Every finding on record at Inniswood Health and Rehabilitation

Based on observation, resident interview, and staff interview, the facility failed to ensure hot water temperatures were provided to residents to maintain a homelike environment. This affected seven (#8, #21, #25, #64, #70, #85, and #90) of seven residents observed for water temperatures on the 400 and 500 hallway. The census was 86. Findings include:Observation on 06/14/26 at 08:23 A.M. of the hot water temperature from the bathroom faucet in room [ROOM NUMBER], occupied by Resident #64, revealed the hot water was tepid to touch.Observation on 06/14/26 at 12:50 P.M. of room [ROOM NUMBER]'s hot water temperature from the bathroom faucet revealed the water was tepid to touch. Interview on 06/14/26 at 12:50 P.M. with Resident #70, the resident of room [ROOM NUMBER], revealed the hot water was always cold.Observation on 06/14/26 at 12:55 P.M. of the hot water temperature from the bathroom faucet in room [ROOM NUMBER], occupied by Resident #21 and Resident #90, revealed the hot water was tepid to touch. Interview on 06/14/26 at 12:55 P.M. with Resident #21, one of the residents of room [ROOM NUMBER], revealed the hot water was always cold.Interview on 06/15/26 at 9:16 A.M. with Maintenance Director (MD) #74 revealed the water temperatures of the 400 and 500 hallways were a little low, but the facility increased the temperature at the mixing valve with some improvement.Interview on 06/15/26 at 9:30 A.M. with Registered Nurse (RN) #79 revealed residents occasionally complained regarding the temperature of the water not being at preferred temperatures. RN #79 stated the staff allow the water to run longer to ensure the water was warm enough.Interview on 06/15/26 at 10:04 A.M. with the Director of Nursing (DON) revealed residents have complained in the past regarding hot water temperatures being too cold, but the complaints were received when the outside temperatures were approximately 10 degrees Fahrenheit (F).Interview on 06/15/26 at 11:07 A.M. with the Administrator revealed water temperatures were brought up in past Resident Council meetings in the context that the residents' requested the water run for while until the water gets to the residents' preference. The Administrator was unsure what date it was discussed in the Resident Council meeting.Interview on 06/16/26 at 7:29 A.M. with MD #74 revealed the water temperatures of the 400 and 500 hallway are low because of the distance from the hot water heater and the mixing valve.Observation on 06/16/26 from 7:29 A.M. to 7:45 A.M. of resident bathroom water temperatures on the 400 and 500 hallways, with MD #74, revealed a hot water temperature of 100.0 degrees F after allowing the water to run for two (2) minutes and 52 seconds for room [ROOM NUMBER], occupied by Resident #85, and a hot water temperature of 86.4 degrees F after allowing the water to run for one (1) minute and 57 seconds for room [ROOM NUMBER], occupied by Resident #8 and Resident #25. For each hot water temperature observation, MD #74 used the facility's thermometer, selected the rooms at random, and decided the maximum time to let the water run before providing the temperature.Interview on 6/16/26 at 7:55 A.M. with MD #74 confirmed the hot water temperatures obtained on the 400 and 500 hallway were too cold.Further observation on 06/16/26 from 7:59 A.M. to 8:06 A.M., with MD #74 and MD #124, of resident bathroom and facility shower room hot water temperatures on the 400 and 500 hallways revealed a hot water temperature of 98.4 degrees F after allowing the water to run for 2 minutes and 54 seconds for room [ROOM NUMBER] and a shower head hot water temperature of 92.8 degrees F after letting the water run for four (4) minutes and three (3) seconds for the 500 hallway shower room. For each hot water temperature observation, MD #74 used the facility's thermometer and decided the maximum time to let the water run before providing the temperature.Interview on 06/16/26 at 8:06 A.M. with MD #74 and MD #124 confirmed the hot water temperatures obtained were too cold.Interview on 06/16/26 at 9:15 A.M. with Resident #6 using Interpreter #204 revealed the resident reported the hot water temperatures were kind of cold.Interview on 06/16/26 at 9:19 A.M. with Resident #8 and Resident #25, occupants of room [ROOM NUMBER], revealed both residents reported the hot water temperatures in the room were kind of cold.Interview on 06/16/26 at 9:20 A.M. with Resident #85, occupant of room [ROOM NUMBER], revealed the hot water was cold when she took a bath and stated she can feel it in her bones.Interview on 06/16/26 at 8:43 A.M. with the Administrator revealed the facility did not have a policy for hot water temperatures to resident rooms.This deficiency represents non-compliance investigated under Complaint Number 3014949.

Based on record review, interview, and facility policy review, the facility failed to timely report an allegation of involuntary seclusion. This affected one, (Resident #94) of one resident reviewed for abuse. The facility census was 87.Findings include:Review of Former Resident #94's medical record revealed the resident was admitted on [DATE]. Diagnoses included seizure disorder, autism spectrum disorder, aphasia, and cognitive impairment.Review of the Minimum Data Set (MDS) assessment dated [DATE] and the Care Area Assessment (CAA) Trigger Summary dated 01/27/26 revealed the resident demonstrated severely impaired decision-making ability.Review of the Elopement Risk assessment dated [DATE] revealed the resident was independently mobile and exhibited wandering and exit-seeking behaviors, requiring supervision and monitoring for safety.Review of facility-provided email communication revealed no documentation of the reported incident involving placement of a Hoyer lift in front of the resident's door.Interview on 04/09/26 at 3:00 P.M. with Licensed Practical Nurse (LPN) #301 revealed LPN #301 worked on the day of the reported incident and confirmed that a Hoyer lift was positioned in front of Resident #94's door. LPN #301 stated the mechanism of how the lift came to be in that location was unknown.Interview on 04/09/26 at 11:40 A.M. with the Director of Nursing (DON) revealed the facility was notified of the allegation involving the Hoyer lift being placed in front of Resident #94's doorway. The DON stated the facility conducted an internal investigation but was unable to confirm the incident. The DON further stated that a Self-Reported Incident (SRI) was not submitted.Interview on 04/09/26 at 1:10 P.M. with the Administrator revealed during the time of this incident she was off on leave and there was another Administrator, Administrator #428 who was the acting Administrator during her absence. It was revealed according to Administrator #428, an SRI was not submitted after the allegation was reported. The Administrator stated, Administrator #428 contacted the resident's Power of Attorney (POA), who indicated no concerns regarding the reported situation. The Administrator confirmed based on this information, the incident was not reported to the State survey agency. The Administrator further stated under similar circumstances, an SRI would be expected to be submitted.Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, revealed the facility is required to report all allegations of abuse or potential abuse to the State survey agency within required timeframes and conduct a thorough investigation.

Based on observation, record review, and staff interview, and facility policy review, the facility failed to ensure appropriate transmission based precautions (TBP) were maintained for Residents #28 and #14. This had the potential to affect all 17 residents residing on the 100 hall. Additionally, the facility failed to ensure acceptable infection control practices were maintained while administering medications to Resident #36. This affected one resident (#36) of four residents reviewed for medication administration. The facility census was 74. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 08/29/22, with diagnoses including extended spectrum beta-lactamase (ESBL) resistance and a non-pressure chronic ulcer of the left lower leg. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #28's physician orders revealed an order dated 05/20/25 for active contact isolation precautions for ESBL (an enzyme produced by certain bacteria that make them resistant to many commonly used antibiotics) colonization in a wound. Observation on 06/30/25 at 12:16 P.M. revealed a staff member applied a gown prior to entering Resident #28's room. The staff member was not observed to apply gloves and proceeded to enter the room. A moment later, the staff member was observed exiting the Resident #28's room, who was in contact precautions, proceeded to retrieve gloves, and then re-entered Resident #28's room. Interview on 06/30/25 at 12:21 P.M. with Director of Nursing (DON) confirmed the unnamed staff member entered Resident #28's room, exited while still wearing personal protective equipment (PPE) to retrieve gloves, and then re-entered the room. The DON additionally confirmed the orders for Resident #28's contact precautions were active. 2. Review of the medical record for Resident #14 revealed an admission date of 08/01/18, with diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease, dementia with behavioral disturbance, and conjunctivitis. Review of the MDS quarterly assessment dated [DATE] revealed Resident #14 had a BIMS score of 7, indicating severely impaired cognition. Review of Resident #14's physician orders dated 06/19/25 revealed an order for contact isolation precautions for conjunctivitis every shift for 13 days, from 06/19/25 through 07/02/25. Observation on 06/30/25 at 12:20 P.M. revealed the DON entered Resident #14's room without any PPE to deliver a meal tray. Interview on 06/30/25 at 12:21 P.M. with the DON confirmed he stepped into Resident #14's room without putting on PPE prior to entering. The DON additionally confirmed the contact precaution orders for Resident #14 were active. Review of the facility policy titled Infection Control Policy/Procedure: Antibiotic Stewardship Program, revised April 2025, revealed the facility shall implement protocols to reduce adverse events associated with infection transmission, and that all staff shall adhere to protocols for the appropriate use of PPE. The policy emphasized the use of infection prevention strategies, including isolation precautions and staff compliance with PPE requirements, to reduce transmission risks. Section 4 of the policy stated that nursing staff are responsible for evaluating residents and following protocols, and Section 7 emphasized that the elements of the infection prevention program are to be implemented and reviewed regularly to ensure effectiveness. 3. Review of Resident # 36's medical record revealed that she was admitted on [DATE] with diagnoses that included COPD, cerebral infarction with left hemiplegia, type two diabetes mellitus, chronic pain, epilepsy, fibromyalgia, depression, and hypertension. Review of Resident #36's MDS Quarterly assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating intact cognition. Observation on 06/29/25 at 9:18 A.M. of the medication administration pass with Registered Nurse (RN) #192 revealed that he did not wash or sanitize his hands prior to preparing medications for Resident #36. RN #192 then removed three pharmacy packages for Resident #36 that had medication descriptions on the front and individually packed medication tablets inside of them. He opened the three pharmacy packages and placed the individually packed medication tablets on his nursing cart. He used his right first finger to guide each pill into the medication cup. RN #192 then placed the three empty pharmacy packages into the trash can that was attached to his nursing cart. RN #192 then explained that Resident #36 sometimes liked to know which medications she was receiving, and he took the three packages out of the trash can and entered Resident #36's room where he placed the packages which had previously been in the trash on Resident #36's bedside table. Resident #36 held each of the packages to read her medications as RN #192 explained each one. Interview on 06/29/25 at 9:35 A.M. with RN #192 confirmed that he did not wash or sanitize his hands prior to or after administering medications, and confirmed that he used his ungloved finger to touch each medications when preparing Resident #36's medications. RN #192 additionally confirmed that he placed the pharmacy packages that had been in the trash on Resident #36's bedside table. Review of the facility policy labeled Medication Administration, dated 06/21/27, revealed that the nurse should cleanse hands as appropriate and never touch any medications with fingers when preparing medications for administration.

Based on observation, interview, and record review, the facility failed to ensure Resident #52 was appropriately covered to maintain dignity and privacy. This affected one Resident (#52) of three residents reviewed for dignity. The facility census was 74. Findings include: Record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including chronic diastolic (congestive) heart failure, chronic kidney disease, and depression. Record Review of Resident #52's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required substantial/maximal assistance for toileting, showering/bathing, and lower body dressing. Resident #52 required supervision or touching assistance for rolling left to right and partial/moderate assistance with lying to sitting. Observation on 06/29/25 at 2:29 P.M. of Resident #52 revealed the resident was sleeping on her right side in bed with her back to the open door. Resident #52's incontinence brief was fully visible to the hallway. Observation on 06/30/25 from 8:24 A.M. to 8:39 A.M. of Resident #52 sleeping on her right side in bed. She was positioned with her back to the open door and her bare buttocks were visible from the hallway. Interview on 06/30/25 at 08:39 A.M. with the Director of Nursing (DON) confirmed Resident #52's bare buttocks were visible from hallway. The DON reported that Resident #52 thrashes and throws the bed covers off. Interview on 06/30/25 at 12:49 P.M. with Resident #52 and Resident #52's family revealed the family member reported it would not be good for her behind to be exposed. Resident #52 concurred that she would not want to be exposed in front of the open door.

Based on observation, resident interview, staff interview and record review, the facility failed to place a call light button in a location where Resident #16 was able to utilize the call light. This affected one resident (#16) out of seven residents reviewed for call light placement. The facility census was 74. Findings include: Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses included multiple sclerosis (MS), pressure ulcer of sacral region stage four, type two diabetes mellitus, need for assistance with personal care, need for assistance with personal care, osteoarthritis, and other reduced mobility. Review of a care plan dated 02/25/25 revealed Resident #16 required the use of a soft touch call light. The care plan referenced Resident #16 needed his call light positioned near his head so he could turn it on when in bed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitive intact. Resident #16 was noted to have impairment on both sides on both his upper and lower extremities, and was dependent on staff for eating, toileting, showering, dressing, hygiene, rolling left to right and transfers. Observation on 06/29/25 at 1:56 P.M. revealed Resident #16 was seated upright in bed with head bent over to the right in what appeared to be an awkward position. Resident #16's call light was on right side of bed and appeared out of reach. Interview on 06/29/25 at 1:56 P.M. with Resident #16 confirmed he was uncomfortable. Resident #16 confirmed he was unable to reposition himself and was unable to reach his call light. Resident #16 stated in order to use his call light he would need the call light to be placed on his stomach near his left hand. Observation on 06/30/25 from 10:38 A.M. to 11:50 A.M. revealed Resident #16 was lying in bed and his call light was dangling down off of the right side of the bed, almost touching the floor. Interview on 06/30/25 at 11:29 A.M. with Resident #16 confirmed he would not be able to press the call light if it were by his head. He said he needed it on his stomach near his left hand. Interview and observation on 06/30/25 at 11:50 A.M. with Certified Nursing Assistant (CNA) #151 confirmed Resident #16's call light was dangling down to the floor and he would not be able to reach it in that location. CNA #151 confirmed she would normally put the call light on the table and relocated the call light to the bedside table. When asked if Resident #16 would be able to reach the call light on the table, she hesitated and asked the resident who confirmed he needed the call light placed on his stomach in order to reach it. Observation and interview on 06/30/25 at 1:58 PM Resident #16 was sitting up in bed and had the call light button positioned under his right elbow. Resident #16 said he didn't know where the call light button was because he couldn't see it. Interview on 06/30/25 at 2:25 PM with MDS Licensed Practical Nurse (LPN) #175 confirmed she had just updated the care plan that day for Resident #16 to say the call light should be near head or on stomach. She said that his abilities were variable and acknowledged that at the present time he was not able to press call light button with his head. She said that when she met with him earlier that day he told her he needed it on his stomach. She confirmed Resident #16 would not be able to reach call light button on the table or dangling to the floor.

Based on observation, interview, and record review, the facility failed to provide nail care for one resident (#32) out of four residents reviewed for activities of daily living (ADLs). The facility census was 74. Findings include: Review of the medical record for Resident #32 revealed an admission date of 05/17/16. Medical diagnoses include dementia, cerebral infarction, hypertensive heart disease, chronic kidney disease, chronic pain, major depressive disorder, deaf and non-speaking, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severely impaired cognition. Resident #32 was noted to have impaired range of motion, required supervision for eating, and was dependent on staff for self-care and mobility. Review of the care plan dated 06/05/25 revealed a goal that Resident #32's ADL needs will be met through the next review date with listed interventions which included assisting the resident with shaving and nail care. Review of Resident #32's shower sheets for the month of June 2025 revealed his fingernails were clipped each shower day except for 06/09/25. The last shower sheet for June 2025 revealed Resident #32's nails were clipped on 06/26/25. Observation on 06/30/25 at 2:44 P.M. of Resident 32 revealed the resident was noted to have long, thick nails on his right, contracted hand. Interview on 06/30/25 at 2:22 P.M. with Licensed Practical Nurse (LPN) #177 revealed residents are to be offered nail trims on their scheduled shower or bathing days. Observation on 07/01/25 at 11:21 A.M. of Resident #32 with LPN #188 revealed Resident #32's fingernails on the right hand remained unchanged from the prior observation. Resident #32's fingernails appeared jagged and long, approximately one half inch in length. LPN #188 stated Resident #32's fingernails were too long and should be cut with each shower day. Interview on 07/01/25 at 11:57 A.M. with the Director of Nursing (DON) confirmed the facility did not have a policy for nail care.

Based on observation, interview, record review, review of facility policy, and review of the National Pressure Injury Advisory Panel recommendations, the facility failed to ensure interventions to prevent the development or decline of pressure ulcers were in place. This affected two residents (#16 and #228) out of three residents reviewed for pressure ulcers during the annual survey. The facility census was 74. Findings include: 1. Record review for Resident #228 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparesis, protein-calorie malnutrition, and altered mental status. Review of the care plan, dated 06/17/25, revealed Resident #228 was at risk for alteration in skin integrity. Interventions included pressure reduction boots as tolerated. Review of the physician order dated 06/26/25 revealed an order for prevalon boots (pressure reduction boots to offload pressure from a resident's heels) every shift. Observation on 06/29/25 at 11:24 A.M. revealed Resident #228 was lying in bed with bare feet lying flat against the mattress. No prevalon boots were present on the resident's feet or in the room. Observation on 06/30/25 at 8:14 A.M. revealed Resident #228 was lying in bed and again did not have prevalon boots in place on his feet. Interview on 06/30/25 at 8:14 A.M. with Nurse Manager #405 at the time of the observation confirmed Resident #228 did not have prevalon boots on his feet or present in his room. 2. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), pressure ulcer of sacral region stage four, type two diabetes mellitus, need for assistance with personal care, osteoarthritis, and other reduced mobility. Review of the care plan dated 01/14/25 revealed Resident #16 had alteration in skin integrity as evidenced by pressure ulcer present to his coccyx. Listed interventions included to administer treatments per physician order, staff to provide assistance with activities of daily living (ADLs) and repositioning as needed, and to encourage and assist the resident to turn and reposition as needed. An additional care plan focus dated 02/05/25 noted non-compliance and noted that Resident #16 had declined pressure reduction boots and was non-compliant with constrictive shoes. There were no other examples of noncompliance noted. Review of the Braden Scale for Predicting Pressure Sore Risk dated 05/14/25 revealed a score of 12 on a scale of 6 (high risk) to 23 (no risk), which indicated Resident #16 to be at high risk for skin breakdown. Review of the physician order dated 01/21/25 for staff to encourage/assist to turn and reposition as tolerated every shift. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitive intact. Resident #16 was noted to have impairment on both sides on both his upper and lower extremities, and was dependent for eating, toileting, showering, dressing, hygiene, rolling left to right, and transfers. Resident #16 was noted to have one stage 4 pressure ulcer that was not present upon admission to the facility. Review of the care plan dated 06/20/25 revealed Resident #16 was at risk for alteration in skin integrity related to MS, weakness, and impaired dexterity. Listed interventions included for staff to provide assistance with ADLs and positioning as needed and to encourage and assist resident to turn and reposition as needed. Observation on 06/29/25 at 1:56 P.M. Resident #16 was sitting up in bed with head at awkward position. The call light was on right side of bed in a place where he was not able to press it to ask to be repositioned. Interview on 06/29/25 at 1:56 P.M. Resident #16 confirmed he is unable to reposition himself. Resident #16 reported staff are supposed to reposition him every shift. Resident #16 reported sometimes the staff does not reposition him and that whether he gets repositioned would depends on which staff was working. Review of Progress Notes for Resident #16 for May 2025 and June 2025 revealed no documentation of Resident #16 refusing to be repositioned or turned. Interview on 06/30/25 at 2:25 P.M. with MDS Licensed Practical Nurse (LPN) #175 confirmed resident did not have care plan entry indicated he declined to be repositioned. Interview on 06/30/25 at 2:28 P.M. with the Administrator confirmed the facility did not have any documentation or care plan evidence of Resident #16 declining to be repositioned, as it had not been a problem with him. The Administrator noted staff only documents refusals if there are ongoing issues. Review of Wound Care Report from 06/23/25 revealed Resident #16 had a stage 4 pressure ulcer on his coccyx acquired in-house with full-thickness depth exposure, a wound size of 1.5 x 0.8 x 2.5 cm with 100% granulation and heavy seroanguinous exudate. The report noted that the wound had increased in size from the previous visit and was slightly expanded and deeper. The report said that the contributing factors included that the resident was poorly compliant with offloading, had overall poor medical condition, and incontinence. Interview on 06/30/25 at 2:50 P.M. with Wound Certified Nurse Practitioner (Wound CNP) #210 clarified that when she said Resident #16 was poorly compliant with offloading (removing pressure on coccyx) in her 06/23/25 report, she did not mean that Resident #16 was refusing to be turned, but rather he is unable to turn himself due to his medical condition. In regard to how frequently Resident #16 should be turned/repositioned, she said she would defer to the facility policy. She confirmed professional standards of care would normally expect a resident with a pressure ulcer to their coccyx to be repositioned/turned every two to three hours and that once every eight hours would not be enough. Review of the facility policy Skin Assessment revised 03/15/24 revealed risk factors impacting the development, treatment and/or healing of pressure injuries, including underlying medical conditions, intrinsic/extrinsic risk factors and causal factors are evaluated and provide the basis for defining approaches for the prevention and management of pressure injuries in accordance with the resident's needs, goals and professional standards of practice. Review of the National Pressure Injury Advisory Panel Quick Reference Guide recommendations dated February 2025 noted it is good practice to reposition individuals at risk of pressure injuries regardless of the type of pressure redistribution full body support surface being used. The frequency recommended is dependent on whether the individual is able to reposition themselves.

Based on observation, interview, and record review, the facility failed to ensure care and services to prevent the worsening of contractures were provided. This affected one resident (#23) out of four residents reviewed for limited range of motion. The facility census was 74. Findings include: Review of the medical record for Resident #23 revealed an admission date of 01/05/12. Medical diagnoses include myocardial infarction, contracture right hand, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, legal blindness, deaf nonspeaking, and adult failure to thrive. Resident #23 utilized an American Sign Language (ASL) interpreter and utilized tactile signing for communication. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a severe cognitive impairment and the Brief Interview for Mental Status (BIMS) score was unable to be completed. Resident #23 required supervision or touch assistance with self-care and mobility and utilized a manual wheelchair. The assessment further noted Resident #23's hearing and vision were highly impaired, and she had no speech. Resident #23 was noted to have received physical therapy services beginning on 03/26/25 and concluding on 04/23/25. Review of the care plan dated 05/30/25 for Resident #23 revealed the care plan did include any mention of the resident having a right hand contracture, nor did it include any goals or interventions addressing any type of contracture. Review of physician orders dated 06/11/25 did not include orders to address Resident #23's right hand contracture and included no current orders for occupational or physical therapy. Observation on 06/29/25 at 3:23 P.M. revealed Resident #23 had a contracted right hand with limited movement resting down at her side. Resident #23 did not have any type of splint or positioning device or equipment in use to her contracted extremity. There was no splint, hand roll, or any other type of device present at Resident #23's bedside. Interview on 06/30/25 at 11:35 A.M. with Director of Rehab Services (DRS) #101 revealed she was unsure if Resident #23 had a hand splint or adaptive device for her right hand contracture. DRS #101 stated that Resident #23 was evaluated for occupational therapy services on 06/30/25. DRS #101 confirmed there had been no care plan goals or interventions added to Resident #23's care plan regarding the contracture. Interview and observation on 06/30/25 at 4:54 P.M. with Resident #23, utilizing Interpreter #209, revealed the resident could not extend her contracted right fingers. Resident #23 could extend her pointer finger using left hand, but no other fingers were able to be manually extended by Resident #23. Interview on 07/01/25 at 11:27 A.M. with the Director of Nursing (DON) revealed no knowledge of Resident #23's contracture care and confirmed the facility had no policy regarding range of motion and/or care of contractures. Interview on 07/01/25 at 2:46 P.M with Licensed Practical Nurse (LPN) #188 confirmed no splint or range of motion exercises were a part of Resident #23's routine care.

Based on observations, interviews, and record reviews, the facility failed to ensure tube feeding solution was administered at the rate ordered by the physician and failed to ensure placement and residual were verified prior to using Resident #228's gastrostomy tube. This affected one resident (#228) out of one resident reviewed for gastrostomy tubes. The facility census was 74. Findings include: 1. Record review for Resident #228 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparesis, protein-calorie malnutrition, altered mental status, and encounter for gastrostomy tube. Review of the care plan, revised 06/27/25, revealed the resident had an alteration in nutrition and hydration. The resident was to have nothing by mouth and received 100 percent of calories through tube feeding. a. Review of the physicians order, dated 06/26/25, revealed the resident was to be administered Isosource 1.5 (a tube feeding formula) at a rate of 65 milliliters (ml) per hour by gastrostomy tube. Observation on 06/29/25 at 11:24 A.M. revealed Resident #228 was lying in bed with with Isosource 1.5 being administered at a rate of 60 ml per hour by gastrostomy tube. Observation on 06/29/25 at 12:43 P.M. revealed Resident #228 was lying in bed. Isosource 1.5 continued to be administered at a rate of 60 ml per hour by gastrostomy tube. Observation on 06/30/25 at 8:14 A.M. revealed Resident #228 was lying in bed. Isosource 1.5 continued to be administered at a rate of 60 ml per hour by gastrostomy tube. Interview on 06/30/25 at 8:14 A.M. with Nurse Manager #405 at the time of the observation confirmed Resident #228 was being administered Isosource 1.5 at a rate of 60 ml by gastrostomy tube and confirmed the physicians order was for 65 ml per hour of Isosource 1.5 to be administered. b. Review of Resident #228's clinical physician orders, dated 06/30/25, revealed the resident had orders for Keppra Oral Solution (an anticonvulsant) 100 milligrams (mg)/ml, give 5 ml via gastrostomy tube twice daily, Senna (laxative) 8.6 mg tablet, give one tablet via gastrostomy tube twice daily, Lisinopril (an antihypertensive) 20 mg tablet, give one tablet via gastrostomy tube once daily, Clopidogrel bisulfate (an antiplatelet) 75 mg tablet, give one tablet via gastrostomy tube once daily, famotidine 20 mg tablet, give one tablet via gastrostomy tube once daily, Baclofen (a skeletal muscle relaxant) 10 mg tablet, give one tablet via gastrostomy tube twice daily, aspirin 81 mg tablet, give one tablet via gastrostomy tube once daily and Amlodipine (an antihypertensive) 10 mg tablet, give one tablet via gastrostomy tube once daily. Resident #228's physician orders did not include orders for checking gastrostomy tube placement or residual (the amount of liquid or food remaining in the stomach after a period of enteral feeding). Observation on 06/29/2025 at 11:10 A.M. revealed Registered Nurse (RN) #192 prepared all scheduled medications for Resident #228. RN #192 proceeded to crush all oral medications together and placed the combined crushed tablets into a second cup. RN #192 was then observed adding approximately 60 cc's of water to the cup of combined tablets. Observations on 06/29/25 at 11:25 A.M. revealed RN #192 proceeded to administer Resident #228's crushed and combined medications via gastrostomy tube. RN #192 did not check Resident #228's gastrostomy tube for proper placement or check the tube feed residual prior to administering the crushed and combined medications. Interview on 06/29/25 at 11:37 A.M. with RN #192 following the observation confirmed that he should have checked Resident #228's gastrostomy tube for proper placement and residual prior to administering the medications. Review of the facility policy titled Enteral Tube Feeding dated 06/11/24, revealed it is the practice of the facility to provide enteral nutrition as prescribed and in accordance with current clinical standards of practice. The policy noted nurses should verify provider's prescription and check expiration date on formula, and confirm the placement of the feeding tube.

Based on medical record review, observation, and staff interview, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had seven errors out of 37 opportunities for a medication error rate of 18.9%. This affected one resident (#228) of four residents reviewed for medication administration. The facility census was 74. Findings include: Review of Resident #228's medical record revealed an admission date of 06/14/22 with diagnoses that included gastrostomy status, hypertension, cerebral infarction affecting the right dominant side, convulsions, dysphagia and peripheral vascular disease. Review of Resident #228's clinical physician orders, dated 06/26/25, revealed the resident had orders for Keppra Oral Solution (an anticonvulsant) 100 milligrams (mg) per milliliter (ml), give 5 ml via gastrostomy tube twice daily, Senna (laxative) 8.6 mg tablet, give one tablet via gastrostomy tube twice daily, Lisinopril (an antihypertensive) 20 mg tablet, give one tablet via gastrostomy tube once daily, Clopidogrel bisulfate (an antiplatelet) 75 mg tablet, give one tablet via gastrostomy tube once daily, famotidine 20 mg tablet, give one tablet via gastrostomy tube once daily, Baclofen (a skeletal muscle relaxant) 10 mg tablet, give one tablet via gastrostomy tube twice daily, aspirin 81 mg tablet, give one tablet via gastrostomy tube once daily and Amlodipine (an antihypertensive) 10 mg tablet, give one tablet via gastrostomy tube once daily. Resident #228's physician orders included an order to crush medications that are crushable as needed. There was no physician order to combine or cocktail medications together during administration. Observation on 06/29/2025 at 11:10 A.M. revealed Registered Nurse (RN) #192 began to gather all scheduled medication for Resident #228. RN #192 poured Keppra 5 ml (liquid) into a small medicine cup before proceeding to crush the oral medications in tablet form; Lisinopril 20 mg, Aspirin 81 mg, Famotidine 20 mg, Clopidogrel 75 mg, Baclofen 10 mg, Senna 8.6 mg, and Amlodipine 10 mg. The medications were crushed and combined together in a small drinking cup. RN #192 was then observed adding approximately 60 ml of water to the cup of combined tablets to dilute and mix the crushed medications. Observations on 06/29/25 at 11:25 A.M. revealed RN #192 proceeded to administer the crushed and combined tablets mixed with water to Resident #228 via his gastrostomy tube. Interview on 06/29/25 at 11:38 A.M. with RN #192 confirmed that he crushed and combined Resident #228's seven oral medications prior to administering them altogether to Resident #228 via gastrostomy tube. Review of a nursing journal article titled Administering medications through a gastrostomy tube dated December 2022, located at https://journals.lww.com/nursing/citation/2002/12000/administering_medication_through_a_gastrostomy.14.aspx, revealed that nurses should not mix medications with tube feeding formula or another medication.

Based on record review, staff interview, and facility policy review, the facility failed to ensure antibiotics were not administered unnecessarily for two residents (#17 and #26) out of three residents reviewed for urinary tract infections. The facility census was 74. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 01/22/21 and diagnoses including Parkinson's disease with dyskinesia, recurrent urinary tract infections (UTIs), chronic kidney disease, urinary retention, obstructive uropathy, and neurogenic bladder. Review of the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment also noted Resident #26 had an indwelling catheter, frequent incontinence, impaired mobility, and was dependent for many activities of daily living. Review of the physician orders for Resident #26 revealed an order dated 12/10/24 for Cephalexin (an antibiotic) 500 milligram (mg) three times daily for seven days to treat a UTI and an order dated 12/11/24 for phenazopyridine (a medication used to relieve pain, burning and discomfort commonly caused by a UTI) 200 mg, give one tablet by mouth after meals for two days for UTI. Review of the Medication Administration Record (MAR) dated December 2024 for Resident #26 confirmed both medications, Cephalexin and phenazopyridine, were administered for the full length of treatment as ordered. Review of a progress note dated 12/10/24 at 11:29 A.M. revealed Resident #26 was noted to have pain throughout the shift in her stomach and perineal area. Her urinary catheter was in place and patent. Resident #26's urine was noted to be a light brown color. The physician was notified and was in to assess the resident. Resident #26 requested to go to the emergency room. Resident #26 was transported to a local emergency room at approximately 10:45 A.M. and the resident's family was notified. A subsequent note dated 12/10/24 timed 5:56 P.M. revealed Resident #26 had returned from the hospital at approximately 5:45 P.M. Resident #26 was diagnosed with a UTI and new antibiotic orders were noted. Review of Resident #26's hospital record dated 12/10/24 revealed a urine culture had been collected at a local emergency room on [DATE], with the final report dated 12/13/24. The final report noted multiple organisms grew in the sample, and results suggested improper specimen collection or delay in delivery. If clinical condition warrants, laboratory suggests repeat specimen. The report further listed care coordination notes by a hospital provider dated 12/13/24 which stated Given symptoms of UTI and history of foley (indwelling urinary) catheterization, highly recommend repeat specimen collection. Continue taking antibiotic that has already been prescribed in the meantime. Further review of Resident #26's record revealed there was no evidence that laboratory testing, including a culture and sensitivity, was completed at the facility upon the resident's return to the facility to determine if the antibiotic prescribed was appropriate for treatment of the urinary tract infection. An interview conducted on 06/30/25 at 8:48 A.M. with Nurse Practitioner (NP) #200 confirmed that no repeat culture and sensitivity was obtained for Resident #26 in December 2024. NP #200 stated the antibiotic was prescribed for broad-spectrum coverage and was based on hospital discharge documentation without confirmation of effectiveness through laboratory results. An interview conducted on 06/30/25 at 12:07 P.M. with Regional Clinical Manager #205 confirmed that a culture and sensitivity was not completed after Resident #26 returned from the hospital in December 2024. She explained that when a resident returns from the hospital on an antibiotic, cultures may not provide accurate results due to active medication in the resident's system. However, she acknowledged that a follow-up culture and sensitivity should be obtained after the antibiotic course is completed, and confirmed this was not done. 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with medical diagnoses included non-traumatic brain dysfunction, hypertension, hyperlipidemia, and Alzheimer's disease. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #17 had a BIMS score of 07, indicating severely impaired cognition. The assessment documented the resident used a walker for ambulation, was independent for toileting hygiene, and was recorded to be always continent of bowel and bladder. Review of Resident #17's laboratory report dated 06/13/25 revealed there was no valid specimen received. There were no additional laboratory results identified in Resident #17's record to reflect a urinalysis and/or a urine culture and sensitivity was completed prior to initiating antibiotic therapy or to confirm that Resident #17 had a urinary tract infection and that the ordered antibiotic was appropriate to treat the resident's suspected urinary tract infection. Review of a progress note dated 06/14/25 at 1:45 P.M. indicated that the laboratory had notified staff that the urine specimen for Resident #17 needed to be resent. The note documented that the nurse was aware and attempting to recollect, and the Nurse Practitioner (NP) #200 was also notified. However, subsequent review of Resident #17's progress notes revealed no additional documentation was found indicating a new sample was collected for a urinalysis or that a culture and sensitivity was performed. Review of the physician orders for Resident #17 revealed an order dated 06/14/25 for Ciprofloxacin (an antibiotic) for a suspected urinary tract infection (UTI). The order called for Ciprofloxacin 500 mg, give one tablet by mouth two times a day for a suspected UTI for 7 days from 06/14/25 through 06/21/25. Review of the Medication Administration Record (MAR) for June 2025 confirmed Resident #17's Ciprofloxacin antibiotic was administered for the full course of the ordered seven-day treatment. An interview conducted on 06/30/25 at 8:00 A.M. with the Director of Nursing (DON) revealed Resident #17 did not have an additional urine culture completed as Resident #17 had stopped having symptoms after the initial specimen was deemed invalid. An interview conducted on 06/30/25 at 11:03 A.M. with NP #200 confirmed that no culture and sensitivity was obtained. NP #200 stated that Ciprofloxacin was prescribed for Resident #17 for broad-spectrum coverage. NP #200 acknowledged that although Ciprofloxacin was later continued for treatment of cellulitis, the indication on the order remained listed as treatment for a UTI. Review of the facility policy titled, Infection Control Policy/Procedure: Antibiotic Stewardship Program revised April 2025, revealed diagnostic testing shall be in accordance with the provider's order. Prescriptions for antibiotics shall specify the dose, duration, and indication for use. Reassessment of empiric antibiotics is conducted for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. Antibiotic orders shall be reviewed for appropriateness, including those obtained from consulting, specialty, or emergency providers.

Based on observations and interviews, the facility failed to ensure daily staffing information was posted for residents and visitors to view. This had the potential to affect all residents residing in the facility. The facility census was 74. Findings include: Observation on 06/29/25 at 9:20 A.M. revealed no daily staffing information was posted in the facility for residents and visitors to view. Observation and interview with the Administrator on 06/29/25 at 9:22 A.M. confirmed there was the previous day's schedule in the plastic holder located at the entrance desk of the facility. The Administrator confirmed it was the staffing schedule for 06/28/25 and the schedule for the current day 06/29/25 should have been in the plastic holder on display.

Based on staff interview, review of facility self-reported incidents (SRI's), medical record review and review of facility policy, the facility failed to ensure an incident of potential sexual abuse was timely reported to the Administrator and to the state agency. This affected two residents (#36 and #67) of three residents reviewed for abuse. The facility census was 72. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including hemiplegia affecting left side, adjustment disorder with anxiety, major depressive disorder, anxiety disorder, deaf, dysphagia, and history of unspecified adult abuse. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #67's medical record revealed an admitted [DATE] with diagnoses including schizophrenia, type two diabetes mellitus, schizoaffective disorder, major depressive disorder, sleep disorder, mild intellectual disabilities, mixed receptive-expressive language disorder, dysphagia, hypertension, and unspecified macular degeneration. Review of Resident #67's comprehensive MDS assessment dated [DATE] revealed moderate cognitive impairment. Review of the SRI created 12/24/24 at 8:33 A.M. revealed on 12/22/24 at 11:45 P.M. the night shift nurse found Resident #67 lying in Resident #36's bed on top of the covers with his pants down. Resident #36 was dressed and under the blankets. Resident #67 got out of bed and was directed out of the room. During subsequent interviews Resident #36 reported she was touched on the breast, but no sexual penetration took place. She reported she had been okay with it at the time but did not want it to happen again. Resident #67 was unable to be interviewed due to his cognition at the time but was moved to another hallway. Review of the printed texts to Licensed Piratical Nurse (LPN) #101 revealed on 12/24/24 a statement about the incident between Resident #67 and Resident #36 was requested and LPN #101 was told to always write a witness statement for similar situations. Interview on 01/21/25 at 10:11 A.M. with LPN #101 verified he did not timely report an incident of potential abuse. LPN #101 reported the night it occurred he got busy and distracted. In the morning, he notified his supervisor who said the (former) Director of Nursing (DON) needed notified, however, the DON had not been available. Interview on 01/21/25 at 1:38 P.M. with the DON verified the incident was not timely reported as an SRI. Review of the policy 'Abuse, Neglect, Exploitation, & misappropriation of Resident Property' dated 11/21/16, revealed all incident and allegations of abuse of a resident must be reported immediately to the Administrator or designee. Additionally, all alleged violations involving abuse are reported immediately, but not later than two hours after the allegation to the Administrator and the state survey agency. This deficiency represents noncompliance investigated under complaint OH00161124.

Based on staff interview, review of facility self-reported incidents (SRI's), medical record review, and review of facility policy, the facility failed to ensure an incident of potential sexual abuse was thoroughly investigated. This affected two residents (#36 and #67) of three residents reviewed for abuse. The facility census was 72. Findings include: Review of the SRI created 12/24/24 at 8:33 A.M. revealed on 12/22/24 at 11:45 P.M. the night shift nurse found Resident #67 lying in Resident #36's bed on top of the covers with his pants down. Resident #36 was dressed and under the blankets. Resident #67 got out of bed and was directed out of the room. During subsequent interviews Resident #36 reported she was touched on the breast, but no sexual penetration took place. She reported she had been okay with it at the time but did not want it to happen again. Resident #67 was unable to be interviewed due to his cognition at the time but was moved to another hallway. Review of the facility investigation revealed it included resident interviews, an email from the social worker explaining she had been unable to interview Resident #67, the electronic SRI, and a text message from Licensed Practical Nurse (LPN) #101. There were no additional staff interviews. Review of the printed texts to LPN #101 revealed on 12/24/24 a statement about the incident between Resident #67 and Resident #36 was requested. Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including hemiplegia affecting left side, adjustment disorder with anxiety, major depressive disorder, anxiety disorder, deaf, dysphagia, and history of unspecified adult abuse. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #67's medical record revealed an admitted [DATE] with diagnoses including schizophrenia, type two diabetes mellitus, schizoaffective disorder, major depressive disorder, sleep disorder, mild intellectual disabilities, mixed receptive-expressive language disorder, dysphagia, hypertension, and unspecified macular degeneration. Review of Resident #67's comprehensive MDS assessment dated [DATE] revealed moderate cognitive impairment. Interview on 01/21/25 at 8:17 A.M. with Manager of Clinical Services #110 at 8:17 A.M. revealed the facilities investigation for Resident #36 and #67 included resident interviews and one statement from staff. Interview on 01/21/25 at 1:38 P.M. with the Director of Nursing (DON) verified there were no additional staff statements related to the incident. Review of the policy 'Abuse, Neglect, Exploitation, & misappropriation of Resident Property' dated 11/21/16, revealed in response to allegations of abuse the facility must have evidence that all alleged violations are thoroughly investigated.

Based on observations, staff interview, and facility policy review, this facility failed to ensure medication carts were locked at all times unless in use and under direct observation of the medication administration personnel. This had the potential to affect all 26 residents who were noted to be mobile on the 300 and 500 unit. The facility census was 74. Findings include: Observation on 08/28/24 at 8:15 A.M. of Registered Nurse (RN) #34 completing medication administration for residents who resided on the 500 unit revealed this units medication cart was noted to be unlocked and RN #34 was not in view of this medication cart and was noted to be in a residents room. Observation completed on 08/28/24 at 8:39 A.M. of Licensed Practical Nurse (LPN) #160 administer morning medication revealed there was a medication that was not available in the 300 unit medication cart. LPN #160 was noted to leave the 300 unit medication cart unlocked and walk away from the cart to a different facility unit to obtained the needed medication from the facility's medication storage room. During this time, the medication cart on the 300 until remained unlocked and out of view of LPN #160. Interview on 08/28/24 at 8:40 A.M. with LPN #160 confirmed her medication was left unlocked while out of sight. Interview on 08/28/24 at 9:23 A.M. with RN #34 confirmed she had her medication cart had been left unlocked and out of sight earlier that morning. Review of the facility policy titled, Administration Procedures for All Medication revision date of 01/2018 revealed All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication administration personnel. This was an incidental finding identified during investigation for Complaint Number OH00155915.

Based on medical record review, medication administration observation, staff interviews, and medication administration policy review, the facility failed to ensure an medication error rate of 5% or less when medication that was noted to be delayed release was crushed, or capsule were opened during administration. Medication error rate was 9%. This affected two residents (Resident #6, and #32) of the four residents reviewed for medication administration. The facility census was 74. Findings included: 1. Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included dementia, depression, and osteoarthritis. Review of Resident #32's quarterly Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating an severely impaired cognition for daily decision making abilities. Review of the plan of care dated 06/26/23 revealed Resident #32 uses antidepressant medication related to depression and weight loss. Resident is at risk for complications related to antidepressant medication including, dry mucosa, constipation, urinary retention, suicidal ideation, and increased signs/symptoms of depression. Interventions include to give antidepressant medications as ordered by physician. Review of physician orders for Resident #32 revealed the following: -Duloxetine Hydrochloride (HCL) capsule, delayed release particles, 30 milligrams (MG), give one capsule by mouth daily for depression. Ordered 07/25/2024. -May crush appropriate medications, ordered 08/28/24. -Regular diet, with regular texture, regular/thin consistency liquids. Ordered 04/26/21. Observation completed on 08/28/24 at 8:39 A.M. of Licensed Practical Nurse (LPN) #160 administer morning medication revealed after pulling the capsule Duloxetine HCL from the medication cart, LPN #160 proceeded to open the capsule up and release the sprinkles into a medication cup with pudding along with other medication that had been crushed for this resident. Also during this time, LPN #160 was noted to need medication from the medication stock room which this nurse was noted to walk away from her medication cart on two different occasions while leaving her medication cart unlocked while out of view. Interview on 08/28/24 at 8:40 A.M. with LPN #160 confirmed Resident #32 was ordered the medication Duloxetine HCL delayed release capsule which she just administered to this resident by opening the capsule and placing the sprinkles into a medication cup with other crushed medication and pudding for administration. LPN #160 verified when a medication is delayed released, it is not to be opened or crushed as this will alter the delayed release of the medication. 2. Review of the medical record review for Resident #6 revealed an admitted [DATE]. Diagnoses included paranoid schizophrenia, dementia, and conversion disorder with seizures or convulsions. Review of Resident #6's quarterly Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 out of 15 indicating an severely impaired cognition for daily decision making abilities. Review of care plan dated 12/19/23 and revised 03/19/24 revealed Resident #6 had a seizure disorder related to past cerebral vascular accident. Interventions included to administer medication as per physician orders. Review of physician orders for Resident #6 revealed the following: -Divalproex Sodium oral tablet delayed release 250 milligram (mg). Give one tablet by mouth three times a day for convulsions. Ordered 11/28/23. -Regular diet, pureed texture, nectar thick consistency fluids. Ordered 03/25/24. Observation on 08/28/24 at 9:21 A.M. of Registered Nurse (RN) #34 administering medication for Resident #6 revealed the medication Divalproex Sodium, delayed release tablet was placed into a small plastic pouch along with other medication which was then then crushed into a powder form. All crushed medications were then placed into a medication cup along with pudding and administered to Resident #6. Interview on 08/28/24 at 9:23 A.M. with RN #34 confirmed she crushed the Divalproex Sodium medication which was also noted to be a delayed release medication and not to be crushed. Review of facility policy titled Administration Procedures for All Medications, revised date of 01/2018 revealed C. Review 5 Rights (3) times: 2) Prior to removing the medication from the container, a. Check the label against the order on the medication administration record. b. Note any special labeling that applies (fractional tablet, multiple tablet,s volume of liquid, shake well, give with another medication, etc.). This deficiency represents non-compliance investigated under Complaint Number OH00155915.

Based on medication administration observation, staff interview and facility policy review, this facility failed to ensure infection control measures were maintained during medication administration. This affected two residents (Resident #32 and #42) out of the four residents observed during medication administration. The facility census was 74. Findings include: 1. Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included dementia, depression, and osteoarthritis. Review of Resident #32's quarterly Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating an severely impaired cognition for daily decision making abilities. Review of the plan of care dated 06/26/23 revealed Resident #32 uses antidepressant medication related to depression and weight loss. Resident is at risk for complications related to antidepressant medication including, dry mucous, constipation, urinary retention, suicidal ideation, and increased signs/symptoms of depression. Interventions include to give antidepressant medications as ordered by physician. Observation on 08/28/24 at 8:39 of Licensed Practical Nurse (LPN) #160 removing medication from the medication bottle revealed this nurse using her ungloved thumb to pull multiple tablets of Vitamin D 3 25 microgram (mcg) from the bottle and placing them into a medication cup for administration. Continued observation completed on 08/28/24 at 8:40 A.M. of LPN #160 revealed this nurse grabbing a pair of gloves from the box on the medication cart when one glove was put on and the other glove was dropped. LPN #160 was observed picking that glove up off the floor with her gloved hand, throwing it away, followed by grabbing another glove from the box and putting that new glove on. Hand hygiene was not completed after picking the glove up off the floor and prior to touching a resident's medication with that same gloved hand. Interview on 08/28/24 at 8:40 A.M. with LPN #160 confirmed she used her bare hands to obtain medication from a medication bottle follow by placing that medication into a medication cup for administration. LPN #160 also confirmed she had dropped a glove on the floor and using her one gloved hand, picked the glove up off the floor and failed to complete hand hygiene as per facility policy. 2. Review of the medical record for Resident #42 revealed an initial admitted [DATE] and a re-entry date of 07/29/22. Diagnoses included cerebral palsy, dysphasia, and Vitamin D deficiency. Review of Resident #42's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Review of physician orders for Resident #42 revealed the following: -Labetalol Hydrochloride (HCL) 300 milligrams (mg) tablet, give one tablet daily for hypertension. Ordered 07/30/22. -Losartan Potassium-HCTZ 50-12.5 mg tablet, give one tablet by mouth daily for hypertension. Ordered on 07/15/23. -Multiple Vitamins-minerals tablet, give one tablet by mouth daily for supplement. Ordered 10/21/22. -Pioglitazone HCL 15 mg tablet, give one tablet by mouth daily for diabetes. Ordered 07/30/22. -Vitamin D oral tablet, give 2000 units by mouth daily for Vitamin D deficiency. -House protein supplement, give 30 milliliters (ml) by mouth two times a day for wound healing. Ordered 01/26/23. Observation on 08/28/24 at 9:12 A.M. of LPN #147 pulling medication for Resident #42 revealed this nurse was noted to pop each medication out of the medication card or medication bottle, place the medication directly into her hand and them place the medication into a medication cup for administration. Interview on 08/28/24 at 9:14 A.M. with LPN #147 confirmed she had touched each medication tablet or capsule prior to placing the medication into a cup for administration without wearing gloves. LPN #147 verified per facility policy she should wear gloves when handling medication but always forgets. Review of the facility policy titled Medication Administration-General Guidelines, revision date of 01/2018 revealed 2) Hand washing and Hand Sanitization: The person administering medication adheres to good hand hygiene, before beginning a medication pass, prior to handling any medications, after coming into direct contact with a resident. Review of the facility policy titled Hand Hygiene,: revision date of 06/06/2023 revealed Alcohol-Based Hand Rub (ABHR) is to be used before donning gloves, after removing gloves. This was an incidental finding identified during investigation for Complaint Number OH00155915.

Based on observation, medical record review, hospital record review, staff, physician and Registered Dietician (RD) interview, review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, contract reviews, and facility policy review, the facility failed to ensure Resident #32, who was identified at nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring weights and nutritional status, physician and dietitian notification for weight loss and implementation of nutrition interventions to prevent severe weight loss. This resulted in Immediate Jeopardy and actual harm for Resident #32, who experienced severe weight loss from 09/07/23 to 10/04/23 when she lost 19.9 pounds, representing a weight loss of 10.05% in one month (September to October 2023); 6.5% from October to November and 6.0% from November to December 2023 with a total weight loss over this time period of 21.6 % of her body weight (a 43 pound weight loss) due to the facility repeated and systemic failures to assess and address the resident's nutritional status and to implement pertinent interventions based on such an assessment resulting in continued significant/severe weight loss and functional decline. The resident was admitted to the hospital on 01/23/24 and returned to the facility on [DATE], continuing to lose weight. Additionally, a concern that did not rise to an Immediate Jeopardy occurred when the facility failed to monitor weights per physician orders and notify the physician and/or dietician of weight loss for Resident #49. This affected two residents (#32 and #49) of 11 residents reviewed for nutrition. The facility census was 83. On 01/25/24 at 3:35 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 10/04/23 when Resident #32 experienced a severe weight loss of 19.9 pounds/10.05% of her body weight in a one month period of time (September to October 2023); 6.5% from October to November 2023 and 6.0% from November to December 2023 with a total weight loss over this time period of 21.6 % of the resident's body weight (43 pounds) with the weight loss not being comprehensively addressed and monitored ultimately leading to the resident being given the diagnoses of malnutrition related to poor intake and a subsequent admission to the hospital. The Immediate Jeopardy was removed on 01/29/24 when the facility implemented the following corrective actions: On 01/23/24 Resident #32 was transferred to the hospital for evaluation and treatment related to pneumonia, urinary tract infection (UTI), sepsis, diverticulitis, abdominal pain and nausea/vomiting. The resident was readmitted to the facility on [DATE]. The facility implemented a plan for the resident to be encouraged and assisted to attend the assist dining room for lunch and dinner to encourage increase intake of meals. Resident #32's supplement order was modified to include the percentage of intake of the supplement by the Director of Nursing (DON) on 01/25/24. The resident's plan of care was updated on 01/25/24 to review the weight loss. Registered Dietician (RD) #500 reviewed the resident and recommended to continue the supplements as ordered. Resident #32 was started on an appetite stimulant (Remeron) on 01/26/24. On 01/29/24 Dietary Manager (DM) #115 updated Resident #32's food likes and dislikes and on 01/30/24 Resident #32's house supplement was discontinued and an order for mighty shakes three times a day was added. On 01/25/24 at 4:30 P.M. DON and Unit Managers #176 and #213 began in-person re-education for all direct care staff regarding the facility's weight loss policy and procedure. The direct care staff would be educated on the process for documenting the percentage of food intake at meals and the need to notify the nurse and/or dietician when there was a decrease in a meal or supplement intake that may need to be addressed. The direct care staff would document supplement intakes on the Medication Administration Record (MAR) via supplementary documentation. The direct care staff would document meal intakes on the point of care (POC) charting. Direct care staff would not be permitted to work until they have received the education. As of 01/26/24 there were 7 Registered Nurses (RN), 12 Licensed Practical Nurses (LPN), and 20 State tested Nursing Assistant (STNA) who were educated. The clinical management team would be present at shift change to ensure staff did not work prior to being educated. The facility has 13 staff members RN #166, LPN #126, #283, #321 and STNA #122, #124, #168, #211, #259, #311, #320, #340 and #343 out of the country who would not be permitted to work until the education was provided by the clinical management team. On 01/25/24, the facility re-implemented their Weight Change policy. The policy included how to respond to weight loss and significant weight loss and how it should be communicated to the Interdisciplinary Team (IDT), Physician #502, and responsible party. Direct care staff would obtain the weight; if a significant change was identified, they would notify the unit manager assigned to their hallway; that Unit Manager would initiate the standing orders, and contact the physician and dietician for recommendations. On 01/26/24, the DON and Unit Manager #176 reviewed the weights of 82 residents in the facility for undesired significant changes. Seven residents, Resident #1, #9, #31, #42, #46, #57 and #76 triggered for a greater than 5 pound (lb) weight loss. For any residents who were triggered for weight loss during this review, the diet tech and physician were notified by the unit manager or designee (on 1/26/2024 at 11:41 A.M.). The Diet Tech and physician assessed the residents and recommendations were received by 1/27/2024. All residents who triggered were interviewed and/or family interviewed. Moving forward the care conference form has been updated to review nutrition as a systemic approach to address the individual needs of each resident. All residents who triggered to have an undesired weight loss would be reviewed by the IDT team, DON, Unit Manager #176, #213, Licensed Social Worker (LSW) #251, Administrator, Licensed Nursing Home Administrator (LNHA) #110, during the weekly risk meeting. The new weight review would be added to the weekly risk meeting beginning 1/29/2024. Standing orders for house supplements were in place for residents triggering for an undesired weight loss as recommended by the physicians on 1/26/2024. The Unit Managers #176 and #213 would enter the order during the daily IDT meeting. The RD/DR would also be part of the weekly meeting and updates would also be provided at that time. On 01/26/24 supplement orders for Residents #3, #5, #7, #9, #12, #14, #16, #17, #18, #19, #23, #24, #30, #32, 335, #36, #37, #39, #40, #42, #45, #47, #48, #52, #53, #54, #56, #57, #58, #59, #60, #64, #70, #72, #73, #76, #81 and #84 were modified by Unit Manager #176 to track intake percentages for residents who were at risk for weight loss. The documentation would be located in the resident's MAR under supplementary documentation. The facility implemented a plan for the IDT Team to review food intakes for all residents during the weekly risk meeting beginning 01/29/24. On 01/26/24, an ad hoc Quality Assessment Performance Improvement (QAPI) meeting was held with Physician #501, the Administrator, the DON, Regional Registered Dietician (RRD) #503, Unit Manager #176, LNHA #110, Registered Nurse (RN) #508 and RN #510, to discuss the plan of action. The facility also reviewed the re-implemented weight policy for any changes. On 01/29/24 at 12:00 P.M., the Administrator, DON, and RD #500 discussed alternative supplement options (if the resident prefers a different supplement than the one as part of the standing orders). The Dietician/Diet Tech would be attending the communities risk management meeting beginning the week of 01/29/2024 and weekly, thereafter. On 01/29/24 at 12:25 P.M. Resident #32 was interviewed for updated preferences In addition, the resident food committee meets the first Friday of each month to review the menu and add preferences. The facility implemented a plan for the DON/designee to audit 10 resident records three times a week to ensure that meal and supplement intakes were being documented, weights were being obtained in accordance with the plan of care, weight changes were being reported to the IDT and physician as appropriate, and interventions were implemented related to weight changes. The audits would begin on 01/29/24 and continue for 12 weeks. Although the Immediate Jeopardy was removed on 01/29/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #32's medical record revealed an admitted [DATE] with a re-admitted [DATE]. The resident's diagnoses included encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf and nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the resident is at risk for altered nutrition/hydration related to diagnoses encephalopathy, diabetes mellitus, developmental disabilities (DD), vitamin D deficiency, depression, anxiety, history of need for therapeutic diet, usually good by mouth intakes, abnormal labs, body mass index (BMI) indicates obesity and refuses weights occasionally plan of care, dated 04/04/22, revealed interventions which included to educate resident/representative regarding nutritional needs and requirements, modify diet as appropriate according to resident's food tolerance and preferences, monitor for alteration in chewing or swallowing status, alert physician and speech therapy (ST) as needed, provide diet as ordered, encourage intakes of diet and fluids, assist with meals as needed, provide medications as ordered, report to physician any signs/symptoms of dysphagia (swallowing difficulty) report to physician as needed any signs/symptoms of malnutrition, report the physician any signs/symptoms of dehydration, weights as ordered. The care plan also reflected the following weight documentation: On 10/12/23 significant weight loss at one week/30/90/180 days, 11/02/23 significant weight loss at 30/90/180 days, 11/28/23 significant weight loss with varied meals and abnormal labs, 01/15/24 significant weight loss at 90 and 180 days. Review of the resident's re-admission initial nursing assessment dated [DATE], authored by Licensed Practical Nurse (LPN) #191, revealed the resident required set-up, supervision with meals, was non-weight bearing to the right leg and required two staff members with bed mobility and transfers. Review of the medical record revealed no re-admission weight and the first documented weight following the resident's re-admission was obtained on 08/25/23 at 202.7 pounds. Review of the resident's meal percentage intakes for August 2023 revealed the facility failed to document the resident's meal intakes on the following days: 08/06/23, 08/07/23, 08/10/23 for lunch and dinner, 08/14/23, 08/19/23, 08/20/23, 08/21/23, and 08/24/23 for the dinner meal. Review of the resident's weights revealed from 08/25/23 (202.7 pounds) to 09/07/23 (197.9 pounds) the resident had a weight loss of 4.8 pounds or (2.37%) weight loss in 13 days. Review of the resident's meal percentage intakes for September 2023 revealed the facility failed to document the resident's meal intakes on the following days: 09/03/23, 09/04/23 for the dinner meal, 09/07/23, 09/08/23, 09/09/23, 09/17/23, 09/18/23, 09/22/23, 09/25/23, 09/27/23, 09/29/23 and 09/30/23. Review of the resident's weights revealed from 09/07/23 (197.9 pounds) to 10/04/23 (178.0 pounds) the resident had a weight loss of 19.9 pounds or (10.05 %) weight loss in one month. Review of the resident's progress notes revealed no documented evidence Registered Dietician (RD) #500 or Physician #502 were notified of the significant weight loss of 19.9 pounds or 10.05 % in one month until 10/16/23. Further review revealed RD #500 recommended to add house supplement 2.0 240 milliliters (ml) daily and notify the physician or Certified Nurse Practitioner (CNP) of the significant weight loss. The RD was to continue to monitor weight trend and follow up as needed. Review of the resident's physician orders revealed the house supplement 240 ml by mouth daily recommendation from RD #500 was not implemented by the facility until 10/27/23. Review of the resident's weights from 10/04/23 (178 pounds) to 11/01/23 (166.5 pounds) revealed the resident had a significant weight loss of 11.5 pounds or 6.5 % of her total body weight loss in 28 days. Further review of the medical record revealed no documented evidence that the physician was notified of the significant weight loss. Review of the resident's meal percentage intakes for October 2023 revealed the facility failed to document the resident's meal intakes on the following days: 10/05/23, 10/06/23, 10/09/23, 10/13/23, 10/14/23, 10/16/23, 10/17/23, 10/19/23, 10/20/23, 10/21/23, 10/23/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23 and 10/31/23. Review of the Medication Administration Record (MAR) for October 2023 revealed the facility failed to document the percentage of the house supplement consumed. Review of the resident's weights from 11/01/23 (166.5 pounds) to 12/14/23 (156.5 pounds) revealed the resident had a significant weight loss of 10 pounds or 6% weight loss. Review of the weight change note dated 11/02/23 at 12:48 P.M., authored by RD #500, revealed the resident had a significant weight loss at 30/90/180 days and continued with a pressure ulcer to the right heel. The resident continued to receive a regular diet and had no recent meal intakes to review. The resident was receiving house supplement of 240 milliliters (ml) by mouth daily and 30 ml protein supplement twice daily. The note documented all supplements were accepted well. The RD recommended to increase the house supplement to 240 ml twice daily and continue to monitor weights weekly. Review of the medical record revealed the resident's weights were not obtained on 11/08/23 and 11/15/23 as physician ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the assessment revealed the resident had not rejected care. The assessment indicated the resident's weight was 161 pounds and she had a significant weight loss and was not on a prescribed weight loos regimen. Review of the dietary progress note dated 11/29/23, authored by RD #500 revealed the resident continued to have a significant weight loss of 7% in 30 days, 21% in 90 days and 21% in 180 days. The RD recommended to increase the house supplement to 240 ml three times a day, obtain weekly weights as physician ordered and notify the physician and/or CNP of the continued weight loss. Review of the physician's progress note dated 11/30/23, authored by Physician #502, revealed the physician was seeing the resident for unintentional weight loss. Following the review of the medical record the resident had lost approximately 40 pounds in the past six months. The physician gave orders to encourage by mouth intake, increase house supplement to 240 ml to three times a day and obtain weight weekly. Further review revealed the physician ordered a chest x-ray, calcium (CA) laboratory test, carcinoembryonic antigen (CEA) (a type of tumor marker used to monitor for cancer) laboratory test, complete metabolic panel laboratory and stool for guaiac three times (test used to detect blood in stool). Review of the medical record revealed no evidence the CEA, CA or the stool for guaiac three times had been obtained. Review of the resident's meal percentages intakes for November 2023 revealed the facility failed to document the resident's meal intakes on the following days: 11/02/23, 11/05/23, 11/06/23, 11/07/23 and 11/08/23. Review of the MAR for November 2023 revealed the facility failed to document the percentage of the house supplement consumed. Review of the medical record revealed the resident's weights were not obtained on 11/30/23 and 12/07/23 as physician ordered. Review of the resident's weight for 12/14/23 (156.5 pounds) revealed the resident had lost another four pounds or 2.5% weight loss in 22 days continuing the resident's weight loss trend. The medical record contained no documented evidence that the resident's physician or RD were notified of the continued weight loss. Review of the resident's weights revealed the physician ordered weight was not obtained on 12/21/23. Review of the physician progress note dated 12/21/23, authored by Physician #502, revealed the physician reviewed the resident's labs and the complete metabolic panel (CMP) supported the diagnoses of malnutrition with an Albumin low at 2.4 and protein low at 4.6. Further review of the physician progress note revealed the physician again ordered the labs CA, CEA and stool for guaiac three times due to them not being previously obtained. Review of the resident's weights revealed the physician ordered weight was not obtained on 01/04/24. Review of the resident's weight revealed on 01/11/24 the resident's weight was 152.6 pounds indicating another 3.4 pound or 2.18% weight loss continuing the weight loss trend. Review of the dietary progress note dated 01/15/24 at 10:44 A.M., authored by RD #500 revealed the resident had no significant weight loss in the past 30 days however, the resident had an 11% weight loss in the past 90 days and 25% weight loss in the past 180 days. Review of the resident's weights revealed no weight was obtained on 01/18/24 as ordered by the physician. Review of the MAR for January 2024 revealed the facility failed to document the percentage of house supplements consumed. Review of the resident's meal percentage intakes for January 2024 revealed the facility failed to document the resident's meal intakes on the following days: 01/19/24 and 01/20/24. The facility did not identify the resident's weight loss as a severe weight loss. Review of the Centers for Medicare and Medicaid guidance under the intent for 4383.25 (g) revealed the suggested parameters for evaluating the significance of unplanned and undesired weight loss defined severe weight loss as greater than five percent lost in one month; greater than 7.5% in three months and greater than 10% in six months. Observation on 01/23/24 at 12:40 P.M. revealed the resident was offered her lunch meal tray. The resident communicated via sign language to Licensed Practical Nurse (LPN) #219 that she wanted her meal. The resident was served her meal, in a disposable container, which consisted of an oven fried pork chop, buttered parsley noodles, veggie blend, a slice of wheat bread, a slice of creme pie and tea for beverage. A bowl of chicken noodle soup was also on the tray, in a disposable bowl. The resident consumed 75% of her pork chop and bread and began using sign language to communicate that she was sick to her stomach. Interview on 01/23/24 at 12:43 P.M. with LPN #219 revealed the resident had complaints of nausea for the past few days. The LPN shared she had administered Zofran (an anti-nausea medication) to the resident, but she continued to complain of nausea. She revealed the resident was independent with eating and had just recently stopped eating. The LPN revealed the resident only takes sips of the physician ordered supplement but refused it the majority of time. She stated she had not communicated to the physician or the management team the resident's refusal of the supplement or the resident's decreased appetite. Interview on 01/23/24 at 12:56 P.M. with the Director of Nursing (DON) verified the lack of an individualized nutritional plan to include monitoring weights and nutritional status, physician and dietitian notification for weight loss and implementation of nutrition interventions to prevent severe weight loss for Resident #32. Interview on 01/23/24 at 1:06 P.M. with RD #500 revealed she was aware of the significant weight loss the resident had experienced. The RD verified the resident's meal percentages were not documented consistently, the percentage of nutritional supplement consumed was not documented and weekly weights were not obtained. The RD revealed it was difficult to determine if interventions implemented were appropriate due to the lack of charting. The RD stated she would expect her recommendations to be implemented within three days of receiving. The RD verified she was never told the resident refused to be weighed or refused supplements. Lastly, the RD shared she had no additional interventions to implement and was waiting for the physician to implement an appetite stimulant. Interview on 01/23/24 at 4:10 P.M. with the DON verified the physician ordered lab tests CA, CEA and guaiac stools three times were not obtained when ordered on 11/30/23 and again on 12/16/23. The DON also verified this was not communicated with the physician. Further review of the medical record revealed the resident was transferred to the hospital on 01/23/24 due to vomiting and was admitted with sepsis due to unspecified organism, pneumonia of the right lower lobe due to infectious organism, nausea and vomiting, pain of upper abdomen, fecal impaction and acute urinary tract infection. Review of the hospital documentation dated 01/24/24 provided by the facility revealed the resident was admitted to the local acute care hospital after being transferred from the facility for the final diagnoses of sepsis due to unspecified organism, pneumonia of right lower lobe due to infectious organism, nausea and vomiting, pain of upper abdomen, fecal impaction, and acute urinary tract infection. Further review revealed the resident's weight on 01/24/24 (in the hospital) was 149 pounds continuing the weight loss trend. In addition, review of the hospital documentation revealed a bedside modified barium swallow (an x-ray test that takes pictures of the patient's mouth and throat while he or she swallows various foods and liquids) was completed. The resident displayed mild to moderate dysphagia due to impaired cognition, impulsiveness and overall disorganized bolus (a ball-like mixture of food and saliva that forms in the mouth during the process of chewing) formation. Recommendations were made for thickened liquids and an altered diet texture. When the resident returned to the facility on [DATE], the resident had a new diet order for mechanical soft (restricts difficult to chew foods) and nectar thickened liquids (the fluid consistency is altered to the consistency of nectar and aides in swallowing of those with difficulty swallowing). Interview on 01/25/24 at 9:23 A.M. with Physician #502 revealed the resident was given the diagnoses of malnutrition based on the CMP laboratory results and the weight loss. He revealed the facility had not notified him of the resident's trending weight loss, decreased oral intake, decreased and/or refusal of supplements and labs not being completed as he had ordered. Review of the nursing progress notes dated 01/25/24 at 6:29 P.M. revealed the resident would have new medications including a 10-day course of Cefdinir (antibiotic), insulin changes and the resident was oriented to her room and call light. Medications were confirmed with the nurse practitioner (unidentified) at the time of her re-admission from the hospital. Review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, effective 11/30/19 revealed the licensee monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals and intervention strategies to determine the progress made in achieving desired outcomes of nutrition care and whether planned interventions should be continued or revised. Nutrition monitoring and evaluation is the fourth step of the nutrition care process. Monitoring specifically refers to the review and measurement of the patient / client / group's status at a scheduled (preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans / goals and outcomes, whereas evaluation is the systematic comparison of current findings with previous status, intervention goals, or a reference standard. Monitoring and evaluation use selected outcome indicators (markers) that are relevant to the patient / client / group's defined needs, nutrition diagnosis, nutrition goals, and disease state. Review of the facility's contract with the RD, dated 01/24/20 included that RD would formulate nutritional assessments and care plans on all new admissions, make resident visitations, observe eating in rooms and dining areas, and monitor weight, skin, and hydration management programs. Review of the Medical Director (MD) Agreement dated 07/12/21 revealed the MD shall be responsible for the implementation of resident care policies and the coordination of medical care in the facility, overall coordination of physician services in the skilled nursing facility and wellness program. Maintains effective liaison with attending physicians and provides guidance to them regarding the implementation of facility patient care and documentation policies. Review of facility Weight Change policy, dated March 2018, revealed a significant weight loss was defined as five percent in one month, 7.5 percent in three months, and 10 percent in six months. Recheck weights were to be obtained for a five-pound loss or gain if resident weights over 100 pounds and a three-pound gain or loss on a resident weighing less than 100 pounds. A five-pound gain or loss on a resident weighing 100 pounds or more and three-pound gain or loss on a resident weighing less than 100 pounds would be reported to the dietician and physician. 37100 2. Resident #49 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, muscle weakness, acute respiratory failure with hypoxia, pressure ulcer of sacral region, urinary tract infection, dysphagia, congestive heart failure, encephalopathy, chronic obstructive pulmonary disease, dementia, attention deficit hyperactivity disorder, Alzheimer's disease, chronic kidney disease, atherosclerotic heart disease, depression, hypertension, anemia, and deaf nonspeaking. Review of his Minimum Data Set (MDS) assessment, dated 11/14/23, revealed the resident had a mild cognitive impairment. Review of Resident #49's weights revealed the following: On 07/11/23 (188 pounds), 08/14/23 (187.8 pounds), and 11/05/23 (175 pounds). No weight was obtained in December 2023 and no re-weights were obtained to verify the resident's weight loss. The resident's next weight was on 12/05/23, there was no documentation that a re-weight was taken in a timely manner to verify the weight loss. Review of Resident #49's physician orders revealed he was to be weighed once per month which by documentation was not occurring. Interview with the DON on 01/08/24 at 11:30 A.M. revealed staff were to notify the physician when the dietitian looked at the weights/nutritional status and made a new order. She confirmed staff do not notify the dietitian or physician when they take weights, and they had not been responsible to report significant changes; but rather the dietitian reviews this routinely. She confirmed the facility weight change policy was to notify the physician and dietitian when there was a change of five pounds or more. Review of facility Weight Change policy, dated March 2018, revealed a significant weight loss was defined as five percent in one month, 7.5 percent in three months, and 10 percent in six months. Recheck weights were to be obtained for a five-pound loss or gain if resident weights over 100 pounds and a three-pound gain or loss on a resident weighing less than 100 pounds. A five-pound gain or loss on a resident weighing 100 pounds or more and three-pound gain or loss on a resident weighing less than 100 pounds would be reported to the dietician and physician.

Based on observation, medical record review, interviews and facility policy review, the facility failed to implement adequate skin risk interventions for Resident #32 to prevent the development of a pressure ulcer. Actual harm occurred on 08/24/23 when Resident #32, who was readmitted to the facility on [DATE] with a displaced subtrochanteric fracture of right the femur with surgical repair and required extensive assistance with bed mobility for turning and repositioning developed a deep tissue injury (DTI) (A purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.) to the right heel. The resident reported an increased amount of pain due to the development of the pressure ulcer. In addition, it was the resident's physician who first identified the DTI while on site at the facility on 08/24/23. The facility failed to implement comprehensive and individualized interventions to prevent the development of the pressure ulcer and failed to properly assess, monitor, or implement skin interventions for the DTI until 08/31/23. Findings Include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with a re-admission of 08/18/23. Resident #32 had diagnoses including encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the plan of care dated 04/04/22 revealed the resident was at risk for an alteration to skin integrity related to encephalopathy, diabetes mellitus, osteoporosis, groin candidiasis and mood boots in bed as tolerated. Interventions included administer medications and treatments as ordered, encourage nutrition/hydration as needed, encourage/assist with daily hygiene as needed, keep skin clean, dry and odor free as tolerated, weekly skin assessment as tolerated and boots/heel protectors while in bed as tolerated was added to the plan of care. Review of the resident's weekly readmission skin assessment dated [DATE], authored by Licensed Practical Nurse (LPN) #191 revealed the resident was readmitted from an acute care hospital stay to the facility with no pressure ulcers/injuries. Review of the [NAME] scale dated 08/18/23 revealed a score of 10 indicating the resident was at high risk for skin breakdown. Review of the physician progress note dated 08/24/23, authored by Physician #502 revealed the physician was seeing the resident following an emergency room (ER) visit for hypoglycemia. Through interpreter the resident stated, she had a hole in her right heel and had a lot of pain there. Upon examination the resident's right heel was found to be black with eschar. The physician determined the resident had a DTI to the right heel and gave a new order to elevate the heel at that time. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the MDS revealed the resident had not rejected care. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers, toileting, dressing and personal hygiene and was non-ambulatory. The assessment indicated the resident was always incontinent of both bowel and bladder. The resident was assessed as being at high risk for skin breakdown and had no unhealed pressure ulcer/injuries. The MDS noted the facility implemented the intervention of pressure reducing device to bed and applications of ointments/medications other than to feet. Review of the plan of care dated 08/31/23 revealed the resident had a pressure ulcer to the right heel related to presence of fragile skin, weakness/deconditioning, decreased mobility and moon boots while in bed as tolerated. Interventions included administer medications as ordered, administer treatments as ordered, follow facility policies/protocols for prevention/treatment of skin breakdown, inform family/resident of any new areas of skin breakdown, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing process, report improvements and declines to physician, monitor dressing with rounds to ensure it is intact and adhering, report loose dressing to nurse, monitor nutritional status, serve diet as ordered, monitor intake and record, monitor/document/report to physician as needed changes in skin status and Prostat (liquid protein supplement used to promote wound healing) as ordered. Review of an initial weekly pressure ulcer form dated 08/31/23 revealed this wound was not identified by the facility until 08/31/23 despite the physician identifying the DTI on 08/24/23. The facility now classified the wound as an unstageable pressure ulcer measuring 3.0 centimeters (cm) by 2.0 cm. The wound was described as being black and had no exudate. The facility determined the wound had declined despite the assessment being the initial assessment. The facility implemented a treatment of Betadine daily to the pressure ulcer. Review of Wound Physician (WP) #501's initial progress note dated 09/05/23 revealed the resident had an unstageable DTI measuring 2.2 cm by 2.5 cm. The wound was partial thickness and had no exudate. The wound physician continued the Betadine daily and use of a pressure off-loading boot. Review of WP #501's progress note dated 09/19/23 revealed the wound was now classified as unstageable necrosis measuring 2.0 cm by 2.0 cm by 0.1 cm with 40% thick adherent devitalized necrotic tissue and 60% dermis/subcutaneous tissue. The wound had a moderate amount of serous drainage. The physician determined the wound had improved as evidenced by decreased surface area. The physician changed the treatment to cleanse the wound, apply Mesalt (a salt-impregnated gauze that is used for wound with moderate to heavy drainage, yellow slough, fibrin or infection. The dressing absorbs fluid from the wound and releases sodium chloride which has a cleansing and healing effect. The dressing helps to remove dead tissue and bacteria and prevents further bacterial growth.) and cover with a border gauze island dressing daily and use of pressure off-loading boot. The resident refused debridement of the wound during the visit. Record review revealed WP #501 completed progress notes on 09/26/23, 10/03/23, 10/10/23 10/17/23, 10/24/23 and 10/31/23. Each visit note reflected the resident continued with the unstageable necrosis to the right heel. WP #501 included measurements of the wound, amount of drainage present to the wound and was noted to remove necrotic tissue during the visits. There were no changes made to the wound treatments during this time. Review of the resident's medical record revealed no documented evidence the resident was noncompliant with wound care. Review of the October 2023 Treatment Administration Record (TAR) revealed the treatment to the resident's right heel of cleanse the right heel with normal saline, pat dry, apply Mesalt and cover with dry dressing daily was discontinued on 10/20/23. Further review revealed no evidence the facility initiated a new treatment to the right heel following the discontinuation of the treatment on 10/20/23. Review of the November 2023 TAR revealed the facility re-implemented the treatment on 11/01/23 to cleanse the unstageable necrosis to the right heel with normal saline, apply Mesalt and cover with dry dressing daily following WP #501's visit on 10/31/23. Review of the resident's medical record revealed the resident was seen by WP #501 on 11/07/23, 11/14/23 and 11/21/23 for wound care. Each visit note included the resident continued with the unstageable necrosis to the right heel with measurements and an assessment of the amount of drainage. On 11/07/23 and 11/14/23 the wound physician removed the necrotic tissue and established the margins of viable tissue with permission of the resident. On 11/21/23 the resident refused wound debridement during the visit. The physician made no changes in the treatment to the wound during this time. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the MDS revealed the resident had not rejected any care. The assessment indicated the resident was frequently incontinent of both bowel and bladder. The resident was assessed as being at high risk for skin breakdown and had one unstageable pressure ulcer not present on admission. Review of the resident's medical record revealed the resident was seen by WP #501 for wound care on 11/28/23, 12/05/23, 12/12/23 and 12/19/23 for continued care of the unstageable necrosis pressure ulcer to the right heel. Each visit contained the measurements of the pressure ulcer, presence/amount of drainage. The resident refused wound debridement on 11/28/23. Review of WP #501's progress note dated 12/19/23 revealed the physician classified the right heel pressure injury as a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) on this date. The wound measured 0.5 cm by 0.6 cm by 0.3 cm with the wound being 100% slough tissue. The wound had a moderate amount of serous drainage. The physician made no changes in the treatment to the wound. The wound physician determined the wound had improved as evidence by a decreased surface area. The resident was seen by WP #501 on 12/26/23, 01/02/24, 01/09/24, 01/16/24 and 01/23/24 for continued evaluation and assessment of the Stage IV pressure ulcer to the right heel. WP #501 documented the measurements of the ulcer, amount of drainage noted and whether also if the wound was debrided. The pressure ulcer was debrided during the 01/02/24 and 01/09/24 visits. During the visit on 01/16/24 the wound physician changed the resident's treatment order. A new treatment to apply Betadine daily to the Stage IV pressure ulcer and cover with a border gauze island dressing was ordered. Review of WP #501's progress note dated 01/23/24 revealed the Stage IV pressure injury measured 0.5 cm by 0.3 cm by 0.1 cm with the wound being 100% dermis. The wound had no exudate/drainage. The wound physician documented the wound was at goal and made no changes to the treatment. Observation on 01/25/24 at 9:15 A.M. of the assessment and treatment of the resident's right heel by WP #501 revealed he placed a barrier on the bed, removed the resident's Prevalon boot and measured the wound at 0.5 cm by 0.3 cm with a tan scab covering the wound. The physician then painted the wound with betadine and covered the wound with an island gauze dressing. Interview on 01/25/24 at 9:23 A.M. with Physician #502 revealed he was unaware the resident had no treatment in place from 10/20/23 to 11/01/23 to the right heel. Interview on 01/25/24 at 12:13 P.M. with the Director of Nursing (DON) verified the resident had inadequate skin interventions in place to prevent the DTI and the resident's pressure injury was not assessed, monitored or interventions implemented when identified on 08/24/23. The DON verified the resident's medical record had no documented evidence the resident refused skin interventions. The DON verified the resident went without a treatment from 10/20/23 to 10/31/23 when WP #501 identified the resident had no treatment in place. Observation on 01/29/24 at 2:30 P.M. of Resident #32 revealed she was laying in bed with the head of her bed elevated. The resident was observed with no heel protectors/boot in place as physician ordered. Registered Nurse (RN) #182 verified the resident's physician ordered heel protection was not in place at the time of the observation. However, review of the resident's January 2024 Treatment Administration Record (TAR) revealed the boot was initialed as being in place by RN #182. Review of the facility policy titled, Pressure Injury/Ulcer Prevention, last revised 06/14/23 revealed a resident who entered the facility without pressure injury or ulcers should not develop pressure injury/ulcers and/or other non-pressure ulcers, unless the resident's clinical condition demonstrates that they were unavoidable. The facility would implement individualized interventions to attempt to stabilize, reduce or remove underlying risk factors.

Based on record review, staff interview, hospital records review, Hoyer Lift user manual review and facility policy review, the facility failed to ensure Resident #87 was transferred in a safe manner using a mechanical (Hoyer) lift (a mechanical device with a sling used to transfer residents from one place to another). Actual Harm occurred on 10/18/23 when Resident #87, who was dependent on two staff for transfers using a Hoyer lift, sustained a fall out of the lift resulting in a hospitalization and diagnosis of cervicalgia (pain in the neck and shoulders that varies in intensity, and may feel achy or like an electric shock from the neck to the arm) with an order for a cervical collar to be worn at all times for four weeks. The fall occurred as a result of the legs of the lift not being in proper position to accommodate a shift in the resident's weight during the transfer. This affected one resident (Resident #87) of five residents reviewed for accidents. The facility census was 83. Findings Include: Review of the medical record for Resident #87 revealed an initial admitted [DATE] with diagnoses including displaced trimalleolar fracture of the left lower leg, generalized muscle weakness, spinal stenosis, osteoarthritis, chronic pain, anxiety disorder, anemia, obstructive sleep apnea, chronic pain syndrome, severe morbid obesity, and diabetes mellitus. Review of the plan of care dated 09/28/23 revealed the resident had a self-care deficit related to fracture, diabetes mellitus, edema, morbid obesity, congestive heart failure, self transfers when weak and self limiting behaviors. Interventions included one to two assists with activities of daily living (ADL), encourage resident to discuss self care deficit as needed, encourage resident to participate to the fullest extent possible as needed, Hoyer lift for transfers, therapy referral as needed, side rails for positioning and weight bearing as tolerated. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for toileting, bathing and ambulation was not attempted. Review of the progress note dated 10/18/23 at 3:55 P.M., revealed at approximately 3:00 P.M. the resident was being transferred from her wheelchair to bed via Hoyer lift by two staff members and while being guided into her bed, the Hoyer lift shifted to the left which caused the resident to be repositioned on the floor. The resident complained of pain to back, hips and head. The resident was transported to a local acute care hospital at approximately 3:45 P.M. via emergency medical services (EMS). Further review of the medical record revealed the resident did not return to the facility. Review of the staff statement by State tested Nursing Assistant (STNA) #224 dated 10/18/23 revealed at approximately 3:00 P.M. the STNA and Certified Occupational Therapy Assistant (COTA) #400 were transferring the resident from her wheelchair to her bed using a Hoyer lift. The STNA documented she was monitoring the controls while the COTA guided the resident into bed when suddenly the Hoyer shifted to the left and the resident fell to the ground. The Hoyer lift was removed and the aide summoned the nurse on duty. Review of the staff statement of COTA #400 dated 10/18/23 revealed at approximately 3:00 P.M. the COTA and STNA #224 were transferring the resident from her wheelchair to the bed utilizing a Hoyer lift. The COTA was guiding the resident while the STNA monitored the controls when suddenly the Hoyer shifted to the right and the resident fell three feet to the floor. The Hoyer was removed and the STNA went to summons a nurse. The COTA documented she stayed with the resident. Review of the typed document titled, Root Cause Analysis, dated 10/18/23 revealed the resident was being transferred from her wheelchair to bed after being showered using the bariatric Hoyer lift. The Hoyer lift pad was wet. The State tested Nursing Assistant (STNA) maneuvered the Hoyer lift to the bed. The COTA used the handles on the Hoyer pad to turn the resident, to better position her, over the bed prior to lowering the resident to the bed. This caused the lift to tip which resulted in the resident landing on the floor on her buttocks. The resident was taken to the hospital for an evaluation. The facility determined the resident shifted in the Hoyer lift causing it to tip and the resident fell to the floor. The facility implemented a three person assist with this resident in Hoyer transfers. On 01/04/24 at 2:40 P.M., interview with the Director of Nursing DON revealed the resident was admitted to the acute care hospital for observation and then discharged home. On 01/04/24 at 4:18 P.M., interview with COTA #400 revealed she and STNA #224 were transferring the resident from her wheelchair to bed following a shower. She said they were transferring her back into bed and STNA #224 was doing the controls while she was moving the resident. She said there was a sudden shift and the Hoyer topped over. She revealed the Hoyer legs were opened at one point but they had to be closed to get them under the bed. On 01/08/24 at 1:22 P.M., interview with STNA #224 revealed COTA #400 gave the resident a shower and she assisted with transferring the resident. STNA #224 revealed she was maneuvering the Hoyer lift and COTA #400 was moving the sling. She said COTA #400 told her to close the legs and when she closed the legs, the Hoyer fell over. Multiple attempts were made to contact Resident #87 by phone but no return call was provided. Review of the hospital summary provided by the facility for a hospitalization from [DATE] to 10/24/23 revealed the resident presented on 10/18/23 with a fall from a Hoyer lift. Further review revealed the resident had cervicalgia and the plan was for the resident to wear a cervical collar at all times for four weeks. Review of the user manual for the Hoyer lift, provided by the facility, revealed the legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. Review of the facility policy titled, Safe Resident Handling and Transfers Guidelines, last revised 02/07/23, revealed residents require safe handling with transfers to prevent risk to them and to employees. Staff will perform lifts/transfers based on the manufacturer's instructions for use of the device.

Based on record review, interviews and facility policy review, the facility failed to provide adequate pain management for Resident #32 following an unwitnessed fall with pain to the right hip. Actual harm occurred on 07/31/23 when Resident #32 who was noted to have chronic hip pain and received scheduled Tylenol, was found on the floor screaming and pointing to her right leg at 4:30 A.M. The resident was assisted back into bed and continued to scream and point to her right leg for an additional two hours before Physician #502 was notified and an order was obtained for an x-ray. Additionally, the resident rated her pain as 7 out of 10 (zero being no pain and 10 being the worst pain possible) and was not given any pain medication until her scheduled Tylenol at 8:00 A.M. Subsequently the resident was assessed to have a displaced subtrochanteric fracture of right femur, leading to a transfer to a local acute care hospital on 07/31/23 at 2:15 P.M. and a surgical repair of the displaced subtrochanteric fracture of the right femur was required. This affected one resident (#32) of four residents reviewed for falls. The facility census was 83. Findings Include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with a re-admission on 08/18/23. Resident #32 had diagnoses including encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the resident's physician orders revealed an order, dated 03/02/22 for Tylenol Extra Strength 500 milligrams (mg) with the special instructions to give two tablets by mouth three times a day for chronic hip pain. Review of the plan of care dated 04/04/22 revealed the resident had potential for pain related to rhabdomyolysis, cervical disc disease, osteoporosis and diabetes mellitus. Interventions included to administer medications as ordered, inform the physician if pain was not relieved or uncontrolled pain as needed, offer non-pharmacological pain interventions as tolerated and therapy referrals. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the MDS revealed the resident had not rejected care. The assessment revealed the resident required extensive assistance from one staff for bed mobility, transfers, toileting, dressing and personal hygiene and was non-ambulatory. The assessment indicated the resident was always incontinent of bladder and frequently incontinent of bowel. The assessment indicated the resident received scheduled pain medication and had no pain during the pain interview. Review of the nurse's note dated 07/31/23 at 4:30 A.M., authored by Licensed Practical Nurse (LPN) #191 revealed the resident was found lying on the floor on her back. A head-to-toe assessment was completed, vital signs were within normal limits, no bodily injury was noted, and the resident demonstrated pain by screaming and pointing to her right leg. The resident was assisted back to bed with her call light within reach. The on-call Certified Nurse Practitioner (CNP) was notified and no new orders were obtained at that time. Review of the nurse's note dated 07/31/23 at 6:37 A.M., authored by LPN #191 revealed the LPN documented again the resident being found on the floor and the resident demonstrated pain by screaming and pointing to right leg. The CNP was notified of the continued pain and ordered an x-ray. Review of the pain assessment dated [DATE] at 6:40 A.M., authored by LPN #191 revealed the LPN documented the resident had no pain, despite the resident screaming out and pointing to her leg per the entry in the nursing note. Review of the pain assessment dated [DATE] at 8:18 A.M., authored by LPN #515 revealed the resident voiced pain almost constant interfering with sleep and day to day activities at a level of seven out of 10. Review of the resident's July 2023 Medication Administration Record (MAR) revealed the resident was administered her scheduled Tylenol Extra Strength 500 milligrams (mg) for the pain level of 7 out of 10 on 07/31/23 at 8:00 A.M. Review of the medical record revealed no documented evidence the resident's pain was reassessed following the administration of the scheduled analgesic Tylenol Extra Strength due at 8:00 A.M. for effectiveness. Review of the July 2023 MAR revealed the resident was again administered Tylenol Extra Strength 500 mg, two tablets on 07/31/23 at 12:00 P.M. for a pain level of five out of 10. Review of the medical record revealed no documented evidence the resident's pain was reassessed following the administration of the scheduled analgesic Tylenol extra strength due at 12:00 P.M. for effectiveness. Review of the progress note dated 07/31/23 at 12:25 P.M., authored by LPN #515 revealed x-ray results were called to the physician group and they requested the results be faxed to their office. The facility was awaiting new orders. Review of the progress note dated 07/31/23 at 2:14 P.M., authored by LPN #515 revealed a new order was obtained from the resident's physician to send the resident out to the emergency room (ER) due to the x-ray results. Review of the progress note dated 07/31/23 at 5:02 P.M., authored by LPN #219 revealed the local acute care hospital called requesting a consent to perform a nerve block. The facility attempted to call the resident's spouse with no answer. Review of the late entry Intradisciplinary team (IDT) note dated 08/23/23 at 3:15 P.M. for 08/01/23 at 3:15 P.M., authored by the Director of Nursing (DON) revealed Resident #32 was found on the floor writhing in pain. The resident was moved to the bed and physician was called. The resident was sent to the hospital due to x-ray results showing the resident's hip was broken. The resident was given visual reminders to call for assistance when she wanted to get out of bed. Review of the medical record revealed no documented evidence the facility provided effective pain management for the resident's complaints of right hip pain following the unwitnessed fall resulting in the displaced subtrochanteric fracture of right femur requiring surgical repair. Interview on 01/25/24 at 9:23 A.M. with Physician #502 revealed he would have expected the resident's pain to be reassessed within an hour of the administration of the medication (routine) Tylenol and if the resident's pain was not controlled, the staff should have called for a new order for a stronger pain medication. This order for Tylenol had been in place since 2022. Interview on 01/25/24 at 2:49 P.M., interview with the DON verified the resident's pain was not controlled with the use of the scheduled Tylenol and reassessments of the resident's pain were not completed. The DON revealed the facility did not have a policy for pain management.

Based on observation, record review, facility policy and procedure review and interview the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #82. Actual harm occurred on 01/18/22 when Resident #82, who required extensive assistance from two staff for bed mobility and had a known history of pressure ulcers was identified to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the coccyx. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. The facility failed to ensure the pressure ulcer was timely identified prior to being found as an unstageable pressure ulcer and failed to ensure a comprehensive assessment was completed and interventions were implemented to promote healing when the ulcer was first discovered. This affected one resident (#82) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #82's medical record revealed and admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 03/29/18 revealed Resident #82 was at risk for skin breakdown and pressure injury related to MS, weakness, dependence on wheelchair, spastic leg, history of using [MEDICATION(S)] pump, comorbidities, nutritional risks, prefers to have a blanket under him in the wheelchair, history of skin breakdown and impaired dexterity. Interventions included air mattress, encourage/assist with daily hygiene needs as needed, keep area clean, dry and odor free as tolerated, place cube of ice in coffee, report decline in skin condition to physician as needed, treatment to areas as ordered as tolerated and weekly skin assessments as tolerated. The plan of care did not include any interventions related to turning or repositioning for the resident. Review of the resident's physician's orders, revealed an order dated 12/31/18 for moon boots (protective boots) to bilateral lower extremities at all times while in bed, an order dated 12/18/19 for a gel cushion to power wheelchair, an order dated 04/10/20 for a weekly skin assessment every Monday, an order dated 07/07/20 for heels to be floated while in bed, when resident refused to wear mood boots and an order dated 01/08/21 apply skin prep to bilateral heels daily. There was no order for turning and repositioning. Review of the resident's skin risk (Braden Scale) assessment, dated 11/05/21 revealed the resident was at moderate risk for skin breakdown with a score of 14. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/04/22 revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was dependent on two staff for transfers and toilet use. The assessment revealed the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had no unhealed pressure ulcers. The MDS noted interventions included pressure reducing device to bed/chair and application of ointments/medications other than to feet. Review of a wound evaluation and management summary, completed by Wound Physician #208 dated 01/19/22 (the next day) revealed the resident had an unstageable pressure ulcer to his coccyx measuring 3.3 centimeters (cm) in length by 6.2 cm width with 70% adherent black necrotic tissue, 15% adherent devitalized necrotic tissue and 15% skin. The assessment indicated the unstageable pressure ulcer was debrided to remove narcotic tissue and establish the margins of viable tissue. The wound physician implemented a treatment to cleanse the wound, apply calcium alginate and Santyl, cover with bordered gauze daily for 30 days, off load wound and reposition per facility policy. On 01/20/22 a physician order was written to cleanse coccyx, apply calcium alginate and Santyl and cover with gauze island dressing every shift. However, review of the treatment administration record revealed no treatment was completed for the pressure ulcer on 01/20/22. On 01/24/22 the treatment frequency was increased to twice a day. Review of the resident's care plans revealed no plan of care addressing the unstageable pressure ulcer to the resident's coccyx. On 01/24/22 at 9:36 A.M. Resident #82 was observed in bed. The resident was not observed to have an air mattress in place at the time of the observation. On 01/24/22 at 2:53 P.M. interview with Resident #82 revealed he was a quadriplegic and had little feeling to his coccyx area. The resident revealed he needed staff assistance to turn completely over in bed. On 01/25/22 at 1:15 P.M. the resident was also observed in bed with no air mattress in place. Review of the wound evaluation and management summary, dated 01/26/22 and completed by Wound Physician #208 revealed the wound was classified as a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer measuring 3.3 cm in length by 5.2 cm width with 3.0 cm depth with 70% thick adherent devitalized necrotic tissue, 10% slough, 10% muscle and 10% skin. The treatment was changed and a new treatment to cleanse the wound, apply Dakins' solution, calcium alginate with sliver and cover with sponge gauze twice daily for 30 days was initiated. On 01/26/22 at 1:08 P.M. Licensed Practical Nurse (LPN) #176 and LPN #210 (the wound nurse) were observed to complete the resident's coccyx pressure ulcer. At the time of the observation, the wound was observed with blackish tissue and yellowish strings of tissue. LPN #210 cleansed the wound with normal saline (NS) and 4X4 gauze and then washed her hands. She then packed the wound with [MEDICATION(S)] with calcium alginate silver and covered with foam dressing. The resident was noted to have a bolster mattress on his bed. At time time of the observation, interview with LPN #210 revealed [MEDICATION(S)] was used as the facility had not yet received the Dakins' solution. LPN #210 verified the resident did not have an air mattress (as previously care planned) at the time of this observation. On 01/25/22 at 1:11 P.M. interview with Director of Nursing (DON) verified an initial assessment of the pressure ulcer was not completed at the time the ulcer was first identified on 01/18/22. On 01/25/22 at 1:20 P.M. interview with LPN #210 revealed she was verbally notified of the resident's wound on 01/18/22. The LPN revealed she had examined the wound on that date but failed to document an assessment of the wound or implement a treatment. The LPN revealed she felt the wound was at least a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) because the wound was a bluish, gray with yellow in the wound. During the interview, the LPN verified a wound that was bluish/gray/yellow in color was not consistent with a State II pressure ulcer but rather possibly a deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). In addition, LPN #210 verified the resident required staff assistance with bed mobility and turning and repositioning and there was no evidence this had been provided for the resident to assist in pressure ulcer prevention. The lack of turning and repositioning along with the lack of an air mattress placed the resident at increased risk and likely contributed to the development of the unstageable/Stage IV pressure ulcer. On 01/25/22 at 2:59 P.M. interview with the Director of Nursing verified no plan of care had been initiated to address the resident's actual skin breakdown/pressure ulcer to the coccyx. On 01/26/22 11:53 AM interview with Wound Physician (WP) #208 revealed the wound was debrided to a Stage IV on 01/26/22. WP #208 said the wound was never a Stage II pressure ulcer and indicated staff should have noticed the wound prior to the discovery date. Review of the facility policy titled Pressure Ulcer Care Special Considerations, dated 2016 revealed comprehensive skin assessments were to be completed on admission, daily on the unit and upon discharge from the unit.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,[DATE] (NH) dated [DATE] and QSO ,[DATE]-ALL dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), World Health Organization (WHO) recommendations, data contained on the State of Ohio's coronavirus.ohio.gov dashboard, observations, record reviews, review of the facility COVID-19 plan (effective [DATE]), review of facility timeline documentation and review of Droplet Precaution and Contact Precaution Signage and Isolation Policy, and interviews with staff, residents, the local health department and Medical Director #202, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on [DATE] when the facility received notification of their first COVID-19 positive case, a staff member (Activity Assistant (AA) #201) who tested positive. AA #201 worked at the facility on [DATE], [DATE] and [DATE], having contact with at least 65 facility residents throughout these three days without written evidence the employee was screened (for signs/symptoms of COVID-19 or direct exposure) prior to beginning his shift on [DATE] or [DATE]. Information obtained via the local health department revealed AA #201 became symptomatic of COVID-19 on [DATE], was tested and identified to be positive on [DATE]. There was no written evidence at the time AA #201 became symptomatic or immediately after receiving notification of AA #201 testing positive for COVID-19 the facility quarantined all staff and residents determined to have had contact with AA #201. A timeline provided by the facility on [DATE] at 4:45 P.M., revealed a lack of infection control measures implemented until [DATE] when the facility received advice on testing and CDC guidelines from the local health department. The timeline did not elaborate on the CDC guidelines discussed at that time. On [DATE], the facility identified two residents (Resident #1 and Resident #2) who were symptomatic of COVID-19. Both residents were included on the list of residents who AA #201 had contact with during activities from [DATE] to [DATE]. From [DATE] to [DATE], there were 61 residents identified to test positive for COVID-19, with the most current resident (Resident #3) testing positive on [DATE] and 15 residents who expired. In addition, 27 staff members tested positive for COVID-19. During this time period, the facility failed to establish a comprehensive infection control program to provide early identification of, and prevention of, these additional positive COVID-19 resident cases. In addition, the facility failed to implement effective and recommended infection control practices, including the ongoing use of a separate COVID-19 unit (which was located on the 500 unit and named the Nest unit) and dedicated staff to provide care for COVID positive and/or COVID symptomatic residents. Through interviews it was determined the facility failed to coordinate with the local health department to prevent and contain the spread of COVID-19 within the facility. The facility also failed to ensure the infection control tracking system maintained via infection control logs for April and [DATE] were accurate and contained adequate information to identify the necessary components related to the COVID-19 pandemic. On [DATE] at 2:17 P.M., the Administrator was notified that the Immediate Jeopardy began on [DATE] when the facility failed to provide evidence of a comprehensive infection control plan to prevent or contain the spread of COVID-19 to residents residing in the facility following notification Activities Assistant (AA) #201 was symptomatic and then tested positive for COVID-19. The facility failed to operationalize the COVID-19 plan that was developed on [DATE] when subsequent residents identified to test positive were not isolated to a separate part of the facility and the facility did not designate staff to provide care to only those residents who were COVID-19 positive. The facility design/layout included five nursing units, the 100, 200, 300, 400 and 500 unit. The Nest unit was located on the 500 unit and included rooms 501 to 513. One additional room, room [ROOM NUMBER] was included in the 400 unit nursing assignment. Observations on [DATE] revealed seven current residents (Resident #7, #9, #11, #12, #13, #14 and #43) both with and without positive COVID-19 tests, who were in isolation (droplet) precautions residing in rooms intermingled throughout each unit (100, 200, 300 and 400) with residents on the same units who were not positive or symptomatic for COVID-19. There was no evidence these residents had been moved to the Nest unit with staff dedicated to providing for their care, although the Nest unit was being used for other residents on this date. Observations on [DATE] revealed continued ongoing infection control concerns which included but were not limited to the following: All the residents who had been observed residing on the Nest unit on [DATE] had been moved off the unit and were residing in rooms throughout each of the units (100, 200, 300 and 400) and the Nest unit was closed. Ten residents (Resident #3, #7, #8, #9, #10, #11, #12, #13, #14 and #15) were observed to be in rooms in isolation (droplet) precautions for COVID-19 intermingled with residents who were not in isolation for COVID-19. Dedicated staff were not assigned to only care for those residents in isolation for COVID-19. Staff failed to ensure the proper use of personal protective equipment (PPE) and failed to ensure appropriate PPE was utilized when caring for a resident in isolation (droplet) precautions. The lack of a comprehensive infection control program in addition to the continued observations of infection control concerns placed all residents at risk for contracting COVID-19 and experiencing the potential for actual harm associated with COVID-19 including hospitalization and/or death. The facility census was 97. As of [DATE] the Immediate Jeopardy remained ongoing. Findings include: 1. Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions for Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. This document may be requested by surveyors, if an onsite investigation takes place. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and to whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii). During the Covid-19 Focused Infection Control Survey from [DATE] to [DATE] the facility failed to provide evidence of the completion of the CMS recommended voluntary self-assessment. On [DATE] at 2:17 P.M. during a discussion with the Administrator, the Administrator revealed he was unsure if this assessment had been completed by the facility. As of [DATE] at 12:08 P.M., no CMS recommended voluntary assessment was provided for review. 2. Review of the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) updated [DATE] revealed: Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. If infected with [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, residents are at increased risk of serious illness. Covid-19 cases have now been reported in all 50 states and DC; with many areas having wide-spread community transmission. Given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate actions to protect residents, families, and healthcare personnel (HCP) from severe infections, hospitalization s and death. Visitors and HCP continue to be sources of introduction of COVID-19 into nursing homes. In addition, per CDC information and guidelines: Given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to prevent residents, families and healthcare personnel (HCP) form severe infections, hospitalization s and death .Dedicate Space in the Facility to monitor and Care for Residents with COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility .Resident with new onset suspected or confirmed COVID-19. Ensure the resident is isolated and cared for using all COVID-19 PPE. Place the resident in a single room if possible . Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Information obtained as part of the COVID-19 Focused Infection Control Survey, between [DATE] and [DATE] from the Administrator, Director of Nursing and Local Health Department revealed Activity Assistant (AA) #201 was the first employee identified by the facility to test positive for COVID-19. AA #201's last date worked in the facility was on [DATE]. The employee became symptomatic and subsequently tested positive which was communicated to the facility on [DATE]. As of [DATE] AA #201 had not returned to work. On [DATE] at 4:45 P.M. the Administrator provided a timeline which revealed on [DATE] the facility discussed with the local health department the testing process. The Administrator also revealed notification complete and got advice on testing and CDC guidelines. However, the information provided did not contain the specifics of what CDC guidelines were obtained. The Administrator provided the contact information for the Registered Nurse from the Local Health Department (LHD). During follow up communication via email on [DATE] at 12:11 P.M. the DON revealed after being made aware of AA #201 testing positive the facility began monitoring all resident vital signs every shift. At this time there was no evidence to indicate the facility determined which residents or other staff AA #201 had contact with while working in the facility prior to becoming symptomatic on [DATE] and no evidence any residents or staff were placed in quarantine at that time due to possible exposure to the employee. On [DATE] at 4:17 P.M. telephone interview with the Administrator and DON revealed AA #201's last date worked in the facility was on [DATE] from 7:03 A.M. to 1:50 P.M. At this time, the Administrator provided a list of residents AA #201 had contact with on [DATE], [DATE] and [DATE]. This list included on [DATE] four residents for McDonalds brunch and 27 residents for a Birthday Bash/Rootbeer Floats, on [DATE] 65 residents for cheese and crackers and on [DATE] 14 residents for mail. Review of the list of residents, revealed AA #201 had contact with both Resident #1 and Resident #2 (the first two residents subsequently identified to exhibit COVID-19 symptoms) during the activities held on these days. The Administrator revealed he believed the extent of these activities included AA #201 and another staff member (unidentified during the conversation) taking a cart with these items each day and going from resident room to room. The Administrator was unable to provide information related to which resident rooms AA #201 actually went into and did not describe the PPE being used by AA #201 at the time of the contact. The Administrator did indicate he did not believe AA #201 was within six feet of any of the identified residents for greater than ten minutes. On [DATE] at 7:49 A.M. review of the facility employee screening sheets with the DON revealed the form used by the facility included a section to document temperature and then a yes or no for cough and shortness of breath. There was also a section to record whether an employee had direct exposure. A request was made to review the screening sheets for AA #201 from [DATE], [DATE] and [DATE]. Record review and interview with the DON revealed no evidence screening was completed for AA #201 on [DATE] or [DATE]. In addition, the screening sheets were not maintained in date order, some of the forms did not contain the date in which they were completed and did not all include who the person was who had completed the screenings. The DON revealed the receptionist was responsible to screen any persons entering through the main entrance of the facility when she was on duty and the nursing supervisor was to complete the screenings for employees who all had a designated entrance. On [DATE] the Administrator provided a list of facility employees who tested positive for COVID-19 as a result of testing that was offered to all facility employees on [DATE]. The list contained the names of 20 employees with positive results received on [DATE] and 1 employee with a negative test on [DATE] but subsequent positive test over the weekend at a local hospital. Furthermore, the list contained the names of three employees (AA #201, State tested Nursing Assistant (STNA) #240 and STNA #241) identified as previous employees reported (assumed to be previous to whole facility testing done on [DATE]). However, this information provided by the Administrator for these employees did not contain any information related to the date they were tested or date they were symptomatic. Excluding the information that was obtained in regard to AA #201, there was no evidence contained in the information provided by the facility that staff and/or residents with contact to STNA #240 or STNA #241 were identified and quarantined to attempt to prevent the spread of COVID-19 to additional residents. On [DATE] at 10:06 A.M. the Administrator revealed AA #201 had worked in activities by himself on [DATE] and [DATE] and on [DATE] he worked with Activity Director (AD) #245. AD #245 was unavailable for interview on [DATE] as the Administrator revealed she was out of state. When further asked if the activity staff would have been using any type of PPE while working [DATE], [DATE] and [DATE], the Administrator and DON revealed they thought based on the dates they would have been wearing face masks. 3. On [DATE] at 9:25 A.M. information provided by the DON revealed the facility obtained their first COVID-19 resident test on [DATE] for Resident #2, who was the first resident suspected of having COVID-19 in the facility. Per the DON, this resident ' s tests came back negative. However, the DON indicated Resident #2 was moved to the facility isolation (Nest) unit on [DATE] and then recovered and returned to his original room. Review of the facility infection control log for [DATE] revealed two entries for Resident #2. The first entry, dated [DATE] revealed the resident had a temperature and cough, had an examination completed, organism not applicable, was not placed in any type of isolation and was administered the antibiotic [MEDICATION NAME] for five days. The second entry, dated [DATE] revealed the resident had a temperature, had an examination completed, organism not applicable, was not placed in any type of isolation and was administered a one time dose of the antibiotic [MEDICATION NAME]. There was no indication on the infection control log the resident had a COVID test completed or that he was placed in any type of isolation. Record review revealed Resident #2's roommate, Resident #1 was also listed on the [DATE] infection control log. There were two entries for Resident #1. An entry dated [DATE] which indicated the resident had a temperature and cough, had an examination/swab completed which was positive COVID, was placed on droplet precautions and given a one time dose of the antibiotic [MEDICATION NAME]. A second entry, dated [DATE] revealed Resident #1 had a temperature and cough, had an examination/swab completed which was positive COVID, was placed on droplet precautions and started on the antibiotic [MEDICATION NAME] for five days. Information provided from the facility during the survey process revealed Resident #1 was not moved to the COVID isolation unit of the facility until [DATE]. On [DATE] at 7:35 A.M. interview with the DON revealed a COVID-19 test was collected for Resident #1 on [DATE] with positive results received on [DATE]. Per the DON, a COVID-19 test was collected for Resident #2 on [DATE] with negative results received on [DATE]. A TIMELINE provided by the Administrator and Senior Vice President Chief Growth Officer on [DATE] during an interview at 9:27 A.M. revealed an entry on the timeline dated [DATE] at 7:03 P.M. which indicated received a call from (DON) reporting a high temp and symptoms (of COVID-19) for both Resident #1 and #2. The timeline information revealed a sitter was suggested to be placed at the door to the resident's room. There was no evidence either resident was moved to an isolation area of the facility at this time (identification of signs/symptoms of COVID-19). Additional information contained on this timeline for this date was specific to testing for the two residents. Continued review of the TIMELINE revealed on [DATE] testing results were reviewed for both residents which included a positive COVID-19 test for Resident #1 and a negative COVID-19 test for Resident #2. The nurse from the local health department recommended re-testing Resident #2 for a possible false negative result. On [DATE] at 4:14 P.M. the DON was called and told to initiate the Nest. Record review revealed this was two days after both Resident #1 and Resident #2 were identified to exhibit signs/symptoms of COVID-19. The timeline revealed no evidence staff or residents who had contact with Resident #1 and Resident #2 were identified for the need for quarantine or to assess for possible onset of symptoms. This timeline of events stopped on [DATE] at 7:45 P.M. with no additional information after this date. The facility identified three additional residents, Resident #4, Resident #5 and Resident #6 who were also tested for COVID-19 between [DATE] and [DATE] at which time mass testing was done in the facility. Review of the infection control log revealed on [DATE] Resident #4 was identified to have a temperature and cough, had an examination/swab completed which was positive COVID, was placed on droplet precautions and ordered the antibiotic [MEDICATION NAME] for ten days. However, the resident was not moved to the COVID Nest isolation unit until [DATE]. Review of the infection control log revealed on [DATE] Resident #5 was identified to have a temperature and cough, had an examination/swab completed which was positive COVID, was placed on droplet precautions and ordered the antibiotic [MEDICATION NAME] for ten days. However, there was no evidence the resident was moved to the COVID Nest isolation unit. Review of the infection control log revealed no evidence Resident #6 was listed on the log for [DATE]. The facility provided information that indicated Resident #6 was tested on [DATE] and tested positive for COVID. The resident was not moved to the COVID Nest isolation unit. On [DATE] the resident coded (absence of vital signs) and was transferred to the hospital where she passed away. As a result of the increase in positive resident testing, on [DATE] the facility indicated mass testing was initiated. As a result of the testing the following information was provided by the Administrator and/or DON during the survey process: a. Resident #18 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit and passed away in the facility on [DATE]. b. Resident #27 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit and passed away in the facility on [DATE]. c. Resident #24 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit and passed away in the facility on [DATE]. d. Resident #19 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit and passed away in the facility on [DATE]. e. Resident #17 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit, but rather to a different room on the same hall as his original room (a non COVID isolation unit), the resident passed away in the facility on [DATE]. f. Resident #25 was tested on [DATE] with positive results. However, the resident was not moved to the COVID isolation Nest unit until [DATE]. The resident passed away in the facility on [DATE]. g. Resident #29 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit and passed away in the facility on [DATE]. h. Resident #22 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit and passed away in the facility on [DATE]. i. Resident #20 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit and passed away in the facility on [DATE]. j. Resident #26 was tested on [DATE] with positive results. However, the resident was not moved to the COVID Nest isolation unit until [DATE]. The resident passed away in the facility on [DATE]. k. Resident #21 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit. The resident was transferred to the hospital on [DATE] and passed away on [DATE]. l. Resident #23 was tested on [DATE] with positive results. The resident was not moved to the COVID isolation Nest unit and passed away in the facility on [DATE]. 4. Review of the facility infection control logs provided from April and [DATE] revealed the logs contained a section for the resident name and room number, in-house onset date, site of infection, diagnostic test, organism, isolation type, McGeer's Criteria Met? Y/N, Anti-microbial agent and start date. Upon review of the data entered on the logs for the residents revealed the first entry related to COVID-19 was dated [DATE] (in-house onset date) and involved Resident #2. An examination was completed, no organism and no isolation type. The log revealed the resident did not meet the McGeer's criteria for infection. Resident #2's roommate, Resident #1 was listed on log with an in-house onset date of [DATE], site of infection temp/cough, diagnostic test exam/swab, organism COVID and droplet listed for isolation type. The log revealed the resident met the McGeer's criteria. The [DATE] infection control log contained 10 additional residents, Resident #32, #12, #113, #28, #105, #98, #91, #4, #5 and #114, with an in-house onset date from [DATE] through [DATE]. Nine of ten residents were listed to have temp/cough written under the site of infection with the exception of Resident #98 who had [MEDICAL CONDITIONS] listed. The residents had diagnostic testing listed as exam/swab (Resident #32, #12, #113, #28, #105, #98, #91 and #4) or just exam (Resident #5 and #114). The documentation contained the word covid under organism for each of the ten residents with droplet isolation noted for all of the residents with the exception of Resident #98. All ten residents were identified to meet McGeer's criteria. Review of the [DATE] infection control log revealed the first entry date on the log was [DATE]. The log listed 51 residents, Resident #30, #33, #35, #36, #12, #37, #38, #40, #16, #3, #17, #45, #46, #18, #29, #50, #51, #53, #57, #60, #19, #61, #20, #63, #67, #11, #21, #70, #7, #74, #22, #23, #79, #80, #86, #87, #89, #91, #96, #97, #98, #115, #24, #25, #26, #27, #105, #106, #108, #28 and #112 all with an in-house onset date of [DATE]. The section for site of infection was blank for each of these residents. The diagnostic test listed exam/swab. COVID-19 was written for each resident as well as droplet for isolation type. Under the McGeer's Criteria, each of the residents' were marked with a Y, yes they met the McGeer's criteria (for infection). The [DATE] log contained four additional residents with the COVID-19 organism including Resident #15 with an in-house onset date of [DATE], Resident #48 with an in-house onset date of [DATE], Resident #13 with an in-house onset date of [DATE] and Resident #9 who was on the log twice, once without an in-house onset date written, with the COVID-19 organism noted and then on [DATE] with congestion, an exam and no organism listed. Each of these residents, with the exception of Resident #48 were identified to meet the McGeer's criteria for infection. Record review revealed based on the information contained on the infection control log, it could not be determined if the date listed in the in-house onset date column was the date the resident exhibited signs and symptoms of COVID-19 or simply the date the resident was tested for COVID-19 and asymptomatic even though the logs identified (from April and [DATE]) that all but two (Resident #2 and Resident #48) met the McGeer ' s criteria for infection. The logs did not contain the date lab results were received by the facility and did not indicate under the isolation type whether the resident was moved to the facility COVID-19 isolation Nest unit and if moved, on what date. In addition, the log did not contain the date isolation was discontinued for any of the residents and/or what criteria the resident met to have isolation discontinued. Review of the Revised McGeer Criteria for Infection Surveillance Checklist revealed the facility used Table 3. Respiratory Tract Infection (RTI) Surveillance Definitions Influenza-like illness for the assessment of COVID-19. This criteria required the resident to have both a fever and at least three of the following signs/symptoms: chills, new headache or eye pain, myalgias or body aches, malaise or loss of appetite, sore throat, or new or increased dry cough to meet the McGeer ' s criteria. On [DATE] beginning at 7:35 A.M. interview with the DON revealed the infection control logs only contained information related to resident infections. When asked if she had any infection tracking information for staff, specifically related to COVID-19, the DON revealed she did not, the Administrator had this information. Review of the resident infection control logs from April and [DATE] with the DON revealed the documentation of temp/cough were signs/symptoms the resident was exhibiting and the date noted was the onset date of those symptoms. The DON verified the information contained on the log was not specific to identify which residents were moved to the dedicated COVID-19 isolation Nest unit and on what date based on sign/symptoms exhibited. During the interview, the DON revealed the facility completed whole house resident testing for COVID-19 on [DATE]. The DON stated she was off ill at the time the testing was done, but entered the information onto the log upon her return to work on [DATE]. The DON verified there was no site of infection listed for any of the residents tested on [DATE] because she stated they were all asymptomatic at that time. However, the DON verified she had documented that each of these residents met the McGeer ' s criteria for infection. The DON verified the McGeer ' s criteria used for the assessment of infection. On [DATE] at 8:19 A.M. interview with the Administrator and Senior Vice-President Chief Growth Officer (VP) revealed after the facility identified two residents (actual resident names not provided during interview) who were COVID-19 positive they reached out Physician #208 (date not provided) who advised the facility that if they had one positive resident then they likely had 15 positive residents and recommended whole house COVID-19 testing be completed. The VP revealed whole house COVID-19 testing was completed on [DATE] with a goal for all staff and residents to be tested . The VP revealed there was one resident who had refused the testing and believed 95% of the staff were tested . The VP revealed with input from Physician #208 and Medical Director #207, only those residents who were symptomatic of COVID-19 were moved to the nest unit but not until after their actual lab testing came back that confirmed the COVID-19 diagnosis. On [DATE] at 9:27 A.M. interview with the VP and Executive Director of Compliance and Clinical Services revealed at the time whole house testing was completed, the results of the testing were communicated to the Minimum Data Set (MDS) nurse and Administrator. There was no evidence Infection Preventionist Licensed Practical Nurse (LPN) #206 was involved in the coordination and/or implementation of strategies to prevent the spread of COVID-19 following the identification of residents who tested positive for COVID-19 and were symptomatic, tested positive for COVID-19 and were asymptomatic or who tested negative but were symptomatic. The corporate staff revealed on [DATE] 206 total tests were completed in the facility for 106 residents and 100 staff. When the results were received a color coded bed board form was used to highlight which residents were positive and which residents were negative. As a result of testing, they indicated residents who were symptomatic were moved to the Nest unit. However, the bed board did not contain information as to how it was determined which residents were symptomatic or the date symptoms were first identified. The Nest unit was identified to have 26 beds. A copy of the highlighted form revealed 17 residents were moved to the unit. Fourteen of the residents moved to the Nest unit were identified to have positive tests and three of the residents were identified to have negative tests. At this time the concern was shared that from an investigative standpoint and based on a review of the written facility information, it could not be determined how the facility determined which residents to move to the Nest unit or that measures to separate symptomatic residents were initiated while awaiting confirmation of laboratory testing. The highlighted form revealed that although no positive and negative tested residents were sharing rooms, the positive residents who were not moved to the Nest unit were intermingled throughout the entire remainder of the facility (on the 100, 200, 300 and 400 units) even though not all of the beds on the Nest unit were full. There was no evidence any additional measures were implemented in the facility to separate by unit or provide more than one dedicated area within the facility for residents to be isola (TRUNCATED)

Based on observations, staff interviews, and record review the facility failed to provide the required staff assistance for Resident #33 to eat meals. Actual harm occurred when staff failed to feed Resident #33 resulting in a significant weight loss of 15.41% in the last 180 days. This affected one (Resident #33) of three residents reviewed for weight loss. The facility's census was 127. Findings include: Review of the medical record for Resident #33 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had a significant weight loss of greater than 10% for the past six months. Further review also revealed Resident #33 had severe cognitive impairment and needed the assistance of one staff person for activities of daily living including eating. Review of care plan dated 03/07/18 revealed one staff must physically assist Resident #33 with feeding during breakfast, lunch and dinner. Review of a nutritional order dated 03/13/18 revealed Resident #33 was ordered mighty shake, a nutritional supplement, twice a day with lunch and dinner. Resident #33 was to be given finger foods after each meal. Further review of diet orders dated 04/18/17 revealed Resident #33 was on a regular diet. Review of a physician's orders [REDACTED].#33 was on one-on-one feeding program. It also revealed, staff were to physically assist Resident #33 with eating meals. Review of the Treatment Administration Records (TARs) from 10/25/17 through 04/11/18 revealed Resident #33 had sustained a significant 15.41% weight loss for the past 180 days. On 10/25/17, Resident #33's weight was 161.8 pounds ( lbs). Resident #33's weight recorded on 04/11/18 was 140.2 lbs, a loss of 21.6 pounds in the past 180 days. Review of State tested Nurse Aide (STNA) Flow Sheet Records from 04/01/18 through 04/11/18 revealed staff only set-up Resident #33 for his meals and did not physically assist him to eat his food. Further review of these STNA flow records from 04/12/18 through 04/18/18 revealed nothing was recorded to indicate how much Resident #33 ate of his meals. Review of dietary progress notes dated 04/17/18 revealed Resident #33 had a significant weight loss for 180 days. Resident #33 lost two pounds (1.7%) for the past 30 days; seven pounds (4.5%) for the past 90 days and 22 pounds (13.7%) for the past 180 days, which is significant weight loss for 180 days. Further review of the progress notes revealed Resident #33 weight loss was related to his continued decline in condition and increase in confusion. On 04/17/18 at 12:30 P.M., observation in the 400/500 unit dining area revealed Resident #33 did not eat his food and no staff physically assisted Resident #33 to eat his food. On 04/18/18 at 12:26 P.M., observation of Resident #33 during lunch revealed he was not physically fed at lunch. Resident #33 was served Brussel sprouts, pureed potatoes and bread. He was also served 6 ounces of a supplemental shake and 8 ounces of coffee. Resident #33 did not eat his food and was observed to get up and leave the dining room. No staff member made an effort to feed Resident #33 his lunch. On 04/18/18 at 2:28 P.M. interview with Licensed Practical Nurse (LPN) #208 revealed Resident #33 had not been eating well. LPN #208 said sometimes Resident #33 would eat by himself. LPN #208 said the staff only feed Resident #33 when he refuses to eat. On 04/18/18 at 2:45 P.M., interview with STNA #250 revealed the staff intermittently assist Resident #33 with eating. STNA #250 stated Resident #33 normally would not eat by himself unless staff encouraged him. STNA #250 said sometimes Resident #33 eats by himself and other times staff assist him to eat. STNA #250 verified the staff had not been feeding Resident #33 on a daily basis. On 04/19/18 at 8:26 A.M., interview with LPN #210 verified the staff have not been feeding Resident #33 at every meal. LPN #210 stated the STNAs only supervise Resident #33 during meals. On 04/19/18 at 9:03 A.M., interview with STNA #220 during breakfast verified Resident #33 eats by himself and sometimes staff assist him to eat his food. STNA #220 confirmed that staff doesn't always assist Resident #33 to eat his food. She said the staff only supervise Resident #33 during breakfast, lunch and dinner. On 04/19/18 at 10:25 A.M., the Clinical Care Manager (CCM) reviewed and verified that according to the STNA flow sheets, the staff did not feed Resident #33 his meals as ordered from 04/01/18 through 04/18/18.

Based on observations, staff interviews, and record review, the facility failed to ensure nutritional recommendations were implemented and failed to feed one resident (Resident #33) to prevent significant weight loss. Actual harm occurred to Resident #33 when he sustained a significant weight loss of 15.41% in the past 180 days. This affected one of three residents reviewed for weight loss. The facility's census was 127. Findings include: Review of the medical record for Resident #33 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had a significant weight loss of greater than 10% for the past six months. Resident #33 had severe cognitive impairment and required one person assistance with activities of daily living including eating meals. Review of the care plan dated 03/07/18 revealed one staff must physically assist Resident #33 with feeding during breakfast, lunch and dinner. The care plan revealed staff were to provide finger foods to Resident #33 after each meal and staff were to monitor and record his intake after each meal. The care plan indicated staff were to weigh Resident #33 once a week. Review of the nutritional orders dated 03/13/18 revealed Resident #33 was ordered mighty shakes, a nutritional supplement, twice a day with lunch and dinner. Resident #33 was to have finger foods after each meal. Review of the diet order dated 04/18/17 revealed the resident was on a regular diet. Review of a physician's orders [REDACTED].#33 was on a one-on-one feeding program. Staff were to physically assist Resident #33 with eating his meals. Review of a physician's orders [REDACTED].#33 was to be weighed once a week, every Wednesday, for weight monitoring. Review of Treatment Administration Records (TARs) from 10/25/17 through 04/11/18 revealed Resident #33 had lost 15.41% of his weight over the past 180 days. On 10/25/17, Resident #33's weight was 161.8 pounds (lbs). Resident #33's weight recorded on 04/11/18 was 140.2 lbs, a loss of 21.6 pounds and 15.41% weight loss for the past 180 days. Further review of the TARs revealed staff did not check and record Resident #33's weight for the following weeks: 10/01/17 to 10/07/17, 11/01/17 to 11/25/17, 12/03/17 to 12/09/17, 12/17/17 to 12/23/17 and 12/31/17 to 01/06/18. Review of State tested Nurse Aide Records (STNA) Flow Sheet Records from 04/01/18 through 04/11/18 revealed the staff only set up Resident #33 for meals and did not physically assist him to eat. Further review of the STNA Flow Sheets from 04/12/18 through 04/18/18 revealed no meal/food intakes were recorded for Resident #33 for each of those days. Review of dietary progress notes dated 04/17/18 revealed Resident #33 had a significant weight loss in the last 180 days. Resident #33 lost two pounds (1.7%) for the past 30 days; seven pounds (4.5%) for the past 90 days and 22 pounds (13.7%) for the past 180 days, which resulted in a significant weight loss during the last 180 days. Further review of the progress notes revealed Resident #33's weight loss was related to his continued decline in condition and increase in confusion. On 04/17/18 at 12:30 P.M., observation in 400/500 dining area during lunch revealed Resident #33 did not eat his food and no staff physically assisted Resident #33 to eat his food as ordered. On 04/18/18 at 12:26 P.M., observation of Resident #33 during lunch revealed he was not physically fed at lunch. Resident #33 was served Brussel sprouts, pureed potato and bread. He was also served 6 ounces of a supplemental shake and 8 ounces of coffee. Resident #33 did not eat his food, got up and left the dining room. No staff made any effort to feed Resident #33 his lunch. On 04/18/18 at 12:40 P.M., observation of Resident #33 revealed he was not provided with any finger foods after lunch as recommended. On 04/18/18 2:28 P.M. interview with Licensed Practical Nurse (LPN) #208 revealed Resident #33 had not been eating well. LPN #208 said sometimes Resident #33 would eat by himself. LPN #208 said the staff only feed Resident #33 when he refused to eat. On 04/18/18 at 2:45 P.M. interview with STNA #250 revealed the staff intermittently assist Resident #33 with eating. STNA #250 stated Resident #33 normally will not eat his food by himself unless staff encourages him. STNA #250 said sometimes Resident #33 eats by himself and other times staff assist him to eat. STNA #250 verified the staff have not been feeding Resident #33 on a daily basis. On 04/19/18 at 8:26 A.M., interview with LPN #210 verified the staff have not been feeding Resident #33 every day. LPN #210 stated the STNAs only supervise Resident #33 during meal time. On 04/19/18 at 9:03 A.M. interview with STNA #220 verified staff only supervise Resident #33 during breakfast, lunch and dinner. On 04/19/18 at 10:25 A.M. interview with Clinical Care Manager (CCM) #1 verified that on 04/01/18 through 04/18/18, according to the STNA Flow Sheets, the staff did not assist Resident #33 to eat his foods ordered.

Based on closed medical record review, hospital record review, facility policy review and interviews, the facility failed to adequately assess and monitor Resident#141's skin status and provide treatments accordingly. Actual harm occurred when the facility failed to ensure ongoing assessment, monitoring and treatment were provided to Resident #141's toe and the resident was transferred to the hospital and assessed to have osteo[DIAGNOSES REDACTED] (infection of the bone) and Methacillin-resistant Staphylococcus Aureus (MRSA) to the right second toe and the hospital recommended course of treatment including amputation of the toe. This affected one resident (Resident #141) of three sampled residents reviewed for infection. Findings include: Review of Resident #141's closed medical record revealed Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a 05/02/17 podiatry note revealed Resident #141 requested to be seen and had scabbed areas to the left second toe and left fourth toe. The fourth toe had some bleeding. New orders were written by the podiatrist and reviewed with nursing. The note did not mention the resident's right foot or toes. A 07/11/17 podiatry note revealed Resident #141 had a recent bout of [MEDICAL CONDITION] to the right foot and was on the antibiotic, [MEDICATION NAME]. The note stated the resident had a dressing in place to the right foot. The note did not describe the appearance or condition of the right foot or include any type of wound information for the right foot or toes. Record review revealed a plan of care, dated 06/23/17 indicting Resident #141 was at risk for skin impairment and had an open area. The care plan did not specify the location of the open area of skin impairment. An intervention of the wound care plan included to report declines in skin condition to the physician. Review of all of the shower sheets for Resident #141 during the resident's stay at the facility, with the first shower sheet, dated 03/30/17 and the last shower sheet dated 07/17/17, revealed no identified skin impairment to the right foot or toes. Review of Resident #141's March, 2017 through May, 2017 treatment administration records (TAR) revealed no treatments to the right foot. Review of the June, 2017 TAR revealed there was no specific order for a treatment to the right foot or toes. A new order was noted, dated 06/29/17 which included to cleanse with wound cleanser or normal saline, apply hydrogel, ABD pad and Kerlix. The dressing was ordered to be changed three times weekly and as needed (PRN). However, the order did not specify what skin area the treatment was for. There was an additional order for a weekly skin assessment every Monday, and to document any abnormal findings. Review of Resident #141's July, 2017 TAR revealed the order to cleanse the wound with wound cleanser or normal saline and apply hydrogel continued through the resident's discharge from the facility on the evening of 07/23/17. The order continued to not specify the location of the treatment. Additionally, record review revealed no evidence the treatment order was changed at any time between 06/29/17 and 07/23/17. The July, 2017 TAR also continued to list an order to check the resident's skin status weekly and document abnormalities. The TAR was signed by the nurse indicating this was completed every week the resident was in the facility, including on 07/10/17 and 07/17/17. Review of Resident #141's June, 2017 through July, 2017 nurse's notes revealed no notes regarding the skin status of Resident #141 in June 2017. There was no note on 06/29/17 regarding why a new treatment order was written or what the treatment order was for. There was no note regarding the skin status of the resident, and no note regarding the right foot or toes of the resident. No notes regarding the skin status of Resident #141, or any abnormalities to the skin were noted in the July 2017 progress notes for the resident. The nurse's notes did not include any monitoring for infection to the right foot even though the podiatrist had indicated the resident had had [MEDICAL CONDITION] and was on antibiotics. The facility was unable to provide any skin assessments for Resident #141, including skin assessments regarding the right foot or toes. Record review revealed Resident #141 was discharged to the hospital on [DATE] and did not return to the facility. Review of the 07/24/17 discharge Minimum Data Set (MDS) 3.0 assessment revealed the resident required limited assistance from staff for transfers, and supervision for locomotion on the unit and locomotion off the unit. Review of the hospital records for Resident #141 for a hospital stay that began on 07/23/17 revealed a 07/24/17 hospital note that indicated Resident #141 was being seen for osteo[DIAGNOSES REDACTED]. The note revealed Resident #141 was found to have a right second toe wound that probed to the bone. The note stated Resident #141 stayed at a skilled nursing facility, and the resident stated that sometimes the facility looked at the wrong foot. A 07/25/17 hospital note revealed Resident #141 was seen by podiatry in the emergency department and the recommendation was made to amputate the right second toe. An 07/28/17 note stated Resident #141 had osteo[DIAGNOSES REDACTED] to the right second toe, podiatry was consulted, a wound culture had been obtained 07/24/17, and the resident [MEDICAL CONDITION] on the bone biopsy. Podiatry was recommending a toe amputation if the resident was agreeable. An additional 07/28/17 hospital note stated Resident #141 did not want to have an amputation, and the resident was recommended to continue on an intravenous (IV) antibiotic, [MEDICATION NAME] for six to eight weeks. Interview on 09/25/17 at 11:37 A.M., with the Administrator revealed the facility did not have any skin assessments for Resident #141 from during the resident's stay at the facility and there was no documentation of the skin status of the resident's toes. The Administrator verified there were no assessments of Resident #141's right foot. He stated the wound nurse at the time that Resident #141 resided in the facility would have been a practitioner from an outside wound consultant group, however there was no documentation or orders noted from the consultant wound group. Telephone interview on 09/25/17 at 11:47 A.M., with a representative from the consultant wound group revealed no person from that company had been out to see Resident #141, and the company had not even been in the facility for many months. Interview on 09/25/17 at 12:05 P.M., with Licensed Practical Nurse (LPN) #29 revealed when Resident #141 resided in the facility staff called the areas to the resident's toes an abrasion. LPN #29 stated there was a treatment to the right toes started in June, 2017. She stated Resident #141 was often in her wheelchair self propelling throughout the facility and in her room. The LPN stated sometimes Resident #141 would bleed from her feet and the nurse's would dress the abrasions when she would bleed. LPN #29 stated she recalled seeing the right toes of Resident #141 on 06/29/17, and when she looked at them, they looked like the top layer of skin was gone. The area was bleeding from her self propelling in the wheelchair and she after cleaning the area off, it looked like the top layer of skin was gone. She stated she called the resident's house physician when she saw the skin impairment on the resident's foot, and got the order to cleanse and apply hydrogel on that day. LPN #29 verified she did not write an assessment or nursing progress note about this. She stated she was not sure when the wound to the right toes first developed. She confirmed the nurses should have been monitoring for signs and symptoms of infection, including with the resident's recent [MEDICAL CONDITION] to the right foot. LPN #29 was unaware of any other infection to the residents right foot or toes. Additional interview on 09/25/17 at 12:46 P.M., revealed LPN #29 was unsure what Resident #141's right foot looked like at the time the resident went to the hospital on [DATE], and she was unsure the last time she had seen the resident's feet. She stated the nurse on the hall should have been assessing Resident #141's feet weekly, and documenting any findings. She confirmed she could not locate any assessments of the skin status of Resident #141. Review of the undated wound protocol revealed areas would be identified and a treatment would immediately be put in place. The area would be monitored for signs and symptoms of infection, and any other complication that may contribute to complications in healing. The policy stated all steps initiated and monitoring would be documented. A skin care alert form would be given to the wound nurse along with the details of immediately placed treatment. The wound care nurse would determine if a consult with a consultant wound group was warranted and the wounds would be reviewed weekly in the interdisciplinary team meeting. The consultant wound group and the wound nurse would monitor wounds weekly to determine healing and to make adjustments to the treatment regimen as needed. This deficiency substantiates Complaint Number OH 219.

Based on observation, record review, policy review, and family, resident and staff interviews, the facility failed to implement new fall interventions after a fall. This resulted in Actual Harm to Resident #86, when the resident fell , had no new interventions implemented for fall risk, and fell again, fracturing her left upper arm. The facility failed to assess fall risk, investigate falls, implement and maintain fall safety measures and develop and update fall plans of care. This affected 15 (Residents #7, #45, #50, #58, #62, #64, #67, #83, #86, #109, #117, #132, #133, #135 and #138) of 21 residents reviewed for falls. Findings include: 1. Review of the medical record revealed Resident #86 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a 12/02/15 Fall Risk Assessment included preventative sock/grip, wanderguard and assist with transfers as needed as interventions. Review of a 12/03/16 Fall Risk Assessment indicated the resident was at high risk for falls because the resident had one to two falls in the last 90 days, cognitive status change in the last 90 days, eliminates with assistance, confined to a chair, partial physical support during test or stands but does not follow directions, [AGE] years or older, had three or more health conditions and medications increasing potential risk. There were no fall interventions documented on the Fall Risk Assessment since 12/02/15. Review of the medical record revealed there was no plan of care for fall risk. Review of a nurses note dated 02/26/17 revealed Resident #86 was found sitting on the floor near the wheelchair and bed. The resident had slid from the wheelchair to the floor. No injuries were noted and the resident denied pain. The resident was able to move extremities without difficulty, and had no open areas. The physician was notified, and nurse will report to incoming nurse to inform the power of attorney. The resident had no plan of care for fall risk and no new interventions implemented. Review of the 04/21/17 Minimum Data Set (MDS) 3.0 assessment revealed Resident #86 was severely impaired for daily decision making, and had disorganized thinking and inattention. Bed mobility and transfers were an extensive assist of two. There was one fall without injury since the last assessment. Review of a nurses note dated 06/02/17 at 4:18 A.M. revealed Resident #86 sustained a fall. The State tested Nurse Aide (STNA) saw the resident on the floor next to her bed and notified the nurse. When assessed, the resident was unable to move her left arm. The physician was notified, and staff were waiting for an order for [REDACTED].M. revealed a supracondylar fracture and joint effusion. Review of a nurses note dated 06/02/17 at 7:12 P.M. revealed orders were received to send Resident #86 to the emergency room . The resident was transferred to the emergency room to be evaluated, and denied pain at this time. Review of a nurses note dated 06/03/17 at 8:41 A.M. indicated Resident #86 had returned from the emergency room at 4:25 A.M. The resident was alert and oriented times one, her left arm was immobilized with a cast, and she had no signs of distress. Review of the emergency room Report dated 06/03/17 at 11:16 A.M. revealed Resident #86 had swelling to the left arm just above the elbow with obvious deformity. A humerus fracture was treated with immobilization, and a splint was placed. The resident received multiple doses of Haldol and Valium in the emergency room and the resident was unable to be sedated and cooperative. Review of a nurses note dated 06/05/17 at 1:00 P.M. indicated the resident had returned from the emergency roiagnom on [DATE] with instructions to keep splint in place until follow up with orthopedic in five to seven days. The Hospice nurse stated she did not think they should put the resident thru an appointment when they would keep her in the splint from the emergency room . The husband agreed with the Hospice nurse and wanted to keep the resident in the splint and re- x-ray in six weeks. The facility was unable to locate an investigation for this fall. Review of a physician order [REDACTED]. There was no evidence of a comprehensive Fall plan of care developed until 06/22/17. The floor mat was not included on the 06/22/17 Fall plan of care. On 06/23/17 at 11:27 A.M. Resident #86 was observed in her room in a wheelchair with a seatbelt. The floor mat was on the floor next to her bed. Resident #86 did not have her left arm splint on as ordered. On 06/23/17 11:33 A.M. Licensed Practical Nurse (LPN) #163 looked in the computer and verified Resident #86 was to have a splint on her left arm for six weeks due to her fracture, until it was re x-rayed. LPN #163 verified the splint was not on the left arm as ordered. On 06/23/17 at 11:25 A.M. the Director of Nursing (DON) verified Resident #86 was assessed at high risk for falls, had previous falls with a comprehensive plan of care not developed and fell [DATE] sustaining a fracture. The DON verified a Fall plan of care was not put in place until 06/22/17. The DON verified the left arm splint was not in place after the fracture. 2. Review of the medical record revealed Resident #62 was admitted to the facility 09/17/16 with [DIAGNOSES REDACTED]. Review of the comprehensive Fall care plan initiated 10/12/16 indicated the resident was at risk of falls due to confusion, impaired balance and gait, depression, new admission, [DIAGNOSES REDACTED], obesity, and psychotropic medication use. On 02/09/17 added interventions were to use alarms as ordered, dycem to wheelchair, two person assist with transfers, mat at bedside and on 03/13/17 medication adjustments were made. Review of the 02/06/17 Fall Assessment revealed Resident #62 was a high fall risk related to three or more falls in the last 90 days, behaviors, independent and incontinent, confined to chair, not able to attempt balance test without help, three or more health conditions and medications. The intervention on the back of the Fall Assessment was a two person assist for transfers. Review of the resident's MDS 3.0 assessment dated [DATE] revealed the resident's cognition was severely impaired, was an extensive assist of two for bed mobility and extensive assist of one for transfers. Resident had no falls since the previous assessment, exhibited no physical behaviors towards others, inattentive behavior came and went and disorganized thinking was continuously, present exhibited four to six days of verbal behaviors and daily rejected care. Review of the physician orders [REDACTED]. Review of the June fall incident log revealed had Resident #62 two falls on 06/12/17 and one fall on 06/15/17. Interview of the DON on 06/21/17 at 4:02 P.M. indicated she could not find the 06/15/17 incident report but provided the incident reports for 06/12/17. Review of the incident report indicated on 06/12/17 at 3:45 A.M. Resident #62 was found on the floor. Review of the second incident report dated 06/12/17 at 11:10 P.M. revealed the resident stated she fell from the bed to the mat on the floor. She denied hitting her head. She was found sitting in an upright position next to the bed by the State tested Nurse Aide (STNA). Call light functioned. Resident attempted to transfer self to wheelchair without assist and fell to floor mat. New interventions were a bed alarm and perimeter mattress. The facility did not provide an incident report or investigation for the 06/15/17 fall. Review of the nurses note dated 06/15/17 at 1:04 P.M. indicated the nurse was called to the dining room because Resident #62 was on the floor. Resident #62 was sitting in front of the wheelchair facing the wall. She had an abrasion above her right eye. Range of motion was equal to all extremities with no complaints of pain. The resident stated she was trying to get her flag that fell on the floor. There was no notation if her wheelchair alarm was sounding. The new intervention was to discontinue the wheelchair alarm and place a wheelchair seat belt. On 06/21/17 at 1:32 P.M. observation of Resident #62 in the center corridor nurse station of 100-200-300 Hall revealed Resident #62 self propelled her wheelchair. Resident #62 was in dress with a green sweater on, Velcro shoes and slipper socks. She held her baby doll. Resident #62's alarming seat belt was not fastened. There was no dycem observed in the seat of her wheelchair. Resident #62's bottom was toward the front edge of the wheelchair. Marketing Staff #106 verified the alarming seat belt was not fastened. Marketing Staff #106 verified the resident was sliding in her wheelchair. Marketing Staff #106 fastened the alarming seat belt and pushed her in the wheelchair outside. At 2:02 P.M. Marketing Staff #106 indicated she took Resident #62 to the therapy room. She had them stand her and verified there was no dycem in the seat of the wheelchair. Marketing Staff #106 indicated she had a piece of dycem placed in the resident's chair in therapy. On 06/21/17 at 2:10 P.M. interview of STNA #123 revealed Resident #62 was already in her chair when he arrived for 7:00 A.M. STNA #123 indicated he did not check to see if the alarm was on. He indicated he had not heard her seat belt alarm that day. He verified the resident's room had a floor mat next to the bed but no perimeter mattress on the bed as ordered. On 06/21/17 at 2:13 P.M. Registered Nurse (RN) #76 verified the dycem, seat belt alarm and perimeter mattress were not on as ordered. Review of the comprehensive Fall plan of care revealed the new interventions of a bed alarm, perimeter mattress and an alarming seatbelt were not added. Interview with the DON on 06/22/17 at 2:12 P.M. revealed the fall documentation and safety measures were not in place. She verified the care plan had not been updated with the new interventions. 3. Review of the medical record revealed Resident #67 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 04/20/17 MDS revealed Resident #67 was moderately impaired for daily decision making, extensive assist of one for bed mobility and transfer and had no falls since the last assessment. A comprehensive Fall plan of care was not developed until 06/21/17. Review of the STNA Kardex included safety interventions as bed in lowest position, non skid footwear, perimeter mattress, floor mat beside bed, non skid strips at bedside and bed and chair alarm. Review of the incident log revealed Resident #67 fell on [DATE]. The facility was unable to locate an incident report or investigation of the fall. Review of the nurses note dated 06/12/17 at 3:00 P.M. the resident was sitting on the floor in her room. She used sign language to indicate she was going to bed. She denied pain or injury. The chair alarm was on the bed with wires pulled out so a new chair alarm was applied. Observation on 06/21/17 at 3:22 P.M. revealed Resident #67's bed did not have a bed alarm. Interview of STNA #71 at that time revealed she had taken Resident #67 out of bed that morning and an alarm did not ring. STNA #71 indicated she made the bed and there was no alarm in the bed. STNA #71 indicated she did not know Resident #67 was to have an alarm in her bed. STNA #71 verified the STNA Kardex sheets were a guide to care but she had not noted the safety interventions. Interview with the DON on 06/22/17 at 2:12 P.M. revealed the facility had no evidence of an incident report or investigation report of Resident #67's fall on 06/12/17. The DON verified safety measures were not in place as ordered. 4. Review of the medical record revealed Resident #58 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 09/12/16 At Risk for Falls plan of care due to confusion, impaired balance, impaired hearing/deaf, unsteady gait, emphysema, schizophrenia, Barrette's esophagus, Alzheimer's, hearing loss, psychiatric meds and history of falls revealed interventions included to anticipate/meet needs, appropriate non skid footwear when out of bed, call light in reach at all times and personal items in reach at all times. The plan of care had not been updated for interventions since its 09/12/16 initiation. Review of a 01/31/17 Fall Assessment revealed Resident #58 was a high risk for falls related to behaviors, independent and incontinence, partial physical support for balance, doesn't follow directions, three or more health conditions and medications that add to risk of falls. Review of the physician orders [REDACTED]. Review of the 02/20/17 MDS3.0 assessment revealed Resident #58 was severely impaired for daily decision making, an extensive assist of one for bed mobility and transfers and had no falls since the last assessment. A physician's orders [REDACTED]. Review of the facility's Fall Investigation revealed Resident #58 fell on [DATE] at 9:45 A.M. The resident was transferring self from chair to bed. Staff witnessed resident attempting to transfer self unassisted from chair to bed and lost his balance and fell on the floor. The observations at the time of the fall included call light not in reach, independent, resident refuses assistance and alarm sounding. Suspected cause of the fall was self transferring. The new intervention was to place in common areas when in chair. It indicated it was added to the plan of care. A physician's orders [REDACTED]. Review of the STNA Kardex revealed the resident was to have a perimeter mattress, chair alarm, bed alarm and resident to be placed in a common area when up. The STNA Kardex had not been updated for dycem to wheelchair. Observation of Resident #58 on 06/21/17 at 3:30 P.M. revealed Resident #58 was in bed. There was no perimeter mattress on the bed, dycem in the wheelchair or an alarm box observed on the bed. There was an alarm box on the bedside table not connected. On 06/21/17 at 3:34 P.M. interview of STNA #147 revealed she had put Resident #58 to bed around 2:30 P.M She had not checked to see if he had an alarm on his bed. STNA #147 checked Resident #58's bed and discovered an alarm pad was in the bed with a broken wire. There was no alarm box attached to the alarm's pressure sensitive pad. Observation on 06/22/17 at 12:58 P.M. revealed Resident #58 was transferred by STNA #66 to the wheelchair. There was no alarm on the bed or dycem on the wheelchair seat. RN #76 verified the absence of the dycem and alarm at the time of the transfer. Interview with the DON on 06/22/17 at 1:45 P.M. verified safety measures were not in place as ordered including the perimeter mattress. She verified the Fall plan of care and STNA Kardex had not been updated with current fall interventions. The DON verified the lack of documentation related to the fall in the medical record. 5. Review of the medical record revealed Resident #50 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a 01/20/16 Fall Assessment revealed Resident #50 was a high risk of falls with three or more falls in the last 90 days, cognition impairment, loss of vision, elimination with assistance, confined to a chair, unable to test balance without physical help, health conditions and medications of three or more. A Fall plan of care was not developed until 06/21/17. Review of the 04/06/17 MDS 3.0 assessment revealed Resident #50 was severely impaired for daily decision making, needed limited assist of one for bed mobility and transfer, and had no falls since the last assessment. Review of the physician orders [REDACTED]. The STNA Kardex included safety interventions of bed in lowest position, floor mat beside bed, bed and chair alarm and autolock wheelchair brakes. Review of the incident log revealed Resident #50 fell on [DATE]. The facility was unable to locate an incident report or investigation related to the fall. Review of the nurses noted dated 06/02/17 revealed at 4:30 A.M. the nurse was notified the STNA responded to a sound in Resident #50's room and found the resident on the floor next to the bed. There was no evidence the alarm was sounding. Observation on 06/21/17 at 3:28 P.M. revealed Resident #50 was in bed. There was an alarm on the bed but the light was not blinking indicating it was in use. Interview of STNA #67 on 06/21/17 at 3:28 P.M. revealed he had put Resident #50 in bed and thought the alarm was on. STNA #50 indicated he did not know the alarm had to be activated by the resident's pressure on the alarm mat. He was unaware the light on the control box had to be blinking to indicate the alarm had been activated. Interview with the DON on 06/22/17 at 2:12 P.M. revealed the facility had no evidence of an incident report or investigation report. She verified a fall intervention was not put in place after the 06/02/17 fall until 06/21/17. 6. Review of the medical record revealed Resident #83 was admitted [DATE] with [DIAGNOSES REDACTED]. The record contained no Fall Assessment at admission. Review of the incident log revealed Resident #83 fell on [DATE], 06/10/17 and 06/11/17. The facility was unable to locate an incident report or investigation for the 06/03/17 fall. Review of the nurses notes dated 06/03/17 at 9:04 A.M. revealed the nurse was notified the STNA found Resident #83 on the floor by the television lounge. The resident was in a seated position. The resident had been seated in a chair prior to the fall. Review of the physician orders [REDACTED]. Review of the 06/13/17 MDS 3.0 assessment revealed Resident #83 was severely impaired for daily decision making, extensive assist of one for bed mobility and transfer and had two or more falls without injury since the last assessment. A Fall plan of care was not developed until 06/21/17. On 06/21/17 at 3:04 P.M. STNA #162 verified there was no STNA Kardex in place to guide Resident #83's care. Observation on 06/21/17 at 3:47 P.M. revealed Resident #83 was in bed. There was no evidence of a bed alarm on the bed as ordered. On 06/21/17 at 3:47 P.M. Licensed Practical Nurse (LPN) #104 verified the bed alarm was not in place as ordered and Resident #83 was in bed. Interview of the DON on 6/22/17 at 4:13 P.M. revealed the facility had no evidence of an incident report or investigation report for the 06/03/17 fall. She verified the lack of a fall assessment at admission. 7. Review of the medical record revealed Resident #138 was admitted [DATE]. A 12/28/16 Fall Assessment revealed Resident #138 was at high risk for falls due to ambulating with problems and/or devices, partial physical support needed for balance and three or more qualifying medications. No Fall plan of care was developed at that time. Review of the 04/08/17 MDS 3.0 assessment revealed Resident #138 was independent for daily decision making, an extensive assist of one for bed mobility and transfer, and had no falls since the last assessment. Review of the physician orders [REDACTED]. Review of the incident log revealed a fall on 06/14/17. The facility was unable to locate an incident report or investigation related to the fall. Review of the nurses note revealed on 06/14/17 at 7:15 P.M. Resident #83 was found on the floor in the bathroom complaining of left hip pain and had a skin abrasion to the left elbow. Review of the STNA Kardex indicated to not allow Resident #138 to be alone in the bathroom. The intervention to keep the wheelchair away from the bed as a fall prevention was not documented on the Kardex. A Fall plan of care was developed on 06/22/17. It did not include to not allow Resident #138 to be alone in the bathroom or to keep the wheelchair away from the bed as fall preventions. Observation on 06/21/17 at 6:04 P.M. revealed Resident #138 was in her room in her wheelchair. Interview of Resident #138 at the time of the observation revealed on 06/14/17, she had rung her call bell and no one came so she transferred herself to the wheelchair and took herself to the bathroom. After pulling up her pull up she thought the wheelchair was locked. One side wasn't and she fell transferring herself back to the wheelchair. Resident #138's sister was visiting. She said when she arrived on 06/21/17 around 12:25 P.M., Resident #138 was in bed and her wheelchair was next to the bed. The resident's granddaughter was also present. She indicated initially after the fall the wheelchair was kept away from the bed but it was near the bed in most recent visits. On 06/21/17 at 3:47 P.M. LPN #104 verified the bed alarm was not in place as ordered and Resident #83 was in bed. On 06/21/17 at 6:21 P.M. STNA #48 revealed he was unaware the wheelchair was to be kept out of reach when Resident #138 was in bed. Interview with the DON on 06/22/17 at 4:13 P.M. revealed the facillity had no evidence of an incident report or investigation report for the 06/14/17 fall. She verified the lack of a Fall plan of care until 06/22/17. 8. Review of the medical record revealed Resident #109 was admitted [DATE] with [DIAGNOSES REDACTED]. A Fall plan of care related to gait and history of falls was developed 08/23/16. Review of the physician orders [REDACTED]. Review of a 01/30/17 Fall Assessment revealed Resident #109 was at high risk for falls related to a history of falls, moderately impaired vision, ambulating with problems and/or devices, unsteady buy able to balance with out physical support and three or more qualifying medications and diagnosis. Review of a physician order [REDACTED]. Review of the 04/05/17 MDS 3.0 assessment revealed Resident #109 was independent for daily decision making, needed imited assist of one for bed mobility and transfer, and had no falls since the last assessment. Review of the STNA Kardex indicated it included to keep a reacher in reach at all times. It did not include the non skid footwear at all times and non skid strips to the bathroom and bedside. The Fall plan of care was not updated for non skid footwear at all times and non skid strips to the bathroom and bedside. Review of the incident log revealed Resident #109 fell on [DATE]. The facility was unable to locate an incident report or investigation related to the fall. Review of the nurses note revealed on 06/09/17 at 6:30 A.M., Resident #109 was found sitting on the floor near the bed, stating she was trying to transfer from the bed to wheelchair. There was no evidence of a new fall intervention. Observation on 06/21/17 at 5:50 P.M. revealed there were no non skid strips next to Resident #109's bed. On 06/21/17 at 5:50 P.M. LPN #5 verified the non skid strips next to the bed were not in place as ordered. Interview with the DON on 06/23/17 at 10:55 A.M. revealed the facility had no evidence of an incident report or investigation report for the 06/09/17 fall. She verified the Fall plan of care was not updated with the interventions to keep a reacher in reach at all times, or the non skid footwear at all times and non skid strips to the bathroom and bedside. She verified no there was no evidence of a new fall intervention afgter the 06/09/17 fall. 9. Review of the medical record revealed Resident #64 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a 04/04/17 Fall Assessment revealed Resident #64 was a low risk for falls. Review of the 04/14/17 MDS 3.0 assessment revealed Resident #64 was independent for daily decision making, independent for bed mobility and transfer and had one fall without injury since the last assessment. Review of the physician orders [REDACTED]. There was no Fall plan of care until 06/22/17. Review of the incident log revealed Resident #64 fell on [DATE]. The facility was unable to locate an incident report or investigation related to the fall. Review of the nurses note dated 06/04/17 revealed at 7:34 P.M. Resident #64 was found on his knees in his room. He stated he became tangled in his call light and fell to the ground. Intervention was to reroute the call light to the opposite side of the bed from where he gets out. Interview with the DON on 6/22/17 at 4:55 P.M. revealed the facility had no evidence of an incident report or investigation report for the 06/04/17 fall, and no Fall plan of care developed until 06/22/17. 10. Review of the medical record revealed Resident #133 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a 03/27/17 30 Fall Assessment revealed Resident #133 was a high risk for falls related to moderately impaired vision, elimination with assistance, ambulates with problems and with devices, unsteady but able to rebalance without physical support, three or more health conditions and one to two precipitating medications. Review of the 04/30/17 MDS 3.0 assessment revealed Resident #64 was moderately impaired for daily decision making, extensive assist of two for bed mobility, extensive assist of one for transfer and had two falls without injury and one fall with minor injury since the last assessment. Review of the physician orders [REDACTED]. Review of the incident log revealed Resident #64 had a fall on 06/08/17. The facility was unable to locate an incident report or investigation related to the fall. Review of the nurses note revealed on 06/08/17 at 7:15 A.M. Resident #133 was found in a seated position by the side of the bed. She indicated she walked to her bed without staff assist, walker or wheelchair. A Fall plan of care related to pain, recent surgery and impaired balance was developed on 06/22/17. The dycem to be applied under wheelchair cushion to prevent sliding and touch pad were not included on the plan of care. Observation on 06/21/17 at 6:18 P.M. revealed Resident #133 self propelled into the room wearing a back brace. Resident #133 attempted to transfer into the bed and stopped her movement. STNA #48 indicated he did not know how to transfer her. He then assisted her to bed. Observation revealed there was no alarm on the chair, dycem in the wheelchair or a touch pad call light. Interview with STNA #78 at the time of the transfer verified there was no chair alarm, touch call pad or dycem in her chair per orders. Interview with the DON on 06/22/17 at 4:55 P.M. revealed the facility had no evidence of an incident report or investigation report for the 06/08/17 fall. She verified Resident #133 had a history of [REDACTED]. 11. Review of the medical record revealed Resident #7 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of an admission Fall Assessment revealed Resident #7 was a high risk for falls related to confusion, intellectual disability, impaired balance, developmental disabilities, impaired hearing/deaf, new admission, and recent fall. A Fall plan of care related to pain, recent surgery and impaired balance was developed 05/19/17 related to a risk of falls for confusion, intellectual disability, impaired balance, developmental disabilities, impaired hearing/deaf, new admission, and recent fall. Interventions included call light in reach, anticipate needs, non skid footwear. Review of the physician orders [REDACTED]. Review of the 05/30/17 MDS 3.0 assessment revealed Resident #7 was severely impaired for daily decision making, needed extensive assist of two for bed mobility, extensive assist of one for transfer and had one fall without injury since the last assessment. Review of the incident log revealed Resident #7 had a fall on 06/04/17. The facility was unable to locate an incident report or investigation related to the fall. Review of the nurses note revealed on 06/04/17 at 3:44 P.M. Resident #7 was found in a seated position in front of her wheelchair by her room. Staff was unable to reach her in time. There was no evidence of a new intervention after the fall. Interview with the DON on 6/22/17 at 5:05 P.M. revealed the facility had no evidence of an incident report or investigation report for the 06/04/17 fall. She verified there was no evidence of a new intervention. 12. Review of the medical record revealed Resident #45 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the admission Fall Assessment revealed Resident #45 was a high risk for falls related to elimination with assistance, ambulates with problems and devices, not able to attempt balance without physical help, and three or more [DIAGNOSES REDACTED]. Interventions included reeducate on use of call light and non skid footwear when up. Review of the physician orders [REDACTED]. Review of the 03/28/17 MDS 3.0 assessment revealed Resident #45 was independent for daily decision making, needed extensive assist of one for bed mobility and extensive assist of two for transfer and had no falls since the last assessment. Review of the incident log revealed Resident #45 had a fall on 06/08/17. The facility was unable to locate an incident report or investigation related to the fall. Review of the nurses note revealed on 06/08/17 at 4:35 P.M. Resident #45's roommate alerted staff of the resident's fall. Resident #45 was found on the floor in his bathroom with his feet facing the toilet and head and shoulders in the doorway. The resident had his undergarments pulled down. Resident #45 had two new superficial red marks on his back. Resident #45 stated he transferred self in walker but the wheelchair was in his way leading him to fall. Interview with the DON on 06/22/17 at 5:05 P.M. revealed the facility had no evidence of an incident report or investigation report for the 06/08/17 fall. 13. Review of the medical record revealed Resident #135 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the admission Fall Assessment revealed Resident #135 was a high risk for falls related to impaired balance, impaired hearing/deaf, new admission, pain, recent hospitalization /surgery, unstable(TRUNCATED)

Based on observation, record review, resident interview, family interview and facility staff interview, the facility failed to address and effectively treat one resident's pain. This resulted in Actual Harm when Resident #106 sustained back pain at a level of 10 on a scale of one to 10 for 1.5 hours resulting in her inability to complete her morning care needs. This affected one (Resident #106) of three residents reviewed for admission orders [REDACTED] Findings include: Review of Resident #106's record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge paperwork revealed an order for [REDACTED]. Review of the MAR indicated [REDACTED].M. An observation on 03/16/17 at 10:15 A.M. in Resident #106's room revealed the resident was sitting up in the chair trying to brush her teeth. Her hair appeared disheveled and uncombed. The resident was not wearing any pants. An interview on 03/16/17 at 10:15 A.M. with Resident #106 revealed she was just admitted to the facility on [DATE] from the hospital after having a lumbar fusion performed. Resident #106 stated she had therapy several times a day and had pain from her surgery. An observation on 03/16/17 at 10:34 A.M. revealed Registered Nurse (RN) #17 was standing at the medication cart by the nurses station. RN #80 approached RN #17 and stated she had just spoke with Resident #106 and the resident was having severe pain in her back and wanted something for it. RN #17 stated the resident wasn't due for anything at that time. RN #80 suggested RN #17 contact the doctor and see if he could order anything else for pain. RN #17 stated the doctor was supposed to visit the facility that day and she would wait and see if he came. An observation on 03/16/17 at 10:56 A.M. revealed Resident #106 was in bed, moaning and grimacing in pain. Resident #106 had a difficult time speaking with the surveyor. The resident stated her pain was a 9 out of 10. An interview on 03/16/17 at 11:02 A.M. with RN #17 revealed that she was notified by RN #80 that Resident #106 had severe pain. RN #17 stated the physician was supposed to come to the facility that day and she would wait and ask him about Resident #106's pain. An observation and interview on 03/16/17 at 11:40 A.M. revealed Resident #106 was laying in bed moaning and writhing in the bed. Resident #106's daughter was at the bedside and the resident's call light was on. Resident #106's daughter stated her mother was having pain and she was very uncomfortable. Resident #106 stated she had to stop brushing her teeth because of the pain and had to get back in bed. At 11:48 A.M. State tested Nurse Aide (STNA) #12 entered the resident's room and asked her what she needed. Resident #106 was moaning and stated she was having pain. STNA #12 stated he would notify the nurse, and then exited the room. At 11:56 A.M. RN #17 entered the resident's room and asked her what her pain level was. Resident #106 was moaning and moving around in the bed and stated her pain was 10 out of 10. RN #17 left the room. At 12:02 P.M. RN #17 entered Resident #106's room and provided her with [MEDICATION NAME] 50 mg. An interview on 03/16/17 at 12:03 P.M. with RN #17 revealed she did not feel Resident #106's pain was not controlled with the [MEDICATION NAME] that was being given and that she needed something else for pain. RN #17 stated she had texted the physician but he had not responded to her. An interview on 03/16/17 at 1:15 P.M. with the Director of Nursing (DON) and RN #17 revealed that Resident #106 had been taking [MEDICATION NAME] 50 mg every 6 hours as needed for pain and [MEDICATION NAME] (used for nerve pain) 100 mg twice daily at the hospital prior to her admission at the facility. The DON stated when the hospital sent the resident to the facility they did not send a paper prescription for the [MEDICATION NAME] and the pharmacy would not send the medication to the facility without it. The DON confirmed that the [MEDICATION NAME] had not been started upon admission on 03/15/17 as ordered by the hospital. The DON revealed the physician was finally contacted and had ordered [MEDICATION NAME] for the resident's pain. The DON confirmed that the [MEDICATION NAME] had all ready been ordered but had never been given. This deficiency substantiates Complaint Number OH 917.