he remained awake most of the night. Review of hospital notes for Resident #108 dated 06/02/25 revealed the resident presented to the emergency department via squad from facility with a report of a fall out of bed on 05/30/25. The resident had an x-ray of the right femur completed in the morning of 05/31/25 at the facility indicating a nondisplaced intertrochanteric fracture. Review of the facility fall timeline regarding Resident #108's fall on 05/30/25 revealed the resident had surgical repair of a right hip fracture on 06/02/25. Review of the IDT follow-up note regarding Resident #108 dated 06/04/25 revealed on 05/30/25 at approximately 9:00 P.M., CNA #521 notified the nurse that Resident #108 was on the floor. The nurse responded and observed Resident #108 lying on his right side on the floor mat on the left side of the bed. CNA #521 reported while she was providing care the resident experienced an excessive coughing episode during which his upper body shifted causing him to roll off the left side of the bed and onto the floor mat. Resident #108 stated to staff that he fell out of bed, landing on his right shoulder and denied hitting his head. The initial assessment revealed no apparent physical injuries or changes to range of motion or level of consciousness. Resident #108 complained of pain to the right shoulder. Staff assisted Resident #108 off the floor and back into bed without incident via lift sheet. The assessment did not indicate the need for emergency transfer, and Resident #108 indicated he did not want to go to the hospital. The nurse called the on-call physician and was directed to administer as needed Tramadol (pain medication) and routine Tylenol, continue neurochecks, continue to monitor and call back if there are any changes. When Resident #108 complained of increased pain, staff notified the nurse practitioner who gave an order for x-rays of the right shoulder and the right femur. The x-rays showed a right femur fracture. The on-call NP gave an order to send Resident #108 to the hospital for an evaluation. The IDT follow up indicated a new intervention status post fall would be to include side rails to the resident's bed to assist independence with bed mobility. Review of additional written information regarding Resident #108's fall provided by the Director of Nursing (DON) on 06/27/25 revealed the resident's care plan indicated the resident required extensive assistance of one person with bed mobility from 01/09/25 to 05/02/25. On 05/02/25 the fall IDT met and revised the care plan for Resident #108. During this revision the nurse clicked the intervention for total dependence times two staff in Resident #108's electronic medical record, but then immediately revised the intervention to read total dependence times one staff. Interview on 06/26/25 at 11:05 A.M. with LPN #450 confirmed Resident #108 had experienced a decline in condition prior to the fall out of bed on 05/30/25 and should have been a two-person assist. Interview on 06/26/25 at 3:15 P.M. with CNA #185 confirmed when you are providing care by yourself you should never roll a resident away from you. CNA #185 confirmed residents should be rolled towards you to prevent them from falling out of bed. Interview on 06/26/25 at 5:25 P.M. with CNA #521 confirmed she frequently provided care to Resident #108. CNA #521 stated she was providing care to Resident #108 by herself on 05/30/25 when she rolled Resident #108 onto his left side (his below the knee amputation side) and away from where the aide was standing. CNA #521 confirmed Resident #108 fell out of the raised bed and onto the floor of the opposite side of the bed where the aide was standing. CNA #521 stated she was unable to prevent Resident #108 from falling. Interview on 06/30/25 at 3:18 P.M. with LPN #419 confirmed she was passing medications on 05/30/25 when CNA #521 told her that Resident #108 had fallen out of bed. LPN #419 stated she found Resident #108 lying on the floor on his right side. LPN #419 further confirmed she assessed the resident while he was on the floor and saw no signs or symptoms of injury, and she and another aide assisted Resident #108 back into bed. Once in bed, Resident #108 began vomiting. LPN #419 confirmed Resident #108 refused to go the hospital for an evaluation. LPN #419 called the resident's provider regarding the fall and gave an update on the resident's condition and received orders for pain medication which she administered to Resident #108. LPN #419 confirmed by the morning of 05/31/25 Resident #108 was complaining of increased pain to the right leg, and she notified the provider who gave an order for an x-ray. Review of an online clinical resource titled Turning Patients Over in Bed: Medline Plus Medical Encyclopedia undated at: https://medlineplus.gov/ency/patientinstructions/000426.htm#:~:text=Standing%20with%20one%20foot%20ahead,the%20person's%20hip%20toward%20you revealed the following steps should be followed when turning a resident in bed: explain to the resident what you are planning to do so they know what to expect, encourage the person to help if possible, stand on the opposite side of the bed the resident will be turning towards, move the patient towards you, step around to the other side of the bed, ask the resident to look towards you (this will be the direction in which the person is turning.) Review of the facility policy titled Fall and Accident Management dated June 2019 revealed the facility would identify residents at risk for falls and would implement interventions to reduce the risk of injuries, falls, and other accidents. This deficiency represents noncompliance investigated under Complaint Number OH00166410.

Based on observation, staff interview and review of facility policy, the facility failed to ensure refrigerated food was maintained at or below 41 degrees Fahrenheit (F). This had the potential to affect 121 of 123 residents of the facility, excluding two facility-identified residents who received no food by mouth (NPO). The facility census was 123 residents. Findings include: Observation of the facility kitchen on 06/23/2025 at 9:28 A.M. revealed the inside of the walk-in refrigerator was warm. The thermometer on the outside of the door read 60 degrees F. There was no thermometer was located inside the refrigerator. Interview on 06/23/25 at 9:28 A.M. with Executive Chef (EC) #601 confirmed that the temperature of the walk-in refrigerator located was 60 degrees F, and all refrigerated foods should be maintained at or below 41 degrees F. Observation on 06/25/2025 at 11:59 A.M. of the refrigerator in the first-floor dining room kitchenette revealed the digital thermostat on the unit was 65 degrees F. The temperature fluctuated during the lunch meal from 57 degrees F to 67 degrees F. There was no temperature log for the refrigerator. Interview on 06/25/25 at 12:00 P.M. with EC #601 confirmed the temperature of the refrigeration unit in the first-floor kitchenette was 65 degrees F. Review of facility policy titled Food Storage dated January 2019 revealed all readily perishable foods or beverages would be refrigerated at temperatures of 41 degrees F or below.

Based on observation and staff interview, the facility failed to ensure garbage cans in the main kitchen were covered with lids. This had the potential to affect 121 of 123 residents of the facility, excluding two facility-identified residents who received no food by mouth (NPO). The facility census was 123 residents. Findings include: Observation on 06/23/25 at 9:28 A.M. revealed there were three garbage cans in use in the main kitchen which did not have lids. Interview on 06/23/25 at 9:29 A.M. Executive Chef (EC) #601 confirmed the three garbage cans in use in the main kitchen did not have lids and the lids would need to be ordered. Observation on 06/25/25 at 9:48 A.M. revealed the three garbage cans in use in the main kitchen did not have lids. Interview on 06/25/25 at 9:49 A.M. with EC #601 confirmed the three garbage cans in use in the main kitchen still did not have lids, but they were being procured. Interview on 06/26/25 at 1:00 P.M. with the Administrator on 06/26/2026 confirmed the facility did not have a policy regarding garbage can covers for the kitchen.

Based on medical record review, staff interview, interview with home health staff, and review of the facility policy, the facility failed to ensure appropriate information was communicated to resident family and home health provider upon discharge. This affected one (Resident #271) of three residents reviewed for discharge rights. The facility census was 123 residents. Findings include: Review of the medical record for Resident #271 revealed an admission date of 01/28/25 with diagnoses including protein-calorie malnutrition, malignant neoplasm of breast, acute kidney injury, dehydration, adult failure to thrive, iron deficiency anemia and intellectual disabilities. Resident #271 discharged from the facility back to her group home on [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #271 dated 01/31/25 revealed the resident had severe cognitive impairment, was frequently incontinent of bowel and occasionally incontinent of bladder, was dependent on staff assistance with activities of daily living (ADLs), was at risk for the development of pressure ulcers, but had no pressure ulcers. Review of a nurse progress note for Resident #271 dated 04/20/25 revealed staff identified a new open area to the resident's sacrum. The nurse cleansed the area with normal saline and applied barrier cream and a dressing. The nurse notified the resident's physician and obtained a treatment order for the wound. Review of the weekly wound progress note for Resident #271 dated 05/04/25 revealed the resident had a stage II sacral pressure ulcer which measured 1.8 centimeters (cm) in length by 1.2 cm in width by 0.1 cm in depth. The wound was round with a pink wound bed and a small amount of serous drainage. Review of the physician orders for Resident #271 revealed the wound care order upon the resident's discharge from the facility on 05/05/25 was to cleanse the wound with normal saline, pat dry, apply collagen and cover with a foam dressing or ABD pad secured with tape. Review of the discharge summary for Resident #271 dated 05/05/25 for Resident #271 which was provided to the resident's family and the home health Case Manager (CM) #999 revealed the resident had no skin impairment and the summary did not include the current physician's order for wound care. Review of the medical record documents for Resident #271, which included the resident's profile, discharge physician orders summary report, and attending physician progress notes dated 03/10/25 and 04/04/25 revealed all documents were printed by the outside home health agency on 05/11/25 at 8:57 A.M. Review of the home health nurse intake notes for Resident #271 dated 05/13/25 revealed the resident's sacral wound measured 4.0 cm in length by 4.5 cm in width by 0.2 cm in depth. Interview on 06/25/25 at 5:10 P.M. with the Director of Nursing confirmed the Discharge summary dated [DATE] for Resident #271 indicated the resident did not have any skin impairment and the discharge medication list did not include the resident's wound care order on the date of discharge. The DON confirmed the facility made a referral for Resident #271 to have home health nursing but was unable to verify if the facility notified the home health agency of the resident's actual discharge date . Interview on 06/26/25 at 11:39 A.M. with Home Health Nurse (HHN) #995 confirmed the home health care referral from the facility for Resident #271 came on 05/10/25 and the resident's discharge physician orders were printed on 05/11/25. She said the home health care agency called the family and CM #999 on 5/11/25 to schedule the initial nursing visit with the resident and the family said to call back on 05/12/25. The initial visit for Resident #271 from the home health nurse took place on 05/12/25. Phone interview on 06/27/25 at 9:00 A.M. with Home Health Community Care Coordinator (HCCC) #950 verified the home health agency did not receive confirmation from the facility that Resident #271 had discharged on 05/05/25 until 05/10/25, and if the notification came after 5:00 P.M. the orders would not be processed until the following day. HCCC #950 further confirmed the home health agency was part of the facility's parent organization and the home health agency had access to the resident's electronic medical record and could generate needed resident documents such as physician orders, but the facility was required to notify the home health agency when a resident's discharge date was determined and/or when the resident discharged . HCCC #950 verified the timestamp for Resident #271's discharge physician orders being printed was 05/11/25. Review of the policy titled Discharge Planning revised November 2016 revealed when a resident's discharge was anticipated, the facility would develop and implement a discharge plan that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.

Based on observation, interview with staff and emergency services provider (EMT), review of resident medical records, hospital records, emergency services (EMS) reports, and manufacturer guidelines, the facility failed to ensure Resident #109 was safely assisted with personal care to prevent a fall with injury and failed to thoroughly investigate the fall. This affected one (Resident #109) of five residents reviewed for accidents. Findings include: Resident #109 was admitted on [DATE] with a readmission date of 12/29/24 for diagnoses including acute and chronic respiratory failure with hypoxia, diabetes mellitus type 2 (DM2), cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, peripheral vascular disease, and seizures. Review of Resident #109's care plan initiated 03/17/24 for an activities of daily living (ADL) self-care deficit due to impaired mobility and balance revealed the resident required extensive assistance of two staff for bed mobility, toileting, and transfers. Review of physician's orders revealed an order on 05/29/24 for an alternating pressure mattress. Review of Fall Risk Scale Score dated 01/19/25 revealed a score of 12, indicating Resident #109 was at risk of falls. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 had severe cognitive impairment and was dependent on staff for all care. Review of Resident #109's progress note dated 04/10/25 at 8:48 A.M. revealed a fall occurred at 5:55 A.M. Review of EMS report dated 04/10/25 at 7:08 A.M. revealed Resident #109 fell at skilled nursing facility where (per staff) pt was being cleaned up and changed and when the aide went to pull the draw sheet from the pt's left side of the bed, this in turn flipped her over the mattress guards of the bed and then to the floor. Resident #109 has traumatic injuries to the mouth, nose, bridge of nose, and significant hematoma to forehead. Resident #109 was on blood thinners per staff, but aspirin only seen from brief review of paperwork. Resident #109 was baseline mentation and staff report no change in level of consciousness. Resident #109 was lifted back to bed by staff prior to EMS arrival. Aide who was involved did come to bedside and stated same situation as noted above. Resident #109 needed minor assistance for bleeding. Decision made to transport to local hospital due to resident condition, height of fall on head/face, and size of hematoma with associated blood thinner use. Review of hospital records dated 04/10/25 at 7:27 A.M. revealed the ER noted per EMS Resident #109 was being cleaned when the patient fell out of bed, over bed guard. Resident #109 fell, hitting her head. Resident #109 had swelling and abrasion to forehead, bridge of nose, and bleeding from mouth. Review of hospital records dated 04/10/25 at 7:40 A.M. revealed ER physician noted Resident #109 was being turned, or something similar and was rolled out of bed. Resident #109 landed on her face. Resident #109 presented with obvious trauma to the face, including some loose teeth. Review of Resident #109's physician orders revealed an order dated 04/10/25 every day and night shift to cleanse hematoma with normal saline, pat dry, apply double antibiotic ointment, leave open to air. Review of the Interdisciplinary Team (IDT) Follow Up Note for the incident date 04/10/25 at 5:55 A.M. revealed Resident #109 was at risk for falls related to a history of falls, atrial fibrillation, history of cerebrovascular accident, and seizures. Fall interventions put into place were fall mats to bedside, Resident #109 to be screened to assess bed mobility, and nonpowered mattress. The IDT note did not identify the root cause of the fall. A request was made for the fall investigation related to Resident #109's fall and only a statement from CNA #280 was provided. There was no evidence of a thorough investigation being completed. Observation on 04/21/25 at 12:20 P.M. of Resident #109 revealed the resident was lying on a flat mattress without bolsters or a perimeter mattress, with her feet floating on a cushion, fall mats were on the floor on each side of the bed. Resident #109 was not interviewable at the time of the observation. Interview on 04/22/24 at 4:53 P.M. with EMT #650 revealed when they arrived at the facility, Resident #109 was already back in bed, and the mattress she was on had an attached rail on it or like a small speed bump. EMT #650 stated the EMS team had difficulty getting Resident #109 from the mattress to the gurney due to the mattress' side support rail. EMT #650 stated he was concerned an individual would have to exert a lot of effort to get Resident #109 over that bump by themselves. The staff member, possibly a nurse, onsite told him only one aide was performing personal care, and that one aide was attempting to remove the draw sheet out from under Resident #109, by herself, which caused Resident #109 to roll out of bed. EMT #650 stated Resident #109 was not able to move or brace herself against a fall and had significant visible injuries, including teeth that appeared damaged, a large contusion to her head, and the bridge of her nose. Resident #109 was transferred to a local hospital. Interview on 04/23/25 at 3:10 P.M. with Certified Nursing Assistant (CNA) #280 stated she was providing incontinence care, and Resident #109 was a one person assist for personal care prior to the fall. CNA #280 stated she rolled Resident #109 away from her and she was trying to pull out the draw sheet, the mattress and the bolsters leaned away from her and Resident #109, which allowed Resident #109 to roll out of bed. CNA #280 checked on Resident #109 and she was responsive. CNA #280 called for help. Two nurses and CNA #280 were able to lift Resident #109 up and put her back in bed. CNA #280 stated she was suspended for her next scheduled shift and returned the next day for disciplinary education. CNA #280 stated she was told at the time of the re-education that Resident #109's alternating pressure bed could be made firmer during point of care and then turned back to the prescribed setting when the resident was not receiving care. CNA #280 stated she was not aware of that function of the mattress prior to the fall. CNA #280 stated if she had been aware of that function and trained fully on the use of the mattress prior to providing care to Resident #109, she felt the fall would not have occurred. Interview on 04/24/25 at 2:30 P.M. with Director of Nursing (DON) revealed the facility's practice was to educate staff on providing care as instructed in the care plan, such as after a fall. While re-educating CNA #280 after the fall on 04/10/25, it was discovered CNA #280 was following the current plan of care. DON stated the root cause of the 04/10/25 fall was a decline in Resident #109's bed mobility, which was determined by therapy's reassessment of her mobility after the fall. DON stated the mattress was changed out in an abundance of care, as a low air loss mattress could contribute to accidents and falls. DON did not specifically recall speaking to CNA #280 about utilizing the autofirm setting on the low air loss mattress for care, however if CNA #280 stated that they discussed it during her re-education, then it probably happened. Review of Fall and Accident Management, dated 06/2019, revealed the facility will work to 1. Identify hazard(s) and risk(s) to decrease the risk of injury; 2. evaluate and analyze hazard(s) and risk(s). Additionally, A score above 10 indicates an increased risk of falling. Review of alternating pressure mattress manual revealed the mattress had an Autofirm mode which provided maximum air inflation to assist both resident and caregiver during resident care and transfer. Under general repositioning, it was note Autofirm mode may be helpful to achieve a firm surface for repositioning purposes. This deficiency represents non-compliance investigated under Complaint Number OH00164933.

Based on medical record review, observations, staff interviews, and review of manufacturer's instructions, the facility failed to ensure staff prime an insulin pen prior to administration. This affected one (#11) out of three reviewed for medication administration. The facility census was 110. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus (DM II), chronic pulmonary edema, and congestive heart failure (CHF). Review of the care plan dated 08/31/24 revealed Resident #11 had diabetes mellitus. Interventions included administering diabetes medication as ordered. Review of the physician order dated 08/31/24, revealed Resident #11 was ordered Humalog (quick acting insulin) Kwik Pen 100 unit per milliliter (ml) solution pen-injector, inject subcutaneously with meals for DM II per a sliding scale. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup with eating, partial assistance with toileting, dressing, and transfers, and supervision with bathing. Observation on 01/14/25 at 9:40 A.M. revealed Licensed Practical Nurse (LPN) #22 administered two units of Humalog Kwik Pen to Resident #11. LPN #22 did not prime the insulin pen prior to administering the insulin to Resident #11. LPN #22 dialed insulin pen to two units per sliding scale related to blood sugar of 202. Interview on 01/15/25 at 9:45 A.M. with LPN #22 verified she did not prime insulin prior to administering insulin. Review of the manufacturer instructions for Humalog Kwik Pen revealed the following: 1) Pull the pen cap straight off. 2) Check the liquid in the pen. 3) Select a new needle. 4) Push the capped needle straight onto the pen and twist the needle on until it is tight. 5) Pull off the outer needle shield. 6) To prime the pen, turn the dose knob to select two units. 7) Hold the pen with the needle pointing up and tap the cartridge holder gently to collect air bubbles at top. 8) Continue holding the pen with needle pointing up and push the dose knob until it stops and zero was seen in the dose window. This deficiency represents non-compliance investigated under Complaint Number OH00160452.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure medications were stored in a safe and secure manner. This affected one (#4) of four residents observed for medications. The facility census was 98. Findings include: Record review for Resident #4 revealed an admitted [DATE] with diagnoses including atrial fibrillation, history of transient ischemic attack, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. Review of Resident #4's physician's orders revealed the resident was ordered the cholesterol medication atorvastatin 10 milligrams (mg) by mouth at bedtime, the supplement cyanocobalamin 1000 micrograms (mcg) by mouth daily, the blood pressure medication amlodipine besylate 10 mg by mouth daily, and the combination blood pressure medication hydrochlorothiazide and lisinopril 12.5 mg-20 mg by mouth daily on 04/03/24. On 04/16/24, Resident #4 was ordered the supplement Stress B-zinc one oral tablet daily, on 05/13/24 was ordered the anticoagulant apixaban 2.5 mg by mouth twice daily, and on 05/29/24 was ordered the blood pressure medication metoprolol succinate extended release (ER) 100 mg by mouth daily. Observation and interview on 06/03/24 at 11:35 A.M. with Resident #1 verified the presence of two medication cups at her bedside. One medication cup contained one tablet, identified as atorvistatin, and the other medication cup contained with seven various medications. Resident #1 stated she did not recall when the medications were from, but she decided not to take them because she had not been feeling well. Interview on 06/03/24 at 11:35 A.M. with Assistant Director of Nursing (ADON) #1 verified the presence of medications at Resident #1's bedside during observation. Review of a policy titled, Administration Oral Medications, dated 12/2021, revealed the nurse or medication aide administering the medication remains with the resident until the medicine is swallowed. This deficiency represents non-compliance investigated under Complaint Number OH00153632.

Based on medical record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to adequately assess and monitor a resident's skin which resulted in Actual Harm for Resident #20 who was admitted to the facility without pressure ulcers and developed a stage three pressure ulcer (a full thickness skin break into the subcutaneous tissue which did not go into muscle or bone) to the right ischium which was not identified until it had reached an advanced stage. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 113. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, anemia, atherosclerotic heart disease of coronary artery, and hypertension. Review of the weekly skin round assessments for Resident #20 dated 01/29/24, 02/26/24, 03/07/24 and 03/14/24 revealed they did not include documentation regarding the resident's right ischium. Review of the care plan for Resident #20 dated 02/12/24 revealed the resident had potential for skin impairment related to impaired mobility, fragile skin, and incontinence. Interventions included the following: assist as needed with toileting and hygiene, staff to apply barrier cream as needed after incontinent episodes, staff to check skin daily while doing routine care and report changes to the nurse, staff to apply pressure reducing mattress to bed. Review of the pressure ulcer risk assessment for Resident #25 dated 02/25/24 revealed the resident was at moderate risk for the development of pressure ulcers. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #20 dated 02/27/24 revealed the resident was cognitively impaired and dependent with eating, toileting, bathing, dressing, and transfers. Resident #20 was at risk for the development of pressure ulcers but did not have pressure ulcers. Review of the wound progress note for Resident #20 dated 03/20/24 per Wound Nurse Practitioner (WNP) #70 revealed the resident had developed an in-house acquired stage three pressure ulcer to the right ischium first observed by the staff on 03/19/24 which measured 2.0 centimeters (cm) in length by 2.0 cm in width by 0.8 cm in depth. The wound bed was yellow, pink and red with granulation tissue present and moderate amounts of serous and serosanguineous drainage noted. Treatment recommended was to apply alginate to the wound bed. Review of the physician's orders for Resident #20 revealed an order dated 03/20/24 to cleanse the pressure ulcer to the right ischium with normal saline, pat dry, apply calcium alginate and cover with abdominal pad and retention tape. Observation on 04/17/24 at 11:25 A.M. of wound care for Resident #20 per Licensed Practical Nurse (LPN) #200 revealed the resident had a quarter-sized pressure ulcer to right ischium with a moderate amount of serous drainage. Interview on 04/17/24 at 3:46 P.M. with Wound Nurse Practitioner (WNP) #70 confirmed she examined Resident #20 on 03/20/24 and determined the resident had a facility-acquired stage III pressure ulcer to the right ischium which was first identified by the staff on 03/19/24. Interview on 04/18/24 at 11:05 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #20 developed an open area to her right ischium which was first identified by the facility staff on 03/19/24. The wound was first measured and assessed by WNP #70 on 03/20/24 who determined the wound was a stage III pressure ulcer. The ADON confirmed the facility did not complete assessments of the skin to Resident #20's right ischium prior to 03/20/24. Review of the facility policy titled Skin Integrity Team (SIT) - Skin Monitoring Process dated June 2023 revealed the facility team would improve, maintain, and monitor residents' skin integrity with the goal for residents not to develop pressure ulcers unless clinically unavoidable. The nursing assistant should report any new and/or abnormal skin conditions to the nurse. Review of the NPUAP guidelines dated 2014 pages at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that included the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents noncompliance investigated under Complaint Number OH00152496.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to implement nutritional interventions for a resident with significant weight loss in a timely manner. This affected one (Resident #20) of three residents reviewed for weight loss. The facility census was 113. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, anemia, atherosclerotic heart disease of coronary artery, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #20 dated 02/27/24 revealed the resident was cognitively impaired and was dependent on staff assistance for eating, toileting, bathing, dressing, and transfers. Review of the care plan for Resident #20 dated 02/27/24 revealed the resident had a nutritional problem and was at risk for malnutrition related to unintentional weight changes, altered diets, and dysphagia. Interventions included the following: administer medications as ordered staff to monitor weight and make recommendations as needed, staff to obtain and monitor lab/diagnostic work as ordered, staff to provide extra high calorie, high protein food items as needed, staff to provide diet as ordered and monitor intake. staff to obtain weights per clinician orders. Review of the weights records for Resident #20 revealed the following dates and weights: 02/01/24-125.2 pounds (lbs.), 03/01/24- 116.2 lbs., 03/05/24-110 lbs., 03/20/24-108.9 lbs. Review of the nutritional progress note for Resident #20 dated 03/07/24 revealed resident had a significant weight loss of 12.1 percent (%) in thirty days. Resident #20 had impaired skin and increased metabolic demands for healing. The resident's meal intakes varied from zero to 100% of meals. Resident #20 remained dependent on staff for intake of meals. The dietitian recommending adding fortified pudding at lunch and dinner daily for additional nutrition support and for staff to monitor the resident's weight weekly. Review of the physician's orders for Resident #20 revealed an order dated 03/18/24 for the resident to be weighed weekly. Observations of meal service on 04/17/24 and 04/18/24 revealed Resident #20 was dependent on staff for feeding. Interview on 04/18/24 at 10:04 A.M. with Registered Dietician (RD) #60 confirmed weekly weights were not ordered for Resident #20 until 03/18/24. Interview on 04/18/24 at 2:47 P.M. with RD #60 confirmed the recommendation for fortified pudding at lunch and dinner was not implemented as a physician's order. Review of the facility policy titled Weight Monitoring dated June 2020 revealed nursing staff and dietician would evaluate, implement nutritional interventions, and monitor residents' weight status in order to provide appropriate nutritional and clinical care. The dietician reviewed weight differences and determined the next course of action. To appropriately confirm significant weight changes, a re-weight might be indicated. The dietician would ask nursing to complete necessary reweights. This deficiency represents noncompliance investigated under Complaint Number OH00152496.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure food was prepared in a manner to prevent potential contamination and spread of foodborne illness. This had the potential to affect all eight residents (#2, #3, #33, #37, #50, #53, #60, and #82) who received a pureed diet. The facility census was 113. Findings include: Observation on 07/12/23 at 11:18 A.M. revealed Cook #159 use her gloved hand to take four chicken breasts from a baking sheet, and placed them in a food processor, located directly next to the baking sheet, containing approximately ten additional chicken breasts. Cook #159 then reached on top of the steamer, located directly behind her, and obtained and donned a rubber oven mitt. Cook #159 pureed the chicken in the food processor, then removed the oven mitt, setting it on the counter. The arm of the oven mitt was observed sitting directly on top of two chicken breasts still remaining on the baking sheet. Interview on 07/12/23 at 11:20 A.M. with Cook #159 verified the arm of the oven mitt was resting directly on the chicken and removed the oven mitt and placed it on a cart beside the steamer. The cart contained a puddle of water, measuring approximately 10 inches by six inches. Continuous observation on 07/12/23 at 11:21 A.M. revealed Cook #159 changed her gloves, and placed the remaining chicken breasts from the baking sheet, including the two chicken breasts that had previously been in contact with the potentially contaminated oven mitt, into the food processor. Cook #159 pureed the chicken, then transferred into a pan for holding. Interview on 07/12/23 at 11:25 A.M. with Cook #159 verified the chicken, which the potentially contaminated oven mitt was resting on, was used in pureeing the remaining chicken. Review of the facility's residents diet list revealed Residents #2, #3, #33, #37, #50, #53, #60, and #82 received a pureed diet. Review of the facility policy titled Safe Food Handling and Storage, dated 06/2015, revealed proper handling of all foods is essential in preventing chemical, physical, or biological contamination.

Based on observations, resident and staff interview, and record review, the facility failed to maintain Resident #62's room in a clean manner. This affected one (Resident #62) of six residents reviewed for homelike environment. The facility census was 113. Findings include: Record review for Resident #62 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/21/23, revealed Resident #62 had mild cognitive impairment. Review of the progress note, dated 07/10/23, revealed Resident #62 had emesis two times on this day (07/10/23). Interview on 07/11/23 at 9:33 A.M. with Resident #62 revealed she was lying in bed watching television. Resident #62 stated she had vomited two times the previous evening on 07/10/23. Resident #62 stated she vomited in her sink and was concerned because she did not think staff had cleaned her sink out. Observation on 07/11/23 at 9:45 A.M. revealed Resident #62's sink had a ring of what appeared to be emesis around in the inside of the sink with dried brown, yellow, and white chunks of unknown substances. Observation and interview on 07/11/23 at 9:49 A.M. with State tested Nurse Aide (STNA) #252 confirmed Resident's #62's bathroom sink had a large ring of dried brown, yellow, and white chunks of unknown substance. Interview and observation on 07/12/23 at 10:28 A.M. with Licensed Practical Nurse (LPN) #163 confirmed a large, splattered stain remained in Resident #62's bathroom sink. Interview on 07/13/23 at 8:51 A.M. with the Environmental Services Manager (ESM) #267 confirmed Resident #62's bathroom sink was stained with a large round ring stain from emesis on 07/10/23. ESM #267 stated she found cleaner herself and was able to remove the stain. ESM #267 confirmed the Resident's bathroom sinks were supposed to be cleaned daily. This deficiency represents non-compliance investigated under Complaint Number OH00144070.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure the residents who were at risk for falling had their care-planned and/or physician ordered fall interventions in place. This affected three (#13, #42, and #62) of five residents reviewed for falls. The facility census was 113. Findings include: 1. Review of Resident #13's medical record revealed an admitted [DATE]. Diagnoses included pulmonary embolism, insomnia, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the plan of care dated 05/03/23 revealed Resident #13 was at risk for falls related to gait/balance problems, side effects of medications, and incontinence. Interventions included anti-rollback to Resident #13's wheelchair. Observation on 07/13/23 at 10:39 A.M. revealed Resident #13's red emergency call light was activated outside of her room. Resident #13 was observed in the bathroom, seated on the commode, and her wheelchair directly in front of her. There were no anti-rollbacks observed on Resident #13's wheelchair. Further observation revealed no other wheelchairs in Resident #13's room nor outside of her room. Observation and interview on 07/13/23 at 10:42 A.M. revealed Physical Therapy Assistant (PTA) #301 entered Resident #13's room to answer the emergency call light. PTA #301 stated Resident #13 must have taken herself to the bathroom. PTA #301 verified Resident #13's wheelchair did not have anti-rollbacks in place. Interview on 07/13/23 at 10:53 A.M. with the Administrator verified Resident #13 had an active care plan intervention for anti-rollbacks to her wheelchair. 2. Review of Resident #42's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart disease, anxiety disorder, major depressive disorder, and restless leg syndrome. Review of the annual Minimum Data Set (MDS) assessment, dated 07/07/23, revealed Resident #42 had impaired cognition and required extensive assistance from staff with bed mobility, transfers, dressing, and toilet use. Review of the physician orders dated 05/05/22 revealed Resident #42 had an order for fall mats to the sides of the bed. Review of the fall care plan, dated 07/07/23, revealed Resident #42 was at risk for falls related to gait/balance issues, history of falls, side effects of medication, and various health diagnoses. Her interventions included fall mats to the sides of her bed. Observation and interview on 07/13/23 at 9:10 A.M. with State tested Nurse Aide (STNA) #61 confirmed Resident #42 should have a fall mat to each side of her bed. STNA #61 confirmed both fall mats were stacked on top of each other on the left side of the bed only. Resident #61 was lying in bed at the time of the observation. 3. Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, diabetes mellitus type II, severe obesity, vascular dementia, anxiety, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/21/23, revealed Resident #62 was mildly cognitively impaired and required extensive assistance from staff with bed mobility, transfers, dressing, and toilet use. Review of the fall care plan dated 04/2123 revealed Resident #62 was at risk for falls related to confusion, gait balance issues, impaired vision, history of falls, impulsive at times, and history of falls. Interventions included Dycem/posey grip to the seat of Resident #62's wheelchair. Interview on 07/12/23 at 10:02 A.M. with Assistant Director of Nursing (ADON) #300 confirmed Resident #62 required dycem posey grip to the seat of her wheelchair as indicated by an active physician order and confirmed it was located on the care plan. Interview and observation on 07/12/23 at 10:28 A.M. revealed State tested Nurse Aide (STNA) #198 utilized a gait belt and assisted Resident #62 from her wheelchair. Licensed Practical Nurse (LPN) #198 was standing behind Resident #62's wheelchair and she confirmed Resident #62's wheelchair did not contain dycem or posey grip. Review of the facility policy titled Fall and Accident Management, dated 05/2016, revealed the facility will identify residents at risk for falls and interventions will be implemented and evaluated to reduce the risk of injuries, falls, or other accidents. This deficiency represents non-compliance investigated under Complaint Number OH00144070.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a new unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) was measured upon identification. This affected one (#13) of four residents reviewed for pressure ulcers. The facility identified nine residents with pressure ulcers. The facility census was 113. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included pulmonary embolism, major depressive disorder, fibromyalgia, and adjustment disorder with mixed anxiety and depressed mood. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of a nursing progress note dated 06/09/23 revealed an unstageable pressure area was observed on Resident #13's heel. The physician was notified and orders were received for a treatment to the newly identified area. There were no measurements of the wound and no description of the wound. Review of Resident #13's Wound Progress Note, dated 06/15/23, revealed the first measurement of the unstageable pressure ulcer on the left heel was measured on 06/15/23. Review of the plan of care dated 07/10/23 revealed Resident #13 had a pressure ulcer to the left heel related to impaired mobility. Interventions included to administer treatments as ordered and monitor effectiveness, assist with mobility, turning, and repositioning, and evaluate wound for size and depth and document progress on an ongoing basis. Interview on 07/13/23 at 1:18 P.M. with Registered Nurse (RN) #300 verified Resident #13's unstageable pressure area to the left heel was identified on 06/09/23 and had no documented measurements until 06/15/23. RN #300 verified the pressure area should have been measured at the time it was identified and stated she was unsure why it was not measured as the nurse who identified the area should have documented measurements. Review of the facility policy titled Skin Integrity Team (SIT)-Skin Monitoring Process, dated 01/2023, revealed during skin rounds, if a new, significant, skin issue is noted, including unstageable ulcers, the nurse will initiate a wound progress note and complete the wound progress portion to document the specifics of the significant skin issue. This deficiency represents non-compliance investigated under Complaint Number OH00144070.

Based on medical record review, staff interview, and policy review, the facility failed to ensure orders from a wound clinic were implemented and followed for a resident with multiple diabetic wounds. This affected one (#70) of one resident reviewed for diabetic ulcers. The facility census was 113. Findings include: Review of Resident #70's medical record revealed Resident #70 was readmitted to the facility on [DATE]. Diagnoses included morbid obesity due to excess calories, chronic diastolic (congestive) heart failure, chronic respiratory failure with hypoxia, gangrene, type II diabetes mellitus with diabetic chronic kidney disease, and end stage renal disease. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had moderate cognitive impairment. Resident #70 required extensive assistance of two staff for bed mobility, transfer, and toilet use. Review of the care plan revealed Resident #70 had venous/stasis ulcer to his bilateral feet/heels and right ankle related to his decreased functional ability, decreased sensory ability, and impaired/decreased mobility. Interventions included administering treatments as ordered and monitor for effectiveness. He also had a care plan regarding his surgical site to the left transmetatarsal amputation (TMA). The interventions included administering treatments as ordered and monitor for effectiveness. Review of the physician order dated 05/15/23 revealed there was an order for the left dorsal foot to be cleansed with normal saline, pat dry, paint with betadine, and cover with adaptic cover with meplex. It was to be changed on night shift every Monday, Wednesday, and Friday for wound care. The physician order dated 06/16/23 revealed an order to apply Santyl Ointment 250 units/gram (Collagenase) to the left heel, left foot, and right heel topically every night shift every Monday, Wednesday, and Friday for wound care. Before applying, cleanse with normal saline and pat dry. After applying ointment cover with a 4x4 and abdominal pad, wrap with kerlix, and secure. Review of the Wound Care Clinic notes dated 06/19/23 revealed the wound center was following six diabetic ulcers Resident #70 had. The wound care orders dated 06/19/23 were for the TMA and left foot medial wounds to be cleansed with normal saline and pat dry. Apply a silver alginate to the wound beds. Cover with dry gauze, ABD, and roll gauze. Change the dressing Mondays, Wednesdays, and Fridays. There was also an order for the bilateral heels, fifth toe amputation, right ankle and right/left dorsal foot wounds to cleanse the wound with normal saline and pat dry. Apply medihoney to the eschar areas. Cover with dry gauze, ABD, and roll gauze. Change the dressing Mondays, Wednesdays, and Fridays. The Wound Care Clinic note dated 07/10/23 revealed to continue with the same orders as 06/19/23. There was no evidence the Wound Care Clinic orders were implemented for Resident #70 at the facility from 06/19/23 to 07/11/23. Interview with the Director of Nursing (DON) on 07/13/23 at 3:00 P.M. verified the wound clinic orders for Resident #70 dated 06/19/23 and 07/10/23 were not implemented for Resident #70 at the facility. Review of the policy titled Skin Integrity Team (SIT)-Skin Monitoring Process, last revised 01/2023, revealed once the skin rounds and wound progress notes are completed, the SIT meeting will occur. This was to include verifying the treatment orders, care plans, and skin rounds match.

Based on medical record review, staff interview, and review of email correspondence, the facility failed to consistently monitor and document resident meal intakes. This affected four Residents (#29, #52, #86, and #110) out of four residents reviewed for nutrition. The facility census was 109. Findings include: 1. Revew of the medical record for Resident #110 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #110's care plan revealed Resident #110 had a nutritional problem and was at risk for malnutrition related to her chronic [CONDITION(S)], depression/anxiety having a potential for negative impact on intakes, dysphagia, [CONDITION(S)], cancer, hypertension/heart disease, altered diets, increased metabolic requirements related to [CONDITION(S)], and cognitive deficits. Resident #110's interventions included but were not limited to monitoring intakes and recording every meal. Review of Resident #110's meal intake documentation revealed there were missing meal intake documentation for 17 days between 07/01/22 and 07/27/22. There were ten days when no meal intakes were documented, four days when two meal intakes were missing, and three days when one meal intake was missing. 2. Review of the medical record for Resident #29 revealed the resident was originally admitted on [DATE] and was most recently admitted on [DATE]. Resident #29 discharged from the facility on 10/30/22. Resident #29's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's dietary note, dated 09/29/22, revealed he was at risk for malnutrition related to increased needs due to skin breakdown and infection. The note indicated staff would continue to monitor Resident #29's intakes and adjust the nutrition plan of care as needed. Review of Resident #29's meal intake documentation for October 2022, revealed there were meal intakes missing for 19 out of 31 days in October 2022. There were four days in October 2022 which were missing one meal intake, five days which were missing two meal intakes, and 10 days which had no meal intakes recorded. 3. Review of the medical record for Resident #52 revealed Resident #52 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's dietary note, dated 08/23/22, revealed Resident #52's intake was overall stable and she continued to attend meals in the dining room. The note indicated staff would monitor Resident #52 and adjust accordingly. Review of Resident #52's meal intake documentation for October 2022 revealed there were no meal intakes recorded for 13 out of 31 days in October 2022. 4. Review of the medical record for Resident #86 revealed Resident #86 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #86's dietary note, dated 10/24/22, revealed Resident #86 had a significant weight loss likely due to fluid removal in the hospital. His dietary recommendations were for a low sodium diet and to monitor for compliance with nutritional recommendations (whether Resident #86 was eating meals in the facility or was ordering out). Review of Resident #86's meal intake documentation for October 2022 revealed there were meal intakes missing for 17 out of 31 days in October 2022. There were three days which had two meal intakes missing and 14 days which had no meal intakes recorded. Interview with Registered Dietitian #38 on 11/01/22 at 1:29 P.M. revealed meal intakes should be recorded after every meal, but when she see's a residents meal intakes are not being recorded she watches the resident eat. Review of email correspondence with the Administrator dated 11/07/22 at 2:03 P.M. revealed the facility does not have a policy regarding the recording of meal intakes. This deficiency represents non-compliance investigated under Complaint Number OH 748.

Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure residents received assistance with bathing. This affected three (#74, #88 and #108) of three residents reviewed for bathing. The facility identified 82 residents that require assistance with bathing and 21 residents who are totally dependent for bathing. The facility census was 106. Findings include: 1. Review of Resident #74's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #74 dated 07/12/22 revealed she had no cognitive impairment and was totally dependent on two persons for bathing. Review of the care plan dated 08/20/21 revealed Resident #74 has an Activities of Daily Living (ADL) self-care performance deficit related to contracture to the left leg, impaired mobility, impaired balance, limited range of motion. The intervention was to assist with ADL's as needed, and adjust ADL's as needs dictate. Review of Resident #74's shower assignment schedule revealed Resident #74 was scheduled showers twice weekly on Wednesdays and Saturdays. Review of Resident #74's September 2022 ADL Documentation Survey Report revealed the resident was scheduled showers on 09/03/22, 09/07/22, 09/10/22, 09/14/22, 09/17/22, 09/21/22, 09/24/22 and 09/28/22. Further review of the report revealed the resident refused her scheduled showers on 09/14/22 and 09/24/22 and revealed no documentation the resident refused or received her scheduled showers 09/03/22, 09/07/22, 09/10/22, 09/17/22, 09/21/22, and 09/28/22. Review of the progress notes from 09/01/22 to 09/30/22 revealed no documentation of Resident #74 refusals for bathing on 09/03/22, 09/07/22, 09/10/22, 09/17/22, 09/21/22, and 09/28/22. Interview on 10/06/22 at 10:00 A.M., with Resident #74 stated she is not getting her showers as scheduled. 2. Review of Resident #88's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment for Resident #88 dated 09/28/22 revealed she was cognitively impaired and required set up help for bathing. Review of the care plan revised on 09/22/22 revealed Resident #88 has an ADL self-care performance deficit related to impaired mobility, impaired balance, fluctuations in ADL performance are expected related to Alzheimer's disease and the progression of her disease processes. The intervention was to provide extensive assistance of one staff for bathing. Review of Resident #88's shower assignment schedule revealed Resident #88 was scheduled showers twice weekly on Tuesdays and Fridays. Review of Review of Resident #88's September 2022 ADL Documentation Survey Report revealed the resident was scheduled showers on 09/02/22, 09/06/22, 09/09/22, 09/13/22, 09/16/22, 09/20/22, 09/23/22 ,09/27/22 and 09/30/22. Further review of the report revealed the resident received one shower on 09/27/22 and revealed no documentation the resident refused or received her scheduled showers on 09/02/22, 09/06/22, 09/09/22, 09/13/22, 09/16/22, 09/20/22, 09/23/22, and 09/30/22. Review of the progress notes from 09/01/22 to 09/30/22 revealed no documentation of Resident #88 refusals for bathing on 09/02/22, 09/06/22, 09/09/22, 09/13/22, 09/16/22, 09/20/22, 09/23/22, and 09/30/22. 3. Review of Resident #1088's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of the comprehensive MDS assessment dated [DATE] revealed the Resident #108 was cognitively impaired and required one-person physical assistance with bathing. Review of the care plan dated 09/01/22, revealed Resident #108 has an Activities of Daily Living (ADL) self-care performance deficit related to dementia, impaired mobility, and impaired balance. The intervention was to provide extensive one person assistance with bathing. Review of Resident #108's shower assignment schedule revealed Resident #108 was scheduled showers twice weekly on Tuesdays and Fridays. Review of Resident #108's September 2022 ADL Documentation Survey Report revealed the resident was scheduled showers on 09/02/22, 09/06/22, 09/09/22, and 09/13/22. Further review of the report revealed the resident refused one shower on 09/02/22 and revealed no documentation the resident refused or received her scheduled showers on 09/06/22, 09/09/22, 09/13/22. Review of the progress notes from 09/01/22 to 09/14/22 revealed no documentation of Resident #108 refusals for bathing on 09/06/22, 09/09/22, 09/13/22. Interview on 10/11/22 at 12:50 P.M., with the Director of Nursing (DON), while reviewing Residents #74, #88 and #108's medical record, revealed the staff are to document all resident showers on the resident's ADL Documentation Survey Report in the resident's Electronic Health record (EHR). The DON confirmed Residents #74, #88, and #108 had missing documentation and did not receive showers/baths as scheduled. Review of the policy titled, Bathing and General Hygiene, revised May 2015 revealed the facility will provide a minimum of one shower/tub bath/complete bed bath weekly for hygiene and to promote comfort of each patient. This deficiency substantiates Complaint Number OH 096.

Based on observations, interviews, facility policy, and Centers for Disease Control (CDC) guidelines the facility failed to appropriately cleanse hands while passing meal trays. This affected six residents (#27, #28, #47, #71, #75, and #76) who were served meals trays from staff members who didn't cleanse their hands properly. The facility census was 114. Findings include: Observation on 08/03/22 at 8:25 A.M. of the breakfast meal tray pass in the main dining room on the first floor revealed State tested Nursing Assistant (STNA) #40 passed breakfast trays to three residents without cleansing her hands. Breakfast trays were passed to residents (#27, #28, and #47) without STNA #40 using hand sanitizer or washing her hands. Interview on 08/03/22 at 8:30 A.M. with STNA #40 confirmed that she did not cleanse her hands in between passing breakfast trays to three residents (#27, #28, and #47). STNA #40 stated that she was aware she should cleanse her hands in between handling each resident's tray, but she didn't. Observation on 08/03/22 at 8:35 A.M. of the breakfast meal tray pass to the second-floor rooms revealed STNA #224 went into three different rooms, with three different residents (#71, #75, and #76) passing a meal tray to each resident without cleansing her hands. Interview on 08/03/22 at 8:40 A.M. with STNA #224 confirmed that she did not cleanse her hands in between passing breakfast trays to three different residents (#71, #75, and #76) in three different rooms. STNA #224 stated that there's no excuse to not cleanse your hands because each resident room has a hand sanitizer dispenser at the front of the room. Review of the facility policy titled Hand Hygiene, dated 03/2020, revealed Hand rubbing using alcohol-based hand sanitizers can be used for any other situation besides listed above. They are effective products for reducing the number of germs on the hands of healthcare providers. Situations where hand-rubbing is permitted: before and after assisting a resident with meals. Review of CDC guidelines revealed Hand hygiene is to be performed After touching a patient or the patient's immediate environment.

Based on record review, staff interviews, and review of continuing education provided by Elsevier, the facility failed to provide post-mortem care to a deceased resident in a timely manner. This affected one resident (#116) out of three residents reviewed for changes in condition. The facility census was 114. Findings include: Review of the medical record for Resident #116 revealed an original admitted [DATE] with a discharge of [DATE] and a readmission of [DATE] with another discharge of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Medicare Minimum Data Set (MDS) assessment for Resident #116, dated [DATE], revealed the resident had intact cognition. The resident had a brief interview for mental status (BIMS) score of 14 out of 15. No hallucinations, delusions, or rejection of care was noted on the assessment. Resident #116 required extensive assistance from at least one staff member for bed mobility, transfers, locomotion on unit, dressing, and toileting. Supervision from staff was required with hygiene and eating. Review of the nursing notes for Resident #116 revealed Registered Nurse (RN) #236 administered comfort medications on [DATE] at 11:16 P.M. The next nursing note occurred on [DATE] at 8:12 A.M. noting that the resident had expired. The facility was unable to provide any documentation regarding activities of daily living (ADLs) completed for Resident #116 from [DATE] at 11:15 P.M. and [DATE] at 8:12 A.M. Interview on [DATE] at 3:45 P.M. with State tested Nursing Assistant (STNA) #58 confirmed that she took care of Resident #116 on [DATE] from 7:00 P.M. through 12:00 A.M. She stated that during that time period, she cleaned him up as he had vomited. STNA #58 was unaware of what the time of that care was provided. The STNA could not remember who took her place when she left for the evening. Interview on [DATE] at 6:10 P.M. with Licensed Practical Nurse (LPN) #49 revealed that she was in the facility on the night of [DATE] into the morning of [DATE] working as the team leader. LPN #49 stated that she walked down to check on Resident #116 somewhere on [DATE] between 4:30 and 5:00 A.M. and noted that the resident was sleeping comfortably. Review of the Hospice nursing notes for Resident #116 revealed they were called by the facility on [DATE] a little after 8:00 A.M. to notify them that the resident had passed away. The facility asked hospice to come in and assist them with the process. Review of the Hospice nursing notes for Resident #116 written by Hospice RN #244 revealed that the nurse arrived in the facility on [DATE] at 10:00 A.M. The note goes on to say that post-mortem care was not provided until the hospice nurse had arrived at the facility. Phone interview on [DATE] at 10:00 A.M. with LPN #246 confirmed that she was the nurse taking care of Resident #116 on the morning of [DATE]. LPN #246 stated that she came on shift at 7:00 A.M. that morning. After getting report, she started collecting blood sugars from the residents. Upon entering the room of Resident #116 she noted that he was not breathing and confirmed that he was dead. This occurred sometime between 7:45 and 8:00 A.M. LPN #246 stated that she was a newer nurse at this point in her career. She stated that she got a second nurse to confirm that Resident #116 was without pulse and breath. The nursing supervisor was contacted and assisted her in calling hospice and the doctor to get the order for the release of the body. LPN #246 confirmed that she did not notify the family or have nursing staff complete post-mortem care before hospice arrived at the facility. Phone interview on [DATE] at 2:35 P.M. with Hospice RN #244 confirmed the facility had not started post-mortem care until she arrived at the facility that morning. Review of continuing education provided by Elsevier revealed postmortem care should be provided as soon as possible after death to prevent tissue damage or disfigurement. This deficiency substantiates Complaint Number OH 609.

Based on medical record review, staff interviews, review of the facility investigation, and facility policy the facility staff failed to report an allegation of sexual abuse to the Administrator or Director of Nursing within the two hour timeframe expected by the Ohio Department of Health. This affected one resident (#21), out of three residents reviewed for abuse. The facility census was 114. Findings Include: Review of the medical record for Resident #21 revealed an original admitted [DATE]. The resident had a discharge on 08/21/21 with a readmission of 08/26/21. Resident #21 stayed in the facility until the most recent discharge to the hospital on 08/01/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for Resident #21, dated 07/29/22, revealed the resident had intact cognition. No hallucinations, delusions, or rejection of care was noted on the assessment. Resident #21 required extensive assistance from staff for toileting, locomotion on/off unit, walking in the corridor, transfers, and bed mobility. The resident required limited assistance with dressing and supervision with hygiene. Resident #21 could eat independently according to the assessment. Review of the plan of care for Resident #21 dated 03/25/19 revealed the resident had a behavior problem related to non-compliance wearing hipsters, and waiting for assistance with ADLs. Interventions included administering medications as ordered, caregivers to offer a positive interaction with resident, and intervening as necessary to prevent the safety and rights of others. Review of the self reported incident (SRI) # 9 dated 07/30/22 at 2:12 P.M. revealed the family of Resident #21 had reported to the facility that the resident alleged a male caregiver State tested Nursing Assistant (STNA) #53 had climbed into bed with him several days ago. STNA #53 was immediately suspended pending investigation. Facility assessed resident for physical injuries. Resident #21 noted with unrelated physical injuries due to frequent falls. Review of the facility investigation for the incident with Resident #21 dated 07/30/22 at 3:00 P.M. revealed the resident spoke with a hospice nurse, hospice social worker, and family member regarding his concern that a male aide at night had jumped into bed with him several days ago. The investigation concluded that Resident #21 had told the hospice nurse Registered Nurse (RN) #240 and the hospice Licensed Social Worker (LSW) #242 along with the sister on 07/29/22. The facility was not notified of the incident until 07/30/22 by the sister, when they started the investigation. The facility immediately figured out the alleged perpetrator (STNA #53) and suspended him pending investigation. All vulnerable residents were interviewed with no negative outcomes. Staff member statements were taken. The personnel file of STNA #53 was reviewed and verified all correct checks were completed upon hiring and throughout the time at the facility. No concerns were noted regarding STNA #53. Staff members and residents alike were interviewed regarding STNA #53 with no concerns noted. RN #240 and LSW #242 were interviewed by the facility as a part of the process and verified they were aware of the incident on 07/29/22, one day prior to it being reported to the facility by the sister of the resident. Interview on 08/03/22 at 11:55 A.M. with the Administrator confirmed that RN #240 and LSW #242 were aware of the alleged abuse involving Resident #21 on 07/29/22, the day before it was reported to the facility by the sister of the resident. The Administrator stated that she educated RN #240 and LSW #242 on the abuse policy of the facility and they understood. Phone interview on 08/04/22 at 12:55 P.M. with RN #240 that she was in to see Resident #21 on 07/29/22. His sister was there, the social worker from hospice, and a member of the facility therapy staff were all present. RN #240 confirmed that there was an incident brought to her attention from the sister, but the stories varied. The sister stated that there was a male who came into the room of Resident #21 and jumped into bed with him. RN #240 stated she asked the resident separately about what happened to get clarification and the resident stated something about an African American man coming into his room, taking him down the hall and Resident #21 stating that he could see the African American man's genitals. RN #240 reported this to the sister of the resident, who stated that she did not want this reported to the facility. RN #240 confirmed to the surveyor that she did report the allegations of abuse to the Occupational Therapy Assistant (OTA) #120, who was present at the time of her visit. Phone interview on 08/04/22 at 1:34 P.M. with Occupational Therapy Assistant (OTA) #120 confirmed that she had a session with Resident #21 on 07/29/22. OTA #120 revealed that she was having a meeting with hospice, the resident, and his sister regarding her goals and thoughts with his therapy. OTA #120 stated her meeting last approximately five minutes. The Occupational Therapy Assistant denied ever being told of any allegation of abuse by RN #240 on 07/29/22. OTA #120 stated that she would have immediately notified the DON or Administrator if she was notified of any possible wrongdoing toward the resident. Phone interview on 08/04/22 at 2:00 P.M. with LSW #242 confirmed that she had a meeting with the sister and Resident #21 on 07/29/22. The sister of the resident asked the resident to tell the social worker what he had told her earlier. LSW #242 stated that Resident #21 stated there was a big black man who got into his bed with him, then took me to the nurses station. LSW stated that the sister of the resident was adamant about reporting the incident to the facility herself, so she did not report it to the facility at that time. Review of facility policy titled Abuse/Neglect/Misappropriation of Property, dated 11/2016, revealed the facility did not implement the policy regarding the allegation. All incident and allegations of abuse, neglect, exploitation, misappropriation of resident property and all injuries of unknown source must be reported immediately to the administrator or designee. The Administrator should be notified by informing him/her in person, calling via telephone, or sending an email or text message. If abuse or serious bodily injury is alleged- if the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to State Survey Agency immediately, but not later than two hours after the allegation is made. For the purposes of this policy, staff members include employees, consultants, contractors, volunteers, and any other caregivers who provide care and services to residents on behalf of the facility. This deficiency substantiates Complaint Number OH 626.

Based on record review, staff interviews, and facility policy, the facility failed to notify a resident representative of a death in a timely manner. This affected one resident (#116) out of three residents reviewed for changes in condition. The facility census was 114. Findings include: Review of the medical record for Resident #116 revealed an original admitted [DATE] with a discharge of [DATE] and a readmission of [DATE] with another discharge of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Medicare Minimum Data Set (MDS) assessment for Resident #116, dated [DATE], revealed the resident had intact cognition. The resident had a brief interview for mental status (BIMS) score of 14 out of 15. No hallucinations, delusions, or rejection of care was noted on the assessment. Resident #116 required extensive assistance from at least one staff member for bed mobility, transfers, locomotion on unit, dressing, and toileting. Supervision from staff was required with hygiene and eating. Review of the nursing notes for Resident #116 revealed Registered Nurse (RN) #236 administered comfort medications on [DATE] at 11:16 P.M. The next nursing note occurred on [DATE] at 8:12 A.M. noting that the resident had expired. The facility was unable to provide any documentation regarding activities of daily living (ADLs) completed for Resident #116 from [DATE] at 11:15 P.M. and [DATE] at 8:12 A.M. Interview on [DATE] at 3:45 P.M. with State tested Nursing Assistant (STNA) #58 confirmed that she took care of Resident #116 on [DATE] from 7:00 P.M. through 12:00 A.M. She stated that during that time period, she cleaned him up as he had vomited. STNA #58 was unaware of what the time of that care was provided. The STNA could not remember who took her place when she left for the evening. Interview on [DATE] at 6:10 P.M. with Licensed Practical Nurse (LPN) #49 revealed that she was in the facility on the night of [DATE] into the morning of [DATE] working as the team leader. LPN #49 stated that she walked down to check on Resident #116 somewhere on [DATE] between 4:30 and 5:00 A.M. and noted that the resident was sleeping comfortably. Review of the Hospice nursing notes for Resident #116 revealed they were called by the facility on [DATE] a little after 8:00 A.M. to notify them that the resident had passed away. The facility asked hospice to come in and assist them with the process. Review of the Hospice nursing notes for Resident #116 written by Hospice RN #244 revealed that the nurse arrived in the facility on [DATE] at 10:00 A.M. The note goes on to say that notification was not made to the family of Resident #116 until Hospice RN #244 arrived at the facility. Phone interview on [DATE] at 10:00 A.M. with LPN #246 confirmed that she was the nurse taking care of Resident #116 on the morning of [DATE]. LPN #246 stated that she came on shift at 7:00 A.M. that morning. After getting report, she started collecting blood sugars from the residents. Upon entering the room of Resident #116 she noted that he was not breathing and confirmed that he was dead. This occurred sometime between 7:45 and 8:00 A.M. LPN #246 stated that she was a newer nurse at this point in her career. She stated that she got a second nurse to confirm that Resident #116 was without pulse and breath. The nursing supervisor was contacted and assisted her in calling hospice and the doctor to get the order for the release of the body. LPN #246 confirmed that she did not notify the family or have nursing staff complete post-mortem care before hospice arrived at the facility. Phone interview on [DATE] at 2:35 P.M. with Hospice RN #244 confirmed the facility had not notified the family of Resident #116 until she arrived in the facility around 10:00 A.M. on [DATE]. Review of the facility policy titled Change in a Resident's Condition or Status, dated ,d+[DATE], revealed the facility did not implement the policy regarding the allegation. Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). This deficiency substantiates Complaint Number OH 609.

Based on closed medical record review, review of the facility's timeline, review of hospital records, review of the death certificate, interviews with staff, family and emergency services personnel, and review of facility policy, the facility failed to seek timely emergency medical treatment for [REDACTED]. This resulted in Immediate Jeopardy and serious life-threatening harm when the resident began to show a change in condition including being covered in emesis (vomit) and was going in and out of consciousness several hours after the fall without any intervention until the resident was found completely unresponsive. The resident was then transferred to the local emergency room where she was found to be in a deep coma (severe [MEDICAL CONDITION]), suffered a large subdural hemorrhage (brain bleed), underwent an emergent left hemicraniectomy (to relieve increased intracranial pressure and brain tissue shifts), and subsequently expired. This affected one (#07) of eight residents reviewed for a change in condition. The facility census was 69. On [DATE] at 12:44 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Corporate Registered Nurse (CRN) #90 and Chief Operating Officer (COO) #91 were notified Immediate Jeopardy began on [DATE] at 3:30 P.M., when Resident #07 began to show changes in condition after sustaining a fall including being covered in emesis and going in and out of consciousness and the facility failed to consult the physician or seek timely advanced medical treatment. The resident was then transferred to the local emergency room where she was found to be in a deep coma, suffered a large subdural hemorrhage, underwent an emergent left hemicraniectomy, and subsequently expired. The Immediate Jeopardy was removed on [DATE] when the facility reviewed all residents, currently residing in the facility, for a change in condition and the facility implemented the following corrective actions: · On [DATE] at 5:07 P.M., Emergency Medical Services (911) was called to transport Resident #07 to the local hospital. · On [DATE], an audit of progress notes for change of condition were completed on all current residents by Corporate Quality Assurance Nurse (CQAN) #90 at 3:30 P.M. Eight current residents (#01, #06, #25, #26, #27, #28, #29, and #30) were identified with change in conditions and were reviewed further to ensure physician/responsible party and, if needed, emergency services notifications were completed and documented in the medical record. The DON and CQAN #102 completed these audits on [DATE] at 9:00 P.M. The audits revealed the facility did actuate timely and emergent response as needed including notification to the clinician and responsible party for changes in condition. · On [DATE] at 12:30 P.M., licensed nurses present in the facility received additional in-service education by the DON, Assistant Director of Nursing (ADON) #61, Registered Nurse (RN) Unit Manager #62, RN Corporate Nurse Trainers (#102, #200, and #201), to include notification of change in condition including, but not limited to the clinician and responsible party notification of significant changes in a resident condition and activating emergency services. The education also included review of the Change of Condition Policy, Fall and Accident Policy, and Physician Notification Policy. Any licensed nurse who has not been at work, on leave, or on vacation, will complete all education and training prior to working their shift starting on [DATE] at 7:00 P.M. Any newly hired nurses would be provided with this education prior to working on the floor. No licensed nurse will work without first being in-serviced. · On [DATE] at 4:50 P.M., a Quality Assurance (QA) meeting was held with the Administrator, Medical Director (MD) #92, DON, ADON #61, RN Unit Manager #62, Corporate Nurse #90, and COO #91 regarding an action plan. Action plans to address the deficiency as well as review of the policy and the overall system were reviewed and approved by the QA committee. · Effective immediately, a Performance Improvement (PI) worksheet is being completed for change of condition, and notification. The DON or designee will complete the worksheet daily times seven days, then three times per week for two weeks, then weekly times two weeks, then monthly. If issues are noted, the DON or designee takes the appropriate action at the time the concern is noted. Results of the PI worksheet will be reported to the QA committee for a determination of the need for further ongoing monitoring. · On [DATE] at 1:47 P.M., a QA committee meeting was held with the Administrator, MD #92, DON, ADON #61, Corporate Nurse #90, and COO #91 on the complaint survey findings and abatement plan. Plans to address the deficiency and the overall system were reviewed and approved by the QA committee. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Closed medical record review revealed Resident #07 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #07 had intact cognition and required extensive assistance of one person for bed mobility. She had left upper and lower extremity impairment due to a history of [MEDICAL CONDITION]. Review of Resident #07's (MONTH) (YEAR)'s physician orders [REDACTED]. Further review of the orders revealed to monitor for signs of bleeding to include lethargy, sudden headache, nausea/vomiting, and sudden changes in mental status. Review of Resident #07's plan of care with a target date of [DATE] revealed the resident was at risk for bleeding due to taking aspirin therapy. The goal was to be free from signs of bleeding and interventions included monitor for bleeding. Review of the facility's timeline (undated) revealed Resident #07 was found on the floor on [DATE] at 10:42 A.M. Review of Resident #07's nurse's note dated [DATE] at 11:30 A.M., revealed the resident had an unwitnessed fall, vital signs were obtained and were noted to be within normal limits. Physician #202 was notified, and a new intervention of fall mats were put in place. The nurse's note did not indicate if the physician was spoken to, or if a message was left. A (late) nurse's note dated [DATE] at 8:22 A.M., revealed a resident was in the hallway yelling help and was pointing into Resident #07's room. The resident was observed on the floor lying on her left side facing the window with her left arm pinned under her and the left side of her forehead on the ground. Resident #07 was assisted back to bed with additional staff via a mechanical lift. There were no other nurse's notes regarding the condition of Resident #07. Review of Certified Nurse Practitioner (CNP) #71's note dated [DATE] (untimed) revealed Resident #07 fell out of bed when attempting to get up without assistance. She had a hematoma on her left temporal forehead area. The resident reported the area was tender. The hematoma was noted to be a raised area measuring 2.5 centimeters (cm). The plan was to complete neurological checks and obtain vital signs per protocol, ice to the area as tolerated, and if any change of condition to consider a computed tomography (CT) scan. The neurological assessment revealed the resident followed commands, grasps fair on left, slightly stronger on the right, and pupils reactive to light. A discussion with the resident's daughter who was present, agreed to monitor her in the facility at this time. Review of Resident #07's Cranial Check Sheet dated [DATE] beginning at 11:30 A.M., and ending at 5:00 P.M., revealed the resident remained neurologically intact throughout the day. The assessment documented the resident was alert and oriented, right and left pupils were reactive and bilateral hand grasps were normal. Review of the Statement Form dated [DATE] by State tested Nursing Assistant (STNA) #52 revealed the STNA went into Resident #07's room at 3:30 P.M., and found the resident covered in vomit and she notified the nurse. Review of the Statement Form dated [DATE] and untimed by Licensed Practical Nurse (LPN) #305 revealed it was brought to this nurses' attention Resident #07 was unresponsive, however was breathing. The resident was noted to be in bed with oxygen via nasal cannula set at three liters. Her respirations were 20 per minute, pulse was between ,[DATE] per minute, her blood pressure was ,[DATE] mmHg (millimeters of mercury), and her blood glucose was 381. The resident was not responding when her name was called and had no response to sternum rubs (painful stimuli). The resident's pupils were non-reactive and emergency services (911) was called. Review of the Situation Background Action Recommendation (SBAR) dated [DATE] and time locked at 5:30 P.M., revealed Resident #07 had a change in condition, was unresponsive and should be transferred to the hospital. The SBAR revealed the primary care clinician and family were notified on [DATE] at 5:30 P.M. Review of the hospital record dated [DATE] revealed Resident #07 arrived at the Emergency Department on [DATE] at 5:53 P.M. She arrived from the nursing facility after having a fall out of her bed earlier in the day. The resident was found to be largely unresponsive and had sonorous (abnormal breath sounds) respirations. There was a contusion noted to the left forehead, the left pupil was pinpoint, and the right pupil was dilated and gazed. She had a Glasgow Coma Scale (GCS) of 4 (severe [MEDICAL CONDITION] of a score of eight or less) and would only moan with significant painful stimuli, otherwise unresponsive and did not follow commands. She was intubated (full life support). The CT scan of the head showed a massive acute subdural hematoma with a midline shift of the brain to the right. Neurosurgery was consulted as the resident's family wanted to pursue surgical intervention despite the prognosis. An emergent left hemi-craniectomy with evacuation (to drain blood) was performed. In the late evening on [DATE] the resident's status deteriorated quickly, she had essentially no neurological function with absent reflexes, apnoea (not breathing) on breathing trials, and dolls eyes were present. On [DATE] at 12:28 A.M., she went into asystole ([MEDICAL CONDITION]) and was pronounced dead. Review of the Certificate of Death dated [DATE] revealed Resident #07's immediate cause of death was subdural hematoma. Interview on [DATE] at 3:19 P.M., with STNA #56 revealed Resident #07 had fallen out of her bed and had a big knot on her forehead. She became concerned when she checked on the resident in the afternoon because she was going in and out of consciousness. STNA #56 revealed she reported her change of condition to the nurse. Interview on [DATE] at 10:46 A.M., with Housekeeper #300 revealed she was mopping the floor in the room next door to Resident #07 when she heard a loud boom. She ran in the room and saw Resident #07 on the floor and went and told the nurses. She revealed she did see a nurse and STNA go to the room, however, was unsure who they were. Interview on [DATE] at 10:55 A.M., with STNA #52 revealed she was working another hallway when RN Unit Manager #62 asked for her help to get Resident #07 off the floor. She stated they used the mechanical lift to place her back in bed. When she checked on the resident later in the afternoon she was throwing up. STNA #52 revealed she told LPN #51. She was unsure of the exact time, however, knew it was in the afternoon between 2:00 P.M. and 2:30 P.M. Interview on [DATE] at 11:05 A.M. with STNA #56 revealed Resident #07 had a huge knot on her head after she fell on [DATE]. She stated later in the afternoon sometime during the facility activity, which was between 2:00 P.M. and 4:00 P.M., STNA #52 asked her to help clean the resident up because she had thrown up. This was reported to the nurse. STNA #56 revealed she went back in later and kept calling Resident #07's name, however, she was going in and out of consciousness, which she reported to LPN #305. Interview on [DATE] at 11:33 A.M. with CNP #71 revealed she saw Resident #07 after the resident's daughter had called her and asked her to see her because she had fallen out of bed. She arrived at the facility and the resident's daughter was at the bedside. The daughter felt her mother was at her baseline, and they agreed to keep her at the facility and watch for any changes. CNP #71 revealed she was never notified Resident #07 began vomiting and had a change in condition in the afternoon. She further revealed that had she been notified, she would have sent her to the hospital. Interview on [DATE] at 1:15 P.M. with Resident #07's daughter revealed she had received a call from the facility about her mother falling on [DATE] around 10:47 A.M. She said her regular CNP #70 was not working so she called CNP #71 and asked her to go see her mother. She said when she arrived at the facility around 12:30 P.M., her mother had a huge goose egg on her forehead. The daughter revealed she and CNP #71 agreed to monitor her in the facility as she was at her baseline at this time. She said she never received any more phone calls about her mother throughout the day. The daughter revealed she came to the facility after work, a little after 5:00 P.M. She met ADON #61 coming up the hall who said they had found her mother unresponsive. Interview on [DATE] at 1:56 P.M. with Emergency Services Personnel (ESP) #400 revealed the call came into 911 from the facility for Resident #07 on [DATE] at 5:07 P.M. (over one and a half hours after the resident had first experienced vomiting and going in and out of consciousness). They were dispatched at 5:08 P.M., and arrived at the facility at 5:12 P.M. Review of the policy titled Change of Condition revised ,[DATE] revealed the facility staff will report identified significant changes in resident's status. Documentation of the condition will be noted in the nurses charting or interdisciplinary charting as indicated. The resident's physician/clinicians and responsible party will be notified of significant changes in resident's condition. The policy indicated at number 3 Residents Responsible Party and Physician/clinician are notified of significant changes in residents' conditions by phone or facsimile as appropriate in these general situations: a. An accident involving the resident which results in injury and has the potential for requiring physician intervention. b. A significant change in the resident's physical, mental, or psychosocial status (for example deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. At number 5, the policy indicated Significant changes in conditions or events of residents are to be reported to the nursing supervisor. This deficiency substantiates Complaint Number OH 277.

Based on review of a closed medical record, review of the paramedic transport report, review of the hospital records, staff interview, and review of Medscape Advanced Cardiac Life Support (ACLS): [MEDICAL CONDITION](fast heart rate) with Pulse, the facility failed to ensure timely and appropriate emergent response for a change in cardiac condition for a resident with a Full Code status. This resulted in Immediate Jeopardy when facility staff failed to provide timely emergent medical treatment for [REDACTED]. Resident #256's HR continued to be assessed and remained elevated between 188 to 196 bpm for five hours prior to being transported to the hospital. Resident #256 was diagnosed with [REDACTED]. This affected one (#256) of three residents reviewed for a change in condition. The facility census was 119. On [DATE] at 5:40 P.M., the Administrator and Director of Nursing (DON) were notified the Immediate Jeopardy began on [DATE] at 8:30 A.M. when Resident #256 was assessed and found to have a HR of 196 bpm. Resident #256 was assessed by Nurse Practitioner (NP) #610 around 9:00 A.M. and made recommendations for the resident to have an electrocardiogram (EKG). The family was then notified of the resident's increased heart rate and recommendations for an EKG following the resident's third fall that morning (7:30 A.M.) since admission on [DATE], a period of five days. The facility continued to monitor the resident's HR which remained elevated above 190 bpm. There was no evidence of any other documented attempts to inform the family of the seriousness of the resident's medical condition and need for treatment. The family arrived at the facility sometime after 12:00 P.M. and nine-one-one (911) was called at 1:30 P.M. Upon arrival at the facility, the paramedic obtained a HR of 189 and an EKG which showed [MEDICAL CONDITION]. Resident #256 was transported and arrived at the hospital at 2:17 P.M. The hospital diagnosed the resident with [MEDICAL CONDITION] and emergent synchronized cardioversion was completed and the HR returned to normal rhythm at 85 bpm. Resident #256 was then admitted to the Intensive Care Unit (ICU) and expired the next day. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: * On [DATE], an audit was conducted of pulses for all residents at the facility from [DATE] to present by the DON, Assistant Director of Nursing (ADON) #148, and Registered Nurse Unit Managers (RNUMs) #38, #142 and #177. * On [DATE], a Quality Assurance (QA) meeting was held with Medical Director (MD) #615, the DON, ADON #148, and RNUMs #38, #142 and #177. Guidelines were established that any pulse or heart rate greater than 120 bpm would be considered serious and required notification of the physician and the family with emphasis on the serious nature. * On [DATE], licensed nursing staff received specific in-service education by the DON, ADON #148, RNUM #38, #142, #177, and Registered Nurse Corporate Nurse Trainers (RNCNT) #620 and #621. Education included notification of change in condition with emphasis on the serious nature of certain results and conditions including pulse rate greater than 120. Any licensed nurse who has not been at work, on leave, or on vacation will complete all education and training prior to working their shift starting [DATE]. The Administrator will track and ensure all licensed nurses received training prior to working. * The DON, ADON #148, RNUM's #38, #142 and #177, and RNCNT's #620 and #621 will complete a Performance Improvement (PI) worksheet for the physician and family notification as it relates to change of condition related to serious pulse rate greater than 120, daily for 14 days. Results will be reported to the QA Committee for further direction. * The QA committee will meet weekly for four weeks to monitor PI results and make any necessary changes. The DON and ADON #148 will perform periodic informal rounds, as a component of their daily duties, observing the direct care staff in rendering care for the residents. If concerns are noted, the DON and ADON #148 will take appropriate interventions at that time, including physician/responsible party notification and/or additional education of the employee. The DON will monitor by observation, interview and record/audit review. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (No actual harm with potential for minimal harm that is not Immediate Jeopardy) as the facility is still in the process of monitoring their corrective action plan to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident #256 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed cognitive status wasn't assessed. Resident #256 required extensive assistance with transfers, toileting, and personal hygiene. A walker and wheelchair were utilized for mobility. Review of the hospitalization records (prior to admission) dated [DATE] for admission to the facility revealed Resident #256 had a past medical history significant for heart failure with an ejection fraction (how well the heart pumps blood with each beat) of 30 percent (%), [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], and Alzheimer's dementia. The resident had multiple co-morbidities along with dementia and extensive care needs and required 24-hour supervision. The resident was without shortness of breath, chest pain, or other cardiopulmonary symptoms. Review of the nursing progress note documented by Licensed Practical Nurse (LPN) #55 dated [DATE] at 11:34 A.M. revealed Resident #256 was found in front of his wheelchair by State tested Nursing Assistant (STNA) #88 at 7:30 A.M. His blood pressure (BP) was ,[DATE], heart rate (HR) was 77 bpm, respirations (R) 22, and oxygen saturation (O2 SAT) was 94%. NP #610 and the resident's responsible party were notified. Review of the Situation, Background, Assessment, Request (SBAR) communication form and progress note documented by LPN #55 dated [DATE] at 4:26 P.M. revealed Resident #256 experienced an increased HR, R, and decreased BP following a fall. The resident reported he hit his head. Tylenol was administered and effective. NP #610 and the family were notified. NP #610 reported she would assess the resident's condition to confirm being sent to the emergency room instead of in house orders. At the time of the fall his BP was ,[DATE], HR 77, R 22, and O2 SAT 94%. Neurological checks were started and at 8:30 A.M., his BP was ,[DATE], HR 196, R 30. NP #610 was notified of his condition, including his vital signs. The resident was identified as a Full Code. Documentation of notification to NP #610 and the family reflected the date of [DATE] without a time noted. Review of the Cranial Check Sheet revealed on [DATE] at 7:30 A.M., Resident #256 was confused, lethargic but responded verbally, BP was ,[DATE], P 77, R 22, and O2 SAT 94%. At 8:00 A.M. his BP was ,[DATE], P 69, R 32, and O2 SAT 92%. At 8:30 A.M., BP was ,[DATE], P 196, R 30, O2 SAT 95%. At 9:00 A.M., BP was ,[DATE], P 195, R 28, O2 SAT 97. At 10:00 A.M., BP was ,[DATE], P 193, R 28, and O2 SAT 98%. At 11:00 A.M., BP was ,[DATE], P 191, R 24, O2 SAT 100%. At 12:00 P.M., BP was unable to be obtained, P 194, R 24, and O2 SAT 100%. At 1:00 P.M., BP ,[DATE], P 188, R 26, and O2 SAT 99%. Resident #256's level of consciousness remained confused, lethargic but responded verbally throughout all the checks. LPN #55 documented all of the cranial checks. Review of the geriatric provider progress note documented by NP #610 dated [DATE] (no time noted) revealed Resident #256 was seen for a fall without injury this morning. The resident's daughter wanted the resident transported to the hospital and was on the way to the facility. If the resident didn't go to the hospital, would obtain an immediate (STAT) EKG. The resident's BP was recorded as ,[DATE] and HR 196 with a question mark in front of it. Cardiovascular was recorded as regular and normal. Assessment and plan included will place hypertensive medication on hold for systolic BP below 110. Review of the paramedic transport report revealed the paramedics were dispatched to the facility on [DATE] at 1:31 P.M. and arrived at the facility at 1:37 P.M. Resident #256 was lethargic (sluggish) and confused with a HR of 189 and BP ,[DATE]. An EKG revealed [MEDICAL CONDITION]. An intravenous line was started, the resident was placed on a heart monitor, defibrillator pads were attached to the chest in case an electronic shock was required for sudden deterioration, and medication was administered to convert heart rate to a normal rhythm without success. The resident was transported and arrived at the hospital for further treatment at 2:17 P.M. Review of the emergency department attending attestation note dated [DATE] at 3:04 P.M. revealed Resident #256 presented with [MEDICAL CONDITION] the 180's. He received [MEDICATION NAME] (a medication used to treat heart rhythm problems) prior to arrival without response. Cardiology was consulted and synchronized cardioversion was recommended. Due to the emergent condition, verbal consent was obtained from the family. Resident #256 was synchronized cardioverted at 2:45 P.M. to sinus rhythm with a HR of 85. The resident was admitted to ICU for [REDACTED]. An interview on [DATE] at 10:24 A.M. with NP #610 reported LPN #55 contacted her on [DATE], unsure of the time, and informed her about Resident #256's abnormal vital signs. NP #610 reported she didn't believe the resident's HR was in the 190's and when she assessed the resident his HR wasn't in the 190's. She reported she could not remember what the resident's HR was and she did not document his HR. The plan was to obtain an EKG but the family arrived at the facility, came straight to the nursing office without even seeing the resident, and demanded the resident be transported to the hospital at which time 911 was called. NP #610 reported she didn't even get a chance to order the EKG and reported the resident didn't have any complaints during her assessment. NP #610 reported it would be considered a medical emergency if the HR was in the 190's and would require immediate transfer to the hospital for treatment. She further reported she was not notified the resident's pulse remained elevated. An interview with the DON on [DATE] at 11:50 A.M. revealed LPN #55 discovered Resident #256's heart rate was elevated and notified NP #610 on [DATE] at 8:30 A.M. The NP recommended an EKG and reported she would assess the resident upon arrival to the building. LPN #55 called the family to inform them of the NP's recommendations and the daughter loudly instructed the nurse not to do anything until they arrived at the facility. Around 9:30 A.M. or 10:00 A.M., NP #610 arrived at the facility and assessed Resident #256. NP #610 noted regular normal sinus rhythm, questioned the high pulse rate, but didn't document a pulse although she reported she obtained one. The plan was to obtain a STAT EKG if the resident didn't go out to the hospital as the daughter was on her way into the facility. Around 11:30 or 11:45 A.M., therapy attempted to work with Resident #256 but he became uncooperative. Therapy reported the resident didn't appear to be in any distress. Therapy contacted the daughter to inform her about the resident's refusal to participate in therapy and the daughter reported she was on her way into the facility. LPN #55 and therapy telephone contacts with the daughter were the only telephone contact made with the family of Resident #256 on [DATE]. At 12:45 P.M., another therapist worked with Resident #256. He cooperated and was assisted out of bed, to the chair without any distress. The resident's daughter arrived during this time and therapy reviewed fall risk interventions with her. After the meeting with therapy, the daughter approached the nursing office and requested Resident #256 be transported to the hospital at which time 911 was called. An interview on [DATE] at 12:21 P.M. with LPN #55 revealed on [DATE] at 7:30 A.M., STNA #88 reported Resident #256 was on the floor. His vital signs were obtained and were normal at that time and he was without injuries. He was placed on neurological checks as a precaution related to the fall. When he was assessed again at 8:30 A.M., he complained of pain in his arm and his heart rate was elevated. LPN #55 reported his HR was so high she thought it was inaccurate so she attempted to auscultate (listen) to his HR but it was too fast to count so she rechecked his HR and it remained elevated at 196 bpm. LPN #55 notified NP #610, whom was present in the building on the second floor, and she reported she would be down to check on the resident. LPN #55 reported she continued with her medication pass and was unaware of the time NP #610 assessed the resident. After the resident was assessed, NP #610 reported she wanted a STAT EKG. LPN #55 reported she contacted the family and informed them about the fall, the fast HR, and recommendations for an EKG. LPN #55 reported the daughter was extremely upset and focused on the fall since the resident had two prior falls since his admission to the facility. The daughter initially reported she wanted the resident sent out but after the plan to obtain an EKG was explained to her, she reported she was on her way to the facility and she didn't want anything done until the family arrived. LPN #55 reported she didn't explain the seriousness or the actual heart rate to the resident's daughter, but just that his pulse was fast and an EKG was recommended. LPN #55 reported she continued to perform scheduled neurological checks on the resident until the family arrived at the facility two to three hours later. LPN #55 acknowledged Resident #256's pulse remained abnormally high and was unaware if there was any further contact with the family or with NP #610 during this time. Additional interviews with NP #610 on [DATE] at 12:58 P.M. and 2:40 P.M. revealed she was unsure of the time she assessed Resident #256 as she didn't document the time on her progress note but felt it was most likely between 9:00 A.M. and 9:30 A.M. NP #610 reported she did not have any contact with the family of Resident #256 until the daughter arrived at the facility. NP #610 reported LPN #55 and therapy were the only staff who contacted the family and therapy only contacted them about fall interventions. She was aware Resident #256's vital signs remained abnormal with an elevated HR but reported the resident didn't appear to be in any distress. She denied any contact with a physician about Resident #256's change in medical condition. Review of Medscape Advanced Cardiac Life Support (ACLS): [MEDICAL CONDITION] Pulse updated [DATE] revealed heart rate was typically equal to or greater than 150 bpm in tachyarrhythmia. Initial interventions included maintain patent airway, assist breathing as needed, administer oxygen if hypoxemic, attach monitor/defibrillator, and monitor blood pressure and oximetry. Assess for signs of poor perfusion including [MEDICAL CONDITION] (systolic, top number, blood pressure below 90), acutely altered mental status, signs of shock, chest discomfort, and acute heart failure. Therapeutic intervention for poor perfusion included to perform immediate synchronized cardioversion, consider sedation but do not delay therapy. This deficiency substantiates Complaint Number OH 953.

Based on closed medical record review, observation of a heating pad, staff interview, review of the Self- Reported Incident (SRI) and investigation, review of the incident/accident log, review of hospital records, the manufacturers recommendations and specifications and policy review, the facility failed to identify and remove a safety hazard (heating pad) from a moderate cognitively impaired resident until second [MEDICAL CONDITION] observed, and failed to provide immediate treatment to the burns. This resulted in Immediate Jeopardy for one resident (#122) who sustained second [MEDICAL CONDITION] the left thigh extending to the top of the calf just below the knee. [MEDICAL CONDITION] from a heating pad placed and left turned on underneath the resident's leg for over 12 hours. The facility failed to notify the physician immediately of the second [MEDICAL CONDITION] failed to provide immediate treatment to the burns. This affected one (#122) of four residents reviewed for injuries, accidents, neglect and misappropriation. The facility census was 120. On 07/28/15 at 1:21 P.M., the Administrator, Director of Nursing (DON), Vice President of Risk Management (VPRM) #224 and Regional Administrator #225 were notified Immediate Jeopardy began on 07/06/15 at 5:00 P.M., when former Nurse #227 became aware Resident #122 was using a heating pad in his room and failed to remove the heating pad or implement any safety interventions. Subsequently on 07/07/15 between 3:00 P.M. and 5:00 P.M., the heating pad was turned on and placed underneath the left leg of Resident #122, by Resident #122's sister. The heating pad was not removed until 07/08/15 at approximately 6:15 A.M. by Registered Nurse (RN) #205, when Resident #122 was noted with blistering from the left gluteal fold down the back of the thigh and spanned to the top of the calf with open areas of pink and red tissue with yellow drainage seeping from the left leg. Resident #122 was subsequently diagnosed with [REDACTED]. Blisters can be present and the wound will be pink, red in color, painful and wet appearing). There was no physician notification of [MEDICAL CONDITION] no immediate treatment provide to the second degree burn at that time. The Immediate Jeopardy was removed on 07/30/15 at 7:00 A. M., when the facility implemented the following corrective actions: · On 07/08/15 at 6:15 A.M., the heating pad was turned off and removed out from underneath the left leg of Resident #122 by RN #205. · On 07/08/15, Director of Housekeeping #67 and Social Services LSW #220 went through every resident's room, drawers, closets etc., to assure there were no heating pads or any other electrical hazards or safety concerns identified. There were none noted at this time. · On 07/08/15 at 12:00 P.M., the DON began education with all staff on duty about the prohibition of heating pads and other electrical hazardous devices in the facility. All staff completed this education via phone call and/or in person prior to working their next shift. · On 07/10/15, the facility's in-house channel television was updated to include the specific guidance on the prohibition of bringing heating pads and other potentially hazardous devices into the facility. A sign with the prohibition information was also posted at the front desk by the visitor sign-in book. · On 07/10/15, the DON began monitoring rooms three times per week for two weeks, then weekly for four weeks and then monthly. · On 07/13/15, a letter was sent out to families to remind them of some items prohibited by the facility which included but not limited to heating pads and other electrical devices. The letter notified each resident's family that all electrical items brought into the facility needed to go through administration prior to their use. The Resident Handbook that includes this information is located in every resident room and referred to in the admission packet. · On 07/29/15 at 5:00 P.M., the DON began education with nursing staff on the change of condition policy and procedure. The education continued on 07/30/15 and all nursing staff will be in-serviced prior to the start of their next shift. Although the Immediate Jeopardy was removed on 07/30/15, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of educating all nursing staff about change of condition and completing on-going audits of hazardous devices in resident rooms to ensure the corrective action taken is monitored for continued compliance. Findings include: Review of the closed medical record for Resident #122 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission assessment dated [DATE] documented Resident #122 was alert and oriented, non-ambulatory and had no wounds/burns to the left leg. The Admission Braden Scale (predicts the risk of skin issues/breakdown) scored the resident at high risk for break down and identified as having very limited sensory perception. Review of the Plan of Care dated 06/30/15 did not identify heat therapy as an intervention. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #122 had moderate cognitive impairment, required extensive assistance of two staff for bed mobility and transfer, and there were [MEDICAL CONDITION] the left leg noted. Review of the nurse's note written by RN #205 dated 07/08/15 at 7:48 A.M., revealed that State tested Nursing Assistant (STNA) #226 informed RN #205, there was drainage coming from Resident #122's left leg. Upon entering the room to assess Resident #122's leg, RN #205 observed there was a heating pad under his left leg and a blister had formed and broke open. The skin was pink and red on the inside and there was yellow drainage coming from the open blister. The note further revealed the heating pad was removed and placed on the nursing cart for safety. RN #205 educated STNA #226 that heating pads were not allowed under any circumstance. STNA #226 informed RN #205 that the heating pad was in place when she arrived on her shift. STNA #226's shift was from 11:00 P.M. to 7:00 A.M. The nurse's notes did not contain any measurements of the area. There were no notes indicating physician notification of the burn to the left leg. There were no notes indicating any treatment was initiated or any care provided for the second degree burn on Resident #122's leg. Review of the physicians' orders and telephone orders dated for July 2015 and specific to 07/08/15 revealed there were no treatment orders obtained for the burn. Review of Certified Nurse Practitioner (CNP) #228's progress note dated 07/08/15 (no time) documented she was called to Resident #122's room due to unresponsiveness and he was sent out to the local hospital for respiratory distress. There was no documentation of a burn to the residents left leg thigh. Review of the SBAR (a facility incident report) dated 07/08/15 at 9:47 A.M., documented Resident #122 was sent out due to respiratory distress, lethargy and vital sign abnormalities. There was nothing documented about the burn to the left leg. Review of the Incident/Accident logs for the past three months documented on 07/08/15 Resident #122 had a burn; there were no other residents [MEDICAL CONDITION] the log. Review of the hospital history and physical dated 07/08/15 revealed the facility reported the resident had an acute change in mental status and became lethargic with difficulty breathing. Upon a physical exam a second degree burn was identified to the dorsal aspect of the residents' left lower extremity. The report indicated the skin burn was due to an electric heating pad left on Resident #122's skin for more than 12 hours. Initial inspection of the left lower extremity revealed significant denudation of the skin on the entire posterior thigh; they were concerned for a burn to this area secondary to heating pad. The social worker was at the bedside as well and confirmed the area of denuded skin without localized infection. The report indicated Resident #122 may have had a sleeping episode or prolonged therapy on this area. Review of the SRI dated 07/09/15 at 9:29 A.M. documented the facility was made aware by the local hospital of an allegation of neglect to the state department of health for the burn Resident #122 sustained from the heating pad. Review of the investigation documentation revealed the facility became aware of the use of the heating pad in Resident #122's room when former Nurse #227 observed Resident #122's family placing the heating pad on the resident on 07/06/15 between 4:00 P.M. and 5:30 P.M. Review of a witness statement dated 07/08/15 documented STNA #169 observed the heating pad on Resident #122 on 07/07/15 at 5:00 P.M. Review of the witness statement dated 07/08/15 documented by RN #205 revealed STNA #226 came to her on 07/08/15 around 6:00 A.M. and asked if Resident #122's leg wound was supposed to be seeping. STNA #226 was asked what wound and she stated the one with the heating pad under it. RN #205 informed STNA #226 heating pads are not allowed and checked the leg and found blistering and contacted Unit Manager (UM) #216. Witness statement from Licensed Practical Nurse #227 dated 07/10/15 documented the sister had placed the heating pad underneath the resident on 07/07/15 after the afternoon care conference held at 2:00 P.M. and she documented staff had seen Resident #122 use it before. A witness statement from Resident #122's sister, dated 07/10/15 revealed she had switched on the heating pad underneath Resident #122 on 07/07/15 after she had attended the care conference. The statement revealed she did not notify staff that she had switched it on but stated staff was aware Resident #122 had the heating pad. STNA #226's witness statement dated 07/12/15, revealed she saw the heating pad underneath Resident #122 and thought it was part of his treatment and she provided care to him throughout the night. A witness statement dated 07/29/15 documented UM #216 was called to the room due to a wound on Resident #122's left leg. She was told there was a heating pad found underneath the left leg and it had been removed. She found a large wound to left leg on posterior side which resembled a burn. It appeared there was a very large area that had blistered and ruptured and the outer layer of skin came off. The open area extended from the back of the thigh to just below the knee. The exposed tissue was pink with serosanguinous drainage and the Assistant Director of Nursing (ADON) #33, who was making wound rounds with wound CNP #230, was notified. The statement indicated that after CNP #230 left, the ADON would come and look at Resident #122's leg. By this time it was shift change and she (UM #216) was taking an assignment. Review of the witness statement signed by ADON #33, undated and no time, documented she was made aware of the resident having a change in condition and noted a large wound to the posterior left calf. The wound was beefy red and draining a large amount of clear yellow drainage. The wound was wrapped with [MEDICATION NAME] prior to being transported to the hospital. Resident #122 was transported to the hospital on [DATE] at 9:47 A.M. During an interview on 07/27/15 at 11:44 A.M., STNA #161 stated he had seen Resident #122 using the heating pad on 07/07/15. STNA #161 stated he never questioned the heating pad and did not remove it. He further stated he was unaware heating pads could not be used until they just had a training about this on 07/08/15 after Resident #122 was burned. During an interview on 07/27/15 at 3:48 P.M., VPRM #224 stated Resident #122 was harmed with the heating pad. VPRM #224 stated the family brought it in and placed it on him. VPRM #224 confirmed staff were aware of the use of the heating pad and did not remove the heating pad or notify anyone when they saw it. During attempted phone interviews on 07/28/15 at 11:45 A.M., former Nurse #227 and STNA #226 could not be reached as their phone numbers had been disconnected. During an interview on 07/28/15 at 12:07 P.M., RN #205 stated she worked night shift on 07/07/15 and on 07/08/15 from 7:00 P.M. to 7:00 A.M. She stated that she did not actually see the heating pad on Resident #122 during the night. She said around 6:00 A.M. on 07/08/15, STNA #226 came to her and said Resident #122's left leg wound was seeping and she then looked at the Treatment Administration Record (TAR) to verify there was not a new wound. When she went into Resident #122's room she observed the heating pad tucked under the fitted sheet underneath the residents left thigh. She removed the heating pad and went to get UM #216 to observe the area with her. RN #205 stated there were blisters on the back of the left thigh and open areas on the left calf as she pointed to her own leg and showed the areas of the wound covered from about two inches from the gluteal fold to mid-calf. She stated it was pink and red and very large area. She further confirmed she did not call the doctor to obtain an order for [REDACTED].#216 said the wound nurse would come up and look at it. RN #205 confirmed she did not provide any treatment to the burn. During an interview on 07/29/15 at 10:54 A.M., CNP #228 said she was never notified about a burn on Resident #122. She stated she did go into Resident #122's room on 07/08/15 between 8:30 A.M. and 9:00 A.M., when UM #216 said he (Resident #122) had a mental status change and this is when she observed the huge area from the knee up to the thigh and the skin was just raw. Through listening to the staff in the room she was made aware a heating pad was left on his left thigh for a long period of time and was discovered earlier that morning. She confirmed she was never called or notified of the burn. She further confirmed the symptoms of lethargy and [MEDICAL CONDITION] (low blood pressure) could be attributed to the burn and of course at this time she was more concerned about getting him sent out to the local emergency room . She further confirmed she did not order heat therapy for Resident #122. During an interview on 07/29/15 at 2:26 P.M., Maintenance Supervisor #108 and Corporate Maintenance #229 said heating pads have never been allowed in the facility and all staff should get this training in orientation. If something is observed by staff without a maintenance tag they should remove it and notify maintenance. They both confirmed they were not notified about Resident #122 having a Conair moist heating pad. During an observation of the heating pad at the time of the interview, the Administrator, Maintenance Supervisor #108 and Corporate Maintenance #229 confirmed there was no maintenance inspection tag on the heating pad. It was a Conair moist heating pad with one switch (on or off) and had no safety shut off. The dimensions were 12 inches by 15 inches. During an interview on 07/29/15 at 3:07 P.M., UM #216 stated she went in with RN #205 to look at the burn and it was a pretty extensive burn. UM #216 stated she did not call the physician. She stated she knew ADON #33, who is the wound nurse, was in the building so she notified ADON #33 who was doing wound rounds. She stated she was not aware if ADON #33 came up to see him because she began passing medications. UM #216 affirmed she did not provide any treatment to the burn. During an interview on 07/29/15 at 3:20 P.M., ADON #33 said she was in the building with wound CNP #230 and she remembered getting a text but the extent of the burn was not relayed. ADON #33 stated she did not have wound CNP #230 see the wound or notify her of this new area. ADON #33 stated she did not go into the room until he was being sent out to the local emergency room . She confirmed that when a resident is burned, staff should notify the physician and obtain an order to treat the burn. ADON #33 verified the physician was not notified of the second degree burn at the time of discovery and no orders were obtained to treat Resident #122 at that time. During an interview on 07/29/15 at 3:35 P.M., the DON stated she was just made aware of the nurses' failure to notify the physician and obtain treatment orders for a serious second degree burn as a result of this survey. During an interview on 07/29/15 at 4:14 P.M., STNA #169 said he saw the heating pad hanging on the bed and also being used and he did not know what it was for. He said he did have education after this incident and knows now to remove the heating pad from the room and notify nursing. During an interview on 07/29/15 at 4:20 P.M., the DON and VPRM #224 affirmed the nurses should have notified the physician and obtained treatment orders when the burn was first identified. They also stated part of staff orientation includes training on hazardous electrical devices and they are instructed that heating pads or any other electrical device should not be used. They stated staff should have known to remove the item and notify nursing if they did not know if this was part of the treatment or if it had an approved tag they should have questioned the nurse. During interviews on 07/30/15 between 1:30 P.M., and 2:10 P.M., RN #218 and LPNs #82, #84, #89, #90, #96 and #99 said they were given education about a change in condition before the start of their shift. All the above nurses said with any burn they would notify the doctor and get treatment orders. They stated if they were the one to find the area, they were responsible for following through with a newly discovered injury or area, and with a burn it needs to be cooled right when it happens. Review of the manufacturer instructions for use and warnings for the Conair moist heating pad one setting model number HP01RB, 120V AC 60Hz 49W, revealed to reduce the risk of burns, fires and electric shock this product must be used in accordance with the following instructions: · Do not use while sleeping · Do not use on or by an invalid, sleeping person or with poor blood circulation, unless carefully attended · Do not use on areas of insensitive skin · Burns can occur regardless of control setting check skin under pad frequently · Do not sit or lie on pad but rather place pad on person [MEDICAL CONDITION] result Review of the policy titled Preventive Maintenance Program revised 04/03/08 documented all equipment no matter ownership is subject to standards set by the facility. Inspection tag must be present on all electrical and mechanical items. Equipment within the resident environment is checked during the daily routine of both nursing and housekeeping. Review of the policy titled Change of condition revised 08/2007 is for staff to recognize and report significant changes in residents' status. The physician will be notified when significant changes in residents' condition, an accident involving the resident which results in injury and has the potential for requiring physician interventions. Review of the website www.mayoclinic.org <http://www.mayoclinic.org> for Burn First Aid revealed a second degree burn is more serious, it may cause red splotchy skin, swelling, very painful and blisters. If the burned area is larger (over three inches) or covers the hands, feet, face, groin, buttocks or major joint, treat it as a major burn and get medical help immediately. This deficiency substantiates Master Complaint Number OH 920 and Complaint Number OH 884.