Every finding on record at Lake Pointe Rehabilitation and Nursing Center

Based on interviews, and review of the dietitian contract, the dietetic technician's personnel file, and emails, the facility failed to ensure dietitian oversight of a dietetic technician's competency. This had the potential to affect all residents residing in the facility. The facility census was 61.Findings include:Review of the contract between the facility and Consultant Registered Dietitian (CRD) #249 dated 08/01/25 revealed the said dietitian provided the facility with medical nutrition therapy for its residents to include but not limited to nutrition assessments based on the minimum data set (MDS) schedule, and assessments of residents experiencing significant weight changes, compromised skin integrity (pressure ulcers specifically), or has a high risk with receiving specialized care, such as dialysis, tube feeding or hospice services and pediatrics as needed. The primary clinical duties were carried out by the Dietetic Technician (DT), which CRD #249 would supervise. The CRD visited the facility quarterly and more often as needed to complete food service operations audits, sanitation rounds, dining audits and clinical chart audits to ensure proper policies and procedures were in place to be in regulatory compliance. The DT's competency was evaluated annually, based on the documentation reviewed and clinical systems evaluated. The CRD was available for annual state survey or a complaint survey as needed. Review of the personnel file for DT #241 revealed a resume and copy of an associate's degree in applied science in dietetic technology in 1986. There was no evidence of documented initial or ongoing monitoring of competency such as performance evaluations or clinical audits. Interview on 01/05/26 at 9:16 A.M. with DT #241 via phone revealed she worked for an independent consulting company under the license of CRD #249. DT #241 was at the facility once weekly usually on Fridays. She did all the clinical nutritional work, but CRD #249 was available if needed to sign off on such as if there was a special tube feeding. DT #241 stated in a moment's notice she could get CRD #249 on the phone, and CRD #249 came in occasionally, only when needed. Interview on 01/05/26 at 10:20 A.M. with CRD #249 via phone revealed she had an independent consulting company and DT #241 was at the facility the majority of the time and did all the work. CRD #249 stated DT #241 would consult her for high acuity cases where she would review and approve the DT's notes for those cases. She also approved menu changes as needed. CRD #249 stated she was there as a support person and had visited the facility in the past but did not know the last time. CRD #249 stated she did not know any dates. CRD #249 stated that her and DT #241 were close and communicated about twice a week. Review of an email provided by the Administrator dated 01/05/25 at 2:45 P.M. from CRD #249 revealed CRD #249 provided clinical oversight by verbally discussing with DT #241 via telephone regarding high nutritional risk and high acuity patients on an as needed basis. Follow-up interviews on 01/06/26 at 8:52 A.M. and 9:46 A.M. via phone with DT #241 revealed she was not sure if she had received any evaluations from CRD #249. DT #241 stated she did not think she would be able to locate any. DT #241 reiterated that she and CRD #249 talked all the time.

Based on observation, interviews, and facility policy review, the facility failed to maintain resident medical records in a secure environment that safeguarded it from unauthorized use and prevented loss or destruction. This affected an unidentified number of discharged residents. The facility census was 61.Findings include:Interview on 12/30/25 at 12:30 P.M. with Director of Nursing (DON) regarding storage of resident medical records revealed storage of any current residents' records were kept in the locked business office area for confidentiality but stated being unsure of where discharged residents' records were kept.Observation on 12/30/25 at 12:55 P.M. of a detached storage garage on the facility grounds with Director of Maintenance (DOM) #210 revealed it was an unlocked storage area which contained general storage of maintenance equipment and a large amount of banker boxes filled with files. Near the entrance of the garage door were approximately ten opened and unsealed boxes piled on top of each other which contained confidential medical and personal information of discharged residents. At the back of the garage on multiple wooden shelves were additional unsealed banker boxes which contained numerous resident medical and personal records, which included resident shower sheets and assessment sheets. The total number of unsecured boxes exceeded 30. The garage area was easily accessible to any unauthorized individual and was not locked. The residents' records were also not under any climate control to prevent mold, pests, or any environmental changes which could damage the files. A few of the boxes by the garage entrance had damaged corners and were not completely closed. Interview at the time of the observation with DOM #210 revealed he was told to move the boxes to the garage, was unaware of what all the boxes contained and did not realize the garage needed to be locked or that the files needed to be secured as well as protected from the environment. A follow-up interview on 12/30/25 at 1:20 P.M. with the DON revealed she was aware of some resident records being kept in the garage but not of the amount. During the survey, the facility was unable to provide a list of residents by name whose records were being stored in the unsecured garage. Review of facility policy titled, Confidentiality of Information and Personal Privacy revised October 2017 revealed the facility protected and safeguarded resident confidentiality and personal privacy and that access to resident personal and medical records was limited to authorized staff and business associates. This violation is an example of noncompliance investigated under Master Complaint Number 2694466.

Based on interviews, review of the facility surety bond, review of the resident fund balance, and review of a facility email review, the facility failed to maintain surety bond coverage to meet or exceed the total resident fund balance. This affected 29 residents (#1, #2, #3, #6, #9, #12, #14, #16, #20, #25, #27, #28, #29, #31, #32, #33, #35, #38, #39, #41, #44, #45, #47, #48, #51, #52, #53, #56 and #59) out of 29 residents reviewed for resident funds. The facility census was 61.Findings include:Review of the facility document labeled Trust Current Account Balance as of 01/05/26, the total resident fund balance for Residents #1, #2, #3, #6, #9, #12, #14, #16, #20, #25, #27, #28, #29, #31, #32, #33, #35, #38, #39, #41, #44, #45, #47, #48, #51, #52, #53, #56 and #59 was $24,725.31. Review of the facility's surety bond signed 10/24/24 and effective for effective from 02/01/25 through 02/01/26 revealed a coverage amount of $15,000.00, which is less than the total resident fund balance.Review of a facility email dated 01/06/26 at 8:38 A.M. revealed a request by the Chief Financial Officer (CFO) #252 to increase the surety bond to coverage of $25,000.00.Interview on 01/06/26 at 9:30 A.M. with Human Resources #205 verified the surety bond amount of $15,000 and it was less than the total resident account balance of $24,725.31.Interview on 01/06/26 at 10:48 A.M. with the Regional Administrator verified the above findings.

Based on observation, interviews, and facility policy, the facility failed to ensure residents had a clean, comfortable, and homelike environment. This affected five Residents (#15, #19, #24, #25 and #41) out of five residents reviewed for environment. The facility census was 61.Findings include:1. Observation on 12/29/25 at 10:00 A.M. with Maintenance Director (MD) #210 of Residents #24 and #25's room revealed packaging tape wrapped around the window curtains over the window. A strong draft of cold air was felt leaking around the closed curtains. The bathroom had stained and dirty flooring as well as a black substance around the faucet fixtures. The bathroom door had a large piece of wood missing and the door edges were uneven and rough having potential for splintering. The air pressure alarm for Resident #25's mattress was alarming. Interview at the time of the observation with Residents #24 and #25 and MD #210 revealed the residents complained to MD #210 regarding the draft of cold air leaking from the window. MD #210 provided Resident #25 with wide packaging tape to seal the window over the curtains due to the resident's bed location being next to the window. MD #210 stated he would fix the window, however; the residents complained it had been over a month. Resident #24 stated she had asked MD #210 to either fix the low-pressure alarm or provide a new mattress because the alarm would sound whether in or out of the bed. Interview with Regional Maintenance Director (RMD) #211 on 12/29/25 at 10:30 A.M. verified the heavy draft from Resident #24's and #25's window and stated he would remove the tape and seal the window. RMD #211 stated it was unacceptable to just place tape over the drapes to seal it. RMD #211 also verified the bathroom floor being stained and dirty and stated the floor should be replaced. RMD #211 confirmed the black substance around the faucets and damage to the inside of the bathroom door. RMD #211 stated he would refer the cleaning to housekeeping and fix the bathroom door. RMD #211 also confirmed the air mattress alarming and stated it may be a leak in one of the valves. He would check the mattress and if unable to repair it would order a new one. 2. Observation on 12/29/25 at 10:11 A.M. of Resident #41's room revealed two deep wall gashes from mid wall down to the floor with wall debris on floor behind the bed. Interview at the time of the observation with Resident #41 revealed the wall had been that way for a couple of months and that staff were aware. Observation on 12/29/25 at 10:20 A.M. of Resident #41's wall behind the bed with Licensed Practical Nurse (LPN) #234 verified the observed findings. Interview at the time of the observation with LPN #234 revealed the damage to the wall from the resident's bed had been fixed before by maintenance. LPN #41 stated the current state of the wall had been that way for about one month and stated she would inform maintenance. 3. Observation on 12/29/25 at 10:24 A.M. of Resident #19's room revealed the bathroom floor was stained and dirty. There was a heavy leak of air from the window which had a pillow placed over it to defer the draft. The resident's bed was located next to window, and the bathroom was notably stained with blackened areas. The mirror and sink in the bathroom were dirty with dirt built up around the faucets. Interview at the time of the observation with Resident #19 and RMD #211 revealed Resident #19 complained that the window had been leaking cold air and although maintenance and administration were notified one month ago, nothing had been done. RMD #211 verified the large cold air draft coming from Resident #19's window as well as the stained bathroom floor and unclean sink and mirror area. RMD #211 also confirmed there was a pillow placed in the window to defer the cold air draft coming in and stated he would also seal the window. RMD #211 also stated the flooring in the bathroom should be replaced and was stained from prior cleaning products, and there was a plan to replace the bathroom floors in the future. 4. Observation on 12/29/25 at 11:23 A.M. of Resident #15 revealed the resident in bed covered with three blankets. Interview at the time of the observation with Resident #15 revealed he wanted the air conditioner (AC) unit out of the window because it was causing his room to be cold. Resident #15 complained he had asked staff to remove the AC unit for the last two months when it had started to get cold outside. Review of Resident 15's medical record revealed a therapy note dated 12/18/25 at 9:46 A.M. in which a case manager met with Resident #15 in his room and was observed lying in bed covered with multiple blankets. Resident #15 reported feeling cold due to an AC unit remaining installed in the window. Interview on 12/29/25 at 11:28 A.M. with RMD #211 verified Resident #15's AC unit was still installed in the resident's window. RMD #211 stated the AC units were typically removed in September and should have been removed a long time ago. Review of the facility policy labeled Quality of Life-Homelike Environment, undated revealed the facility staff and management maximized to the extent possible the characteristics of the facility that reflect a personalized, homelike setting, which included a clean, sanitary and orderly environment with comfortable and safe temperatures. Review of the facility policy labeled Homelike Environment, revised February 2021, revealed residents were provided a safe, clean, comfortable, sanitary and homelike environment.

Based on interviews, medical records and facility policy, the facility failed to ensure care plans reflected resident needs regarding diagnoses and medications. This affected one Resident (#4) out of eight resident records reviewed. The facility census was 61.Review of medical record for Resident #4 revealed an admission date of 11/04/25 with a diagnoses of cellulitis left lower limb, septic pulmonary embolism, methicillin resistant staphylococcus aureus, staphylococcal arthritis left ankle and foot, neuromuscular dysfunction of bladder, and iron deficiency anemia. Review of comprehensive care plan dated 11/04/25 revealed no goals or interventions to manage Resident #4's foley catheter which was present on admission, or was revised to include diagnosis of anemia and hypokalemia (low potassium) which required a blood transfusion and intravenous potassium chloride infusion at the hospital on [DATE]. Resident labs are now being monitored weekly for any acute changes and medication management and were not included in the plan of care. Review of resident progress notes and hospital record revealed Resident #4 had a critical hemoglobin value of 6.8 on 21/01/25. The hemoglobin reference range is 13.5-17.5 grams per deciliter. Resident received one unit of packed red blood cells on 12/02/25 and ferrous sulfate 325 milligrams twice daily was added to resident's medication regimen. Additionally, the potassium lab value on 11/28/25 resulted in 3.1 milliequivalents per liter with a normal reference range of 3.5-5.3 milliequivalents per liter. Potassium Chloride Extended Release 20 milliequivalents (mEq.) was ordered twice daily and added to the resident's medication regimen. Weekly lab work for basic metabolic panel (BMP) and complete blood count (CBC) was ordered to monitor Resident #4's lab results. Interview with LPN #220 on 01/05/26 at 12:45 P.M. revealed the indwelling foley and diagnoses of anemia and hypokalemia were absent from the comprehensive care plan.Review of facility policy titled, Comprehensive Assessments, dated March 2022, revealed comprehensive assessments are conducted to assist in developing a person-centered care plan. Completed assessment included a significant change in status assessment are used to develop, review and revise the resident's comprehensive care plan.

Based on medical record review, interviews, and review of facility menus, the diet report and resident council minutes, the facility failed to ensure a well-balanced meal was served at lunch on 12/25/25 and the menu changes were approved by the dietitian. This affected one resident (#2) of three residents (#2, #18 and #37) reviewed for food service. The facility census was 61. Findings include: Review of the medical record for Resident #2 revealed an admission date of 04/29/23. Diagnoses included osteoarthritis, depressive disorder, congestive heart failure, and anxiety. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required set up and clean up help with eating. Review of the diet type report dated 12/05/25 revealed Resident #2 received a regular diet. Interview on 12/29/25 at 9:38 A.M. with Resident #2 revealed the food was not nutritional, lunch on 12/25/25 was four ounces of chicken noodle soup and applesauce. Resident #2 stated they get a menu, but do not get what they choose. Resident #2 stated they had been fighting with them about this forever. Review of the menu for 12/25/25 revealed handwritten homemade chicken noodle soup and typed under that was coffee/tea, and condiments. Interview on 01/05/26 at 9:28 A.M. with Diet Tech (DT) #241 and Dietary Manager (DM) #240 via phone revealed DT #241 stated she was not aware of the changes to the lunch on 12/25/25 to chicken noodle soup and apple sauce and confirmed it was not a balanced meal. DM #240 verified it was homemade chicken noodle soup and applesauce, and the change was made due to resident choice through resident council. DM #240 stated she was off on 12/25/25 but received a call that residents were complaining that they were still hungry, so she came in to help serve seconds of the homemade chicken noodle soup. DM #240 stated residents were then satisfied. Follow up interview on 01/05/26 at approximately 11:05 A.M. with DM #240 stated menu changes were usually signed off by the dietitian but verified the lunch changes on 12/25/25 were not approved by the dietitian. Review of the resident council meeting minutes dated 10/02/25, 11/06/25, and 12/04/25 under dietary were silent for residents' choice for Christmas lunch. Interview on 01/05/26 at 12:44 P.M. with DM #240 revealed she had her own food committee that met usually the week following the resident council meeting where they discussed menu changes. DM #240 stated she did not keep minutes for the food committee, and verified the resident council minutes under dietary did not indicate it was residents' choice for changes to the lunch on 12/25/25.

Based on record review, review of the facility investigation, and interview the facility failed to maintain a safe environment to prevent accidents for Resident #44. This affected one resident (#44) of three resident reviewed for accidents. The facility census was 54. Findings include: Review of Resident #44's medical record revealed an admitted [DATE] with diagnoses including paraplegia, traumatic brain injury, suicidal ideations, transsexualism, suicidal behavior, conversion disorder with seizures, cognitive communication deficit, major depressive disorder, post-traumatic stress disorder (PTSD), and borderline personality disorder. Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. She required setup or clean up help with eating, oral hygiene, substantial to maximal assistance with toileting hygiene, dressing, personal hygiene, showers, and bed mobility. Transfers were completed with the use of the Hoyer (mechanical) lift and two staff members. Review of Resident #44's care plan dated 08/19/24 revealed there was a care plan present related to psychosocial well-being fluctuations related to mental health and mood disorders. Resident #44 had a legal guardian due to her mental health fluctuations with delusions, auditory hallucinations, and suicidal ideations. The goal was to be the resident will verbalize feelings related to her emotional state. Interventions included staff to assist with identification of potential solutions to present problems, assist to identify causative and contributing factors, assist to reduce or eliminate causative factors, assist to set realistic goals, avoid loud tones and loud noises in general due to they may trigger PTSD memories, staff were to encourage tolerance to increase communication between residents, family, and caregivers related to care and living environment, and staff were to explain all procedures, treatments, medications, results of lab work and tests, her conditions and any changes, rules, and options. Additionally, there was a care plan reviewed for a history or trauma related to PTSD, sexual assault, self-harm and traumatic brain injury. The goal was the resident would exhibit minimal signs and symptoms of stress or PTSD triggers as evidence by presenting with a calm appearance or voicing on set of triggers. Interventions included all activities in activities room were to be supervised by a staff member at all times, staff were to approach the resident in an unhurried manner, be respectful verbally of the resident's personal space, all staff were to avoid culturally inappropriate or insensitive items in the physical environment, help the resident to manage conflict appropriately, include the resident and/or responsible party in treatment plan, update the physician as indicated by change in condition or treatment, keep noise levels low, keep the resident in touch with their community, cultural heritage, former lifestyle, and religious practices. Staff were to maintain health interpersonal boundaries, provide community required interventions as indicated, provide low lighting when indicated, provide support groups including via [NAME] to provide therapeutic behavior services, room to randomly be searched and any and all items would be removed from the resident's room if they could be harmful or used to cause harm to self, including but not limited to cords, rope, silverware, batteries etc. Staff were to speak in a calm manner, staff were to be aware of their own emotional responses to the resident's trauma. Staff were to update the physician as indicated for change in condition and treatment, utilize calm music throughout the task, and staff were to make sure the resident felt welcome and supported. All staff were to adjust tone and volume of speech to achieve a calming environment. Review of Resident #44's progress notes dated 07/30/24 at 4:44 P.M. authored by Licensed Practical Nurse (LPN) #205 revealed the resident turned on her call light and stated, I cut myself. The resident was observed with an activity's cutter (box cutter) and a superficial laceration to her left wrist. The activity cutter was removed from the room, and the area was cleansed with normal saline and left open to air. The resident stated she took the cutter from the activities room, and she did not know why she did it. One on one and emotional support were provided and effective. One on one staff provided at this time for the resident's safety. The Nurse Practitioner was notified and gave an order to send the resident to the emergency room (ER) for evaluation and treatment for psych services to evaluate. Resident #44's guardian and mother were notified of the transfer and of the incident. Emergency medical services (EMS) were notified as well as the police. Further review of Resident #44's progress notes revealed on 07/31/24 the Interdisciplinary Team (IDT) had a meeting and reviewed the incident. The resident's room was searched, and all items which could be used for self-harming were removed. The Guardian was made aware. At this time, the Guardian made the Director of Nursing (DON) aware the hospital was giving her a hard time getting psych assistance for the resident. The DON called the ER, and they stated she was denied from five behavioral units. The DON provided additional places the resident could go. The ER called back at 5:00 P.M. and stated they could not find placement, they felt she was no longer at risk, and she would be returned to the facility. Progress notes revealed the resident did not require treatment to the left wrist and returned to the facility on [DATE] at 9:00 P.M. with new orders for Bactrim DS 800-160 milligrams (mg) (antibiotic) twice a day for five days because she was positive for a urinary tract infection (UTI). Interview on 11/04/24 at 11:02 A.M. with Activity Director (AD) #203 revealed on 07/30/24, Resident #44 was brought down to the small activity room by staff. Resident #44 put a box cutter that was on the table in her bag and took it to her room and cut her wrist. She was sent to the hospital. AD #203 stated the facility administrative team spoke to her about the incident. She stated she was not disciplined for it due to the box cutter being the old maintenance directors, and she stated she never heard about it again after that. Interview on 11/04/24 at 1:28 P.M. with the DON revealed the DON provided a screen shot of AD #203's social media page indicating AD #203 lied to surveyors to get the facility in trouble for the incident that occurred on 07/30/24 regarding Resident #44. The DON stated AD #203 had turned in her notice and was quitting and just wanted to cause trouble. The DON stated that through the investigation completed by facility administrative team, it was determined the box cutter was in the small activity room on a shelf, and it was very dusty, dirty, and dull. Resident #44 informed the DON that she found it in the activity room and decided to self-harm. She placed it in a small spiderman backpack that belonged to AD #203's son, propelled herself down to her room, she stopped staff in the hallway and asked to be laid down in the bed, which they did, when she was in bed, she asked for her tray table and the backpack. Ten to 15 minutes later, Resident #44 turned her call light on and as soon as staff entered the room she pulled the box cutter out and attempted to cut her wrist. Interview on 11/04/24 at 2:00 P.M. with LPN #205 revealed she was assigned to care for Resident #44 on 07/30/24 when she obtained a box cutter from the activity room and attempted to cut her left wrist with it. LPN #205 stated Resident #44 self-propelled down to the small activity room and when she returned, she had a spiderman bookbag on her lap and requested to be put to bed. The assigned certified nurse aide (CNA) requested help, and two staff members used the Hoyer lift and put the resident to bed. Approximately ten to 15 minutes later, Resident #44 put her call light on, and when LPN #205 entered the room, Resident #44 took out the box cutter and attempted to cut her wrist. LPN #205 stated Resident #44 had a superficial laceration or scratch to her left wrist. She immediately removed the box cutter from Resident #44 and attended to her left wrist. LPN #205 stated she cleansed the area with normal saline and left it open to air as it was not bleeding and was not deep at all. She notified the Nurse Practitioner and the Guardian. She was instructed by the Nurse Practitioner to send the resident to the ER. LPN #205 stated the resident had one on one supervision until she left the facility with EMS. LPN #205 stated she notified the DON and Administrator and was instructed to search the resident's room and to obtain statements from all the staff in the facility. LPN #205 stated the backpack had AD #203's sons initials in it. Review of the facility investigation dated 07/30/24 revealed all like residents were interviewed, skin assessments were completed on all residents at risk for self-harm, all staff were interviewed, and witness statements were obtained. The investigation determined Resident #44 found the box cutter in the small activity room on a shelf, it appeared to have been there for some time as it had dust built up on it. It was determined the box cutter was left there by an old maintenance man who no longer worked at the facility due to his initials being found on the box cutter. All areas of the facility were searched for any items residents could use for self-harm and if found, items were removed. This deficiency represents non-compliance investigated under Master Complaint Number OH00159634 and Complaint Number OH00159198.

Based on observation, interview, record review, and facility policy review the facility failed to maintain enhanced barrier precautions (EBP) and transmission-based precautions (TBP) appropriately as required. This affected nine residents (#2, #4, #12, #15, #21, #24, #39, #49 and #55) and had the potential to affect all 56 residents residing in the facility. Findings include: Observation on 06/17/24 at 8:20 A.M. during a facility tour revealed the following: An EBP sign was posted at the entrance of Resident #2's room. There was a storage bin to the left of the entrance door which held personal protective equipment (PPE). Next to the PPE storage bin placed along the hallway wall were two large garbage containers, one for soiled linen and the other for infectious garbage lined with a red trash bag. An EBP sign was posted at the entrance of Resident #4's room. There was no available PPE at or near the entrance for staff use with EBP. A TBP sign which did not designate the type of precautions and an EBP sign were posted at the entrance of Resident #21's room. The storage bin which contained PPE for staff use was moved to Resident #21's bedside and held a running large fan pointed toward Resident #21 who was lying in bed. Due to the positioning of the PPE bin, the drawers were not easily accessible to obtain PPE when needed. A TBP sign for contact precautions was posted at the entrance of Resident #49's room. There was no available PPE at or near the entrance for staff use with TBP. There was an intravenous pole at the bedside in Resident #55's room. Interview at the time of the observation with Resident #55 revealed a wound was treated with antibiotic therapy. There was no EBP posted and no PPE available at or near the room entrance. Resident #12 was lying in bed with a tracheostomy and an enteral feeding machine running. There was no EBP posted and no PPE available at or near the room entrance. Resident #39 was lying in bed with a tracheostomy. There was no EBP posted and no PPE available at or near the room entrance. Resident #15 was lying in bed with a tracheostomy and a urinary catheter drainage bag secured to the left bedside facing the entrance door. There was a PPE storage bin located outside of the room with no signage posted to indicate the type of precautions needed. Resident #24 was lying in bed with a tracheostomy. There was no EBP posted and no PPE available at or near the room entrance. Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included pressure ulcer of sacral region stage IV (full thickness tissue loss with exposure of bone, muscle or tendon). A physician order dated 06/06/24 indicated contact precautions due to presence of multi-drug resistant organisms (MDRO). Review of the medical record for Resident #4 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II. Physician orders effective June 2024 indicated wound treatment to the left abdomen daily. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II. Physician orders effective June 2024 indicated contact isolation for the presence of a MDRO in the urine until 06/22/24. Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included chronic kidney disease and acute kidney failure. A physician order dated 06/13/24 indicated contact precautions due to the presence of a MDRO in the urine for 14 days. Review of the medical record for Resident #55 revealed an admitted [DATE]. Diagnoses included osteomyelitis of the vertebra, sacral and sacrococcygeal region and diabetes mellitus type II. Physician orders active June 2024 indicated daily wound treatment to the sacrum. A wound note dated 06/10/24 described a stage IV coccyx wound. Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included tracheostomy and gastrostomy status. Physician orders effective June 2024 indicated tracheostomy and gastrostomy tube care daily with enteral feedings. Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included tracheostomy status and gastrostomy status. Physician orders effective June 2024 indicated tracheostomy and gastrostomy tube care daily with enteral feedings. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included obstructive and reflux uropathy and tracheostomy status. Physician orders effective June 2024 indicated tracheostomy and urinary catheter care daily. Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnoses included tracheostomy status. Physician orders effective June 2024 indicated tracheostomy care daily. Interview on 06/17/24 at 8:58 A.M. with the Director of Nursing (DON) verified the above findings and confirmed resident rooms were not appropriately equipped with EBP and TBP, infectious garbage and soiled linen should not be in the facility hallways, and fans should not be in use on top of PPE storage bins. Review of the facility policy titled, Policy on Disease-Specific Isolation/Precautions, initiated 04/01/24, revealed EBP referred to an infection control intervention designed to reduce transmission of MDRO that employed targeted gown and glove use during high contact resident care activities. EBP were indicated for residents with an infection or colonization with a MDRO when contact precautions did not apply, wounds, and/or indwelling medical devices even if MDRO status was unknown. Contact precautions were intended to prevent transmission of infections that were spread by direct or indirect contact with the resident or environment and required the use of appropriate PPE including a gown and gloves upon entering the room (i.e., before making contact with the resident or the resident's environment). This deficiency was an incidental finding identified during the complaint investigation.

Based on interview, record review, and facility policy review the facility failed to prevent significant medication errors for Residents #16 and #42 when medications were signed out from the controlled drug records without evidence of administering the medication on the medication administration record (MAR) and verifying the medication was being administered as ordered by the physician. This affected two residents (#16 and #42) reviewed for controlled drug administration and had the potential to affect 25 additional residents (#2, #6, #10, #12, #15, #18, #19, #21, #23, #24, #25, #27, #28, #29, #30, #31, #37, #39, #41, #44, #47, #48, #49, #52 and #56) who received controlled medications. The facility census was 56. Findings include: 1. Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included low back pain and chronic pain. Review of Resident #16's physician orders revealed an order dated 09/06/23 for oxycodone 10-325 mg (milligrams) (opioid pain medication) every eight hours as needed for moderate to severe pain and no more than two administrations within 24 hours which was discontinued on 05/23/24. Review of the MAR and controlled drug records (CDR) for Resident #16's oxycodone from 04/11/24 to 05/23/24 revealed oxycodone 10-325 mg was signed out of the CDR and signed as administered on the MAR as follows: 04/11/24 at 11:30 P.M. from the CDR and MAR and at 8:00 A.M. from the CDR only. 04/12/24 at 8:00 A.M. from the CDR only 04/13/24 at 2:40 (AM/PM not specified) from the CDR only 04/14/24 at 6:15 A.M. from the CDR only 04/15/24 at 8:00 A.M. from the CDR only and at 8:54 P.M. from the CDR and MAR 04/16/24 at 9:00 P.M. from the CDR only 04/17/24 at 8:00 A.M., 4:00 P.M., and 9:00 P.M. from the CDR only (the medication was administered sooner than every eight hours as ordered and exceeded the maximum ordered doses of twice daily) 04/18/24 at 9:00 P.M. from the CDR only 04/19/24 at 8:00 A.M. and 3:00 P.M. from the CDR only (the medication was administered sooner than every eight hours as ordered) 04/20/24 at 3:59 A.M. from the CDR and MAR and at 8:18 P.M. from the CDR only 04/22/24 at 9:30 (AM/PM not specified) from the CDR only 04/23/24 at 8:00 A.M. and 8:00 P.M. from the CDR only 04/24/24 at 8:00 A.M. from the CDR only 04/25/24 at 8:00 P.M. from the CDR only 04/29/24 at 3:12 P.M. from the CDR and MAR 04/30/24 at 8:38 P.M. from the CDR and MAR 05/01/24 at 3:00 A.M. from the CDR only and at 4:20 P.M. from the CDR and MAR (the medication was administered sooner than every eight hours as ordered) 05/02/24 at 8:00 A.M. and 8:00 P.M. from the CDR only 05/03/24 at 1:30 A.M. from the CDR only and at 10:30 P.M. from the CDR and MAR (the medication was administered sooner than every eight hours as ordered) 05/06/24 at 8:00 A.M. from the CDR only 05/07/24 at 7:49 P.M. from the CDR and MAR 05/08/24 at 3:00 A.M. and 8:00 A.M. from the CDR only and at 5:07 P.M. from the CDR and MAR (the medication was administered sooner than every eight hours as ordered and exceeded the maximum ordered doses of twice daily) 05/09/24 at 10:00 A.M. and 8:00 P.M. from the CDR only 05/10/24 at 8:00 P.M. from the CDR only 05/11/24 at 2:30 A.M. and 10:00 A.M. from the CDR only (the medication was administered sooner than every eight hours as ordered) 05/12/24 at 12:34 P.M. from the CDR and MAR and at 9:00 P.M. from the CDR only 05/13/24 at 3:00 A.M. and 9:10 A.M. from the CDR only and at 5:21 P.M. from the CDR and MAR (the medication was administered sooner than every eight hours as ordered and exceeded the maximum ordered doses of twice daily) 05/14/24 at 11:32 A.M. from the CDR and MAR and at 9:00 P.M. from the CDR only 05/15/24 at 8:00 A.M. and 9:00 P.M. from the CDR only 05/16/24 at 8:00 A.M., 2:00 P.M. and 10:00 P.M. from the CDR only (the medication was administered sooner than every eight hours as ordered and exceeded the maximum ordered doses of twice daily) 05/17/24 at 8:00 A.M. from the CDR only 05/18/24 at 2:22 P.M. from the CDR and MAR and at 8:00 P.M. from the CDR only (the medication was administered sooner than every eight hours as ordered) 05/19/24 at 9:00 A.M. and 10:15 P.M. from the CDR only and at 4:15 P.M. from the CDR and MAR (the medication was administered sooner than every eight hours as ordered and exceeded the maximum ordered doses of twice daily) 05/20/24 at 7:48 A.M. and 11:55 P.M. from the CDR only and at 3:53 P.M. from the CDR and MAR (the medication was administered sooner than every eight hours as ordered and exceeded the maximum ordered doses of twice daily) 05/21/24 at 8:15 A.M. from the CDR only and at 4:21 P.M. from the CDR and MAR 05/22/24 at 9:00 A.M. and 12:30 P.M. from the CDR only and at 7:58 P.M. from the CDR and MAR (the medication was administered sooner than every eight hours as ordered and exceeded the maximum ordered doses of twice daily) 05/23/24 at 8:00 A.M. and 8:00 P.M. from the CDR only Review of Resident #16's physician orders revealed an order dated 05/23/24 for oxycodone 10-325 mg once daily at bedtime for pain which was discontinued on 06/13/24. Review of the MAR and CDR for Resident #16's oxycodone from 05/24/24 to 06/04/24 revealed oxycodone 10-325 mg was signed out of the CDR and signed as administered on the MAR as follows: 05/24/24 at 8:00 A.M. and 4:15 P.M. from the CDR only and at 8:16 P.M. from the CDR and MAR (the medication was administered twice without a physician's order) 05/25/24 at 9:00 A.M. from the CDR only and at 9:00 P.M. from the CDR and MAR (the medication was administered once without a physician's order) 05/26/24 at 8:00 A.M. and 4:30 P.M. from the CDR only and at 9:30 P.M. from the CDR and MAR (the medication was administered twice without a physician's order) 05/27/24 at 7:35 A.M. and 3:45 P.M. from the CDR only and at 8:30 P.M. from the CDR and MAR (the medication was administered twice without a physician's order) 05/28/24 at 8:00 A.M. from the CDR only and at 8:00 P.M. from the CDR and MAR (the medication was administered once without a physician's order) 05/29/24 at 3:00 A.M. and 9:00 A.M. from the CDR only and at 5:10 P.M. from the CDR and MAR (the medication was administered twice without a physician's order and ordered dose was administered too early 05/30/24 at 4:00 A.M. and 1:00 P.M. from the CDR only and at 9:00 P.M. from the CDR and MAR (the medication was administered twice without a physician's order) 05/31/24 at 6:00 A.M. and 1:11 P.M. from the CDR only and at 8:00 P.M. from the CDR and MAR (the medication was administered twice without a physician's order) 06/01/24 at 8:00 P.M. from the CDR and MAR 06/02/24 at 2:00 P.M. from the CDR only and at 8:00 P.M. from the CDR and MAR (the medication was administered once without a physician's order) 06/03/24 at 8:00 A.M. and 4:00 P.M. from the CDR only and at 8:00 P.M. from the CDR and MAR (the medication was administered twice without a physician's order) 06/04/24 at 8:00 A.M. and 4:11 P.M. from the CDR only and at 9:00 P.M. from the CDR and MAR (the medication was administered twice without a physician's order) Interview on 06/17/24 at 2:39 P.M. with the Director of Nursing (DON) verified the above findings. The DON indicated the nurses used the CDR to administer medications instead of the required MAR to verify the order and it caused multiple medication errors and an inaccurate administration record. The DON confirmed the errors had occurred with multiple other residents who received controlled medications and by multiple nurses. 2. Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included arthritis, closed displaced intertrochanteric fracture of left femur, multiple bilateral rib fractures, and pain in left shoulder. Review of Resident #42's physician orders revealed an order dated 04/30/24 for oxycodone 2.5 mg every four hours as needed for moderate to severe pain which was discontinued on 05/03/24. Review of the MAR and CDR for Resident #42's oxycodone from 04/30/24 to 05/03/24 revealed oxycodone 2.5 mg was signed out of the CDR and signed as administered on the MAR as follows: 04/30/24 at 3:30 A.M. and 3:00 P.M. from the CDR only 05/01/24 at 11:55 P.M. from the CDR and MAR 05/02/24 at 7:30 A.M. 11:30 A.M. and 4:00 P.M. from the CDR only and at 8:52 P.M. from the CDR and MAR 05/03/24 at 6:12 A.M. from the CDR and MAR and at 10:00 A.M., 2:00 P.M. and 10:00 P.M. from the CDR only (the medication was administered sooner than every four hours as ordered) Review of Resident #42's physician orders revealed an order dated 05/03/24 for oxycodone 5 mg every four hours for moderate to severe pain which was discontinued on 05/16/24. Review of the MAR and CDR for Resident #42's oxycodone from 05/04/24 to 05/16/24 revealed oxycodone 5 mg was signed out of the CDR and signed as administered on the MAR as follows: 05/04/24 at 5:00 A.M. and 10:00 P.M. from the CDR only and at 1:30 P.M. from the CDR and MAR 05/05/24 at 5:00 P.M. from the CDR only 05/06/24 at 7:15 A.M., 10:50 A.M., 3:00 P.M. and 7:00 P.M. from the CDR only (the medication was administered sooner than every four hours as ordered) 05/07/24 at 6:15 A.M. and 8:00 P.M. from the CDR only 05/08/24 at 12:10 A.M., 2:00 A.M., 3:00 A.M., 6:00 A.M., 10:00 A.M., 2:11 P.M. and 10:30 P.M. from the CDR only and at 6:14 P.M. from the CDR and MAR (the medication was administered sooner than every four hours as ordered and exceeded the maximum ordered doses six daily) 05/09/24 at 4:00 A.M., 10:00 A.M. and 2:30 P.M. from the CDR only 05/10/24 at 11:03 A.M. from the CDR and MAR and at 9:30 P.M. from the CDR only 05/11/24 at 4:00 A.M. and 11:00 A.M. from the CDR only and at 3:47 P.M. and 7:51 P.M. from the CDR and MAR 05/12/24 at 3:00 A.M. and 5:41 P.M. from the CDR only 05/13/24 at 6:52 A.M., 5:47 P.M. and 10:30 P.M. from the CDR and MAR and at 9:45 A.M. and 1:45 P.M. from the CDR only (the medication was administered sooner than every four hours as ordered) 05/14/24 at 8:30 A.M. from the CDR only 05/15/24 at 3:30 P.M. from the CDR only 05/16/24 at 4:35 A.M. from the CDR and MAR and at 8:30 A.M., 12:30 P.M. and 4:30 P.M. from the CDR only (the medication was administered sooner than every four hours as ordered) Review of Resident #42's physician orders revealed an order dated 05/16/24 for oxycodone 5 mg three times daily and must be given at least six hours apart for moderate to severe pain which was discontinued on 05/30/24. Review of the MAR and CDR for Resident #42's oxycodone from 05/17/24 to 05/30/24 revealed oxycodone 5 mg was signed out of the CDR and signed as administered on the MAR as follows: 05/17/24 at 5:25 A.M. from the CDR and MAR and at 11:00 A.M. and 10:00 P.M. from the CDR only (the medication was administered sooner than every six hours as ordered) 05/18/24 at 4:00 A.M., 8:14 A.M., 12:21 P.M. and 4:51 P.M. from the CDR only (the medication was administered sooner than every six hours as ordered and exceeded the maximum ordered doses of three daily) 05/19/24 at 6:18 A.M. and 6:31 P.M. from the CDR and MAR and at 10:30 A.M. and 6:30 P.M. from the CDR only (the medication was administered sooner than every six hours as ordered and exceeded the maximum ordered doses of three daily) 05/20/24 at 7:00 A.M. and 1:00 P.M. from the CDR only and at 7:00 P.M. from the CDR and MAR 05/21/24 at 1:30 A.M., 10:30 A.M. and 2:30 P.M. from the CDR only and at 6:11 A.M. and 6:30 P.M. from the CDR and MAR (the medication was administered sooner than every six hours as ordered and exceeded the maximum ordered doses of three daily) 05/22/24 at 8:15 A.M. and 2:48 P.M. from the CDR and MAR 05/23/24 at 8:47 A.M. from the CDR and MAR and at 2:48 P.M. and 9:00 P.M. from the CDR only 05/24/24 at 3:00 A.M., 9:04 A.M. and 9:00 P.M. from the CDR only and at 3:11 P.M. from the CDR and MAR (the medication was administered sooner than every six hours as ordered and exceeded the maximum ordered doses of three daily) 05/25/24 at 4:00 A.M., 10:00 A.M. and 3:00 P.M. from the CDR only (the medication was administered sooner than every six hours as ordered) 05/26/24 at 7:31 A.M., 1:33 P.M. and 7:30 P.M. from the CDR only (the medication was administered sooner than every six hours as ordered) 05/27/24 at 7:20 A.M., 1:00 P.M. and 7:00 P.M. from the CDR only (the medication was administered sooner than every six hours as ordered) 05/28/24 at 11:39 A.M. from the CDR and MAR 05/30/24 at 5:30 A.M. and 11:30 P.M. from the CDR only and at 11:35 A.M. and 5:45 P.M. from the CDR and MAR (the medication was administered sooner than every six hours as ordered and exceeded the maximum ordered doses of three daily) Review of Resident #42's physician orders revealed an order dated 06/01/24 for oxycodone 5 mg every six hours as needed for pain which was discontinued on 06/06/24. Review of the MAR and CDR for Resident #42's oxycodone from 06/01/24 to 06/06/24 revealed oxycodone 5 mg was signed out of the CDR and signed as administered on the MAR as follows: 06/01/24 at 8:10 A.M. from the CDR only 06/01/24 at 3:15 P.M. from the CDR and MAR 06/02/24 at 8:00 A.M. and 2:00 P.M. from the CDR only 06/03/24 at 8:00 A.M. from the CDR only 06/04/24 at 8:10 A.M. from the CDR only Interview on 06/18/24 at 10:02 A.M. with the DON verified the above findings. The DON indicated the nurses were required to administer controlled medications using both the MAR and CDR and verify the current physician's order on the MAR to prevent medication errors. Review of the facility policy titled, Controlled Substances, revised November 2022, revealed the system of reconciling the receipt, dispensing and disposition of controlled substances included using medication administration records and declining inventory records. This deficiency was an incidental finding identified during the complaint investigation.

Based on interview, record review, and facility policy review the facility failed to report an allegation of misappropriation by medication diversion involving Residents #2, #16 and #42. This affected three residents (#2, #16 and #42) of four residents reviewed for abuse, neglect, and misappropriation. The facility census was 56. Findings include: Interview on 06/17/24 at 9:52 A.M. with Licensed Practical Nurse (LPN) #358 indicated gossip was circulating with facility staff about controlled medications being misused but denied knowledge of any details. Interview on 06/17/24 at 10:50 A.M. with the Director of Nursing (DON) confirmed an allegation was made by Registered Nurse (RN) #333 against an agency nurse, LPN #369, on 06/09/24. RN #333 reported feeling a couple of the controlled medication signatures were forged by LPN #369. Immediately LPN #369 was removed from the schedule and the facility worked with the pharmacy on an investigation. RN #333 submitted copies of controlled medication records which she believed to be questionable. One of the records involved Resident #16. The DON verified an SRI (self-reported incident) was not filed but indicated the pharmacy was first trying to determine if it was misappropriation. RN #333 had claimed someone else was signing out narcotics so the pharmacy looked at it and determined it was not misappropriation because forged signatures could not be proved. The DON stated that normally an SRI was completed, but RN #333 had all the facility nurses upset and questioning signatures so too many nurses were getting involved. The facility did not usually question allegations but it was because so many were getting involved. The DON verified that abuse allegations including misappropriation should not be filtered through to determine validity before being reported. Interview on 06/17/24 at 11:05 A.M. with the Administrator confirmed knowledge of the misappropriation allegation on 06/09/24 and indicated people investigated it. The Administrator described the reported allegation as hearsay but agreed allegations were not known to be credible unless investigated, so the allegation should have been reported as required. Review of the facility investigation for the misappropriation allegation reported on 06/09/24 revealed an incident report dated 06/11/24 at 12:12 P.M. The incident report described a nurse alleged a controlled medication was signed out with a forged signature. Immediate actions taken were removing both the accused nurse and reporting nurse from the schedule. The pharmacy was notified on 06/10/24 who confirmed and accounted for all controlled medication deliveries. The medical director and DON reviewed the allegation, and it was unsubstantiated as misappropriation. The pharmacy was scheduled to return to the facility on [DATE]. The plan was to educate and monitor staff on appropriate use of controlled medication records and wean residents from controlled medications when able. Review of the written statement from RN #333, dated 06/08/24, revealed when looking at the controlled medication sheets for the assignment, there was a sheet for Resident #16 in which her signature dated 05/25/24 appeared forged because it was misspelled, despite having worked on that date and assignment. RN #333 reported it to the DON and Administrator and submitted highlighted controlled medication sheets with questionable signatures involving Residents #2, #16, and #42. Review of the written statement from the DON, dated 06/10/24, revealed the agency nurse, LPN #369, was contacted as the accused and refused to discuss the allegation, but the agency stated they would do an independent investigation through quality assurance. Interview on 06/17/24 at 2:39 P.M. with the DON reported all questionable signatures identified by RN #333 on controlled medication sheets for Residents #2, #16 and #42 were not forged. The one misspelled signature made on 05/25/24 was not proven to be made by any other individual. The accused agency nurse, LPN #369, had no access to the facility and did not work on any of the dates in question. The DON verified the misappropriation allegation and investigation results were not reported to the state agency as required. Review of the facility policy, Identifying Exploitation, Theft and Misappropriation of Resident Property, dated April 2021, revealed examples of misappropriation of resident property, including drug diversion (the taking of a resident's medication). Staff and providers were expected to report suspected misappropriation of resident property. Review of the undated facility policy, Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure revealed the facility had a duty to report all alleged violations of abuse, neglect, exploitation, or mistreatment and misappropriation of resident property. The facility must report the alleged violation to the state survey agency immediately for alleged violations which involved abuse, neglect, exploitation or mistreatment, and misappropriation of resident property but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury, or 24 hours if the alleged violation did not involve abuse and did not result in serious bodily injury. The results of all investigations of alleged violations would be reported within five working days of the incident. This deficiency represents non-compliance investigated under Master Complaint Number OH00154716.

Based on interview, record review, and facility policy review, the facility failed to accurately document controlled drug administration for Resident #1 to prevent a potential significant medication error. This affected one resident (#1) of three residents reviewed for controlled drug administration. The facility identified 30 residents (#1, #3, #7, #8, #9, #10, #12, #14, #15, #16, #17, #23, #24, #26, #28, #35, #36, #39, #40, #41, #42, #43, #44, #45, #46, #48, #50, #54 and #55) who received controlled medications. The facility census was 55. Findings include: Review of the medical record for Resident #1 revealed an admission date of 01/11/24 with a diagnosis of chronic pain syndrome. Review of Resident #1's physician orders revealed an order dated 01/10/24 for morphine 15 milligrams (mg) (opioid pain medication) twice daily for pain, and an order dated 06/13/24 for morphine 15 mg every eight hours as needed (PRN) for pain. Review of the medication administration record (MAR) and controlled drug records (CDR) for Resident #1's morphine from 06/20/24 to 07/10/24 revealed administration of morphine 15 mg was documented as follows: • 06/21/24 at 2:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 06/22/24 at 2:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 06/22/24 at 3:00 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR until 4:22 P.M. • 06/22/24 at 8:30 P.M. it was removed for PRN administration on the CDR but documented on the MAR as administered on 06/23/24 at 12:00 A.M. A corresponding progress note which documented administration was created on 06/23/24 at 5:09 A.M. with an effective date of 06/23/24 at 12:00 A.M. • 06/24/24 at 4:00 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 06/25/24 at 3:00 A.M. it was administered PRN on the MAR but documented as removed on the CDR on 06/24/24 at 3:00 A.M. • 06/25/24 at 2:30 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 06/26/24 at 2:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 06/26/24 at 8:30 P.M. it was administered routinely on the MAR but documented as removed for administration on the CDR on 06/27/24 at 9:00 P.M. • 06/28/24 at 2:30 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 06/29/24 at 2:30 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 07/03/24 at 3:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 07/05/24 at 3:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 07/08/24 at 3:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR • 07/10/24 at 4:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR Interview on 07/10/24 at 2:45 P.M. with the Director of Nursing (DON) verified the above findings, and confirmed the nurses were required to administer and document controlled medications using both the MAR and CDR to prevent medication errors. Review of the facility policy, Controlled Substances, revised November 2022, revealed the system of reconciling the receipt, dispensing and disposition of controlled substances included using medication administration records and declining inventory records.

Based on interview, record review, and facility policy review, the facility failed to accurately document controlled drug administration for Resident #1 to prevent a potential significant medication error. This affected one resident (#1) of three residents reviewed for controlled drug administration. The facility identified 30 residents (#1, #3, #7, #8, #9, #10, #12, #14, #15, #16, #17, #23, #24, #26, #28, #35, #36, #39, #40, #41, #42, #43, #44, #45, #46, #48, #50, #54 and #55) who received controlled medications. The facility census was 55. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE] with a diagnosis of chronic pain syndrome. Review of Resident #1's physician orders revealed an order dated 01/10/24 for morphine 15 milligrams (mg) (opioid pain medication) twice daily for pain, and an order dated 06/13/24 for morphine 15 mg every eight hours as needed (PRN) for pain. Review of the medication administration record (MAR) and controlled drug records (CDR) for Resident #1's morphine from 06/20/24 to 07/10/24 revealed administration of morphine 15 mg was documented as follows: 06/21/24 at 2:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 06/22/24 at 2:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 06/22/24 at 3:00 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR until 4:22 P.M. 06/22/24 at 8:30 P.M. it was removed for PRN administration on the CDR but documented on the MAR as administered on 06/23/24 at 12:00 A.M. A corresponding progress note which documented administration was created on 06/23/24 at 5:09 A.M. with an effective date of 06/23/24 at 12:00 A.M. 06/24/24 at 4:00 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 06/25/24 at 3:00 A.M. it was administered PRN on the MAR but documented as removed on the CDR on 06/24/24 at 3:00 A.M. 06/25/24 at 2:30 P.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 06/26/24 at 2:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 06/26/24 at 8:30 P.M. it was administered routinely on the MAR but documented as removed for administration on the CDR on 06/27/24 at 9:00 P.M. 06/28/24 at 2:30 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 06/29/24 at 2:30 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 07/03/24 at 3:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 07/05/24 at 3:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 07/08/24 at 3:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR 07/10/24 at 4:00 A.M. it was removed for PRN administration on the CDR but not documented as administered on the MAR Interview on 07/10/24 at 2:45 P.M. with the Director of Nursing (DON) verified the above findings, and confirmed the nurses were required to administer and document controlled medications using both the MAR and CDR to prevent medication errors. Review of the facility policy, Controlled Substances, revised November 2022, revealed the system of reconciling the receipt, dispensing and disposition of controlled substances included using medication administration records and declining inventory records.

Based on observation, record review, and interview the facility failed to treat residents with dignity and respect by maintaining uncovered urinary catheter drainage bags in public view. This affected two residents (#15 and #37) of six residents with urinary catheters. The facility census was 56. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, chronic kidney disease stage III, and obstructive and reflux uropathy. Review of the physician orders effective June 2024 revealed Resident #15 required routine urinary catheter related care daily. Observation on 06/17/24 at 8:20 A.M. revealed Resident #15 lying in bed with an uncovered urinary catheter drainage bag hanging on the bed frame facing the doorway which was visible from the hallway outside of the room. Observation on 06/17/24 at 8:58 A.M. revealed Resident #15 lying in bed with an uncovered urinary catheter drainage bag hanging on the bed frame facing the doorway visible from the hallway outside of the room. Interview at the time of the observation with the Director of Nursing (DON) verified Resident #15 had an uncovered drainage bag hanging in public view. 2. Review of the medical record for Resident #37 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II with chronic kidney disease. Review of the baseline care plan dated 06/14/24 revealed an indwelling urinary catheter with catheter care required daily and as needed. Observation on 06/18/24 at 8:36 A.M. revealed Resident #37 lying in bed with an uncovered urinary catheter drainage bag hanging on the bed frame facing the doorway visible from the hallway outside of the room. Interview at the time of the observation with State tested Nursing Assistant (STNA) #344 verified Resident #37 had an uncovered drainage bag hanging in public view. This deficiency was an incidental finding identified during the complaint investigation.

Based on observation, interview, and record review the facility failed to obtain physician orders and provide sufficient care for an indwelling urinary catheter. This affected one resident (#37) of four residents reviewed for urinary catheters. The facility census was 56. Findings include: Observation on 06/18/24 at 8:36 A.M. revealed Resident #37 lying in bed with an uncovered urinary catheter drainage bag hanging on the bed frame facing the doorway visible from the hallway outside of the room. Review of the medical record for Resident #37 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II with chronic kidney disease, and benign prostatic hyperplasia without lower urinary tract symptoms. There was no evidence of a diagnosis or justification for use of an indwelling urinary catheter. Review of the physician orders for June 2024 revealed no orders to monitor, maintain, or care for a urinary catheter. Review of the medication and treatment administration records for June 2024 revealed no evidence of monitoring, maintaining, or caring for a urinary catheter. Review of the nursing progress notes for June 2024 revealed an indwelling catheter was in place upon admission on 06/13/24. There was no evidence of justification for or the monitoring, maintaining, or caring for the urinary catheter. Review of the baseline care plan dated 06/14/24 revealed an indwelling urinary catheter was in place with catheter care required daily and as needed. Review of the activities of daily living flow records for June 2024 revealed Resident #37 was to receive catheter care on every shift. Catheter care was documented as provided from 06/14/24 to 06/17/24 daily on day shift and from 06/15/24 to 06/17/24 daily on night shift. There was no evidence catheter care was provided on 06/13/24 day or night shift nor on 06/14/24 night shift. Interview on 06/18/24 at 1:22 P.M. with the Director of Nursing (DON) verified the above findings and confirmed there remained no justification for Resident #37's continued use of an indwelling urinary catheter. This deficiency was an incidental finding identified during the complaint investigation.

Based on observation and interview the facility failed to ensure the garbage/dumpster area was maintained in a clean and sanitary manner. This had the potential to affect all 58 residents residing in the facility. Findings include: Observation of the facility dumpster area with Dietary Manager (DM) #461 on 11/06/23 at 10:28 A.M. revealed a door of the dumpster was open. A mattress, chair, and two wood pallets were stacked beside the dumpster. DM #461 verified the findings at the time of the observation.

Based on observation and interview the facility failed to maintain a clean and homelike environment for Residents #1, #2, #3, #5, #10, #11, #12, #14, #16, #18, #19, #20, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #45, #46, #48, #51, #53, #54, #55, #57, #58, #263 and #264. The facility census was 58. Findings include: Interview on 11/06/23 at 10:02 A.M. with family of Resident #18 stated the window blinds were old, broken, or bent. Throughout the facility the windows were dirty, and several walls required repair or painting. Observation of the environment during a facility tour on 11/08/23 at 8:32 A.M. revealed the following: Resident #29's room had a large gouge in the lower wall underneath the light fixture. The exit door adjacent to Resident #31's room, and the right hallway wall by Resident #31's entry door had multiple scuffs, chips in the paint, and deep scrapes in the material. Doorway frames and entry room doors for the small and large activity areas, and for Residents #2, #11, #19, #29, #31, #38 and #51 had multiple areas of chipped paint, scrapes, and dents. The center of the hallway wall to the right of Resident #48's room had two large shallow areas of missing wall material. The dry wall was exposed. The hallway wall across from Resident #48's room had large deep scrapes and one small deep hole with dry wall exposed. Dirty windows with dirt buildup, dried dirt smudges and smears, window streaks and cloudy appearance were observed in all areas of the large activity room, adjacent to exit doors #8 and #10, and in the rooms of Residents #1, #3, #5, #10, #12, #14, #16, #18, #19, #20, #22, #23, #24, #25, #26, #27, #28, #30, #32, #33, #34, #35, #36, #37, #39, #40, #45, #46, #48, #53, #54, #55, #57, #58, #263 and #264. Window blinds with multiple broken, missing or bent slats were observed in the rooms of Residents #1, #10, #12, #14, #18, #20, #22, #32, #33, #37, #40, #48, #55, #57, #58 and #263. Interview on 11/08/23 at 8:59 A.M. with Resident #264 stated he would be able to see outside better if the window was cleaned. Interview on 11/08/23 at 9:04 A.M. with Resident #34 stated the window was very dirty and had been for quite a while. It was difficult to watch the leaves change colors and fall from the trees, which was enjoyable. Interview on 11/08/23 at 9:08 A.M. with Resident #12 stated the window was dirty, and the window blinds break easily when touched because it was so old. Observation and interview on 11/08/23 at 9:16 A.M. during an environmental tour with Maintenance Director #409 verified all the above findings.

Based on interview, record review, and review of the Self-Reported Incident (SRI) number (#)238223 the facility failed to ensure Residents #39 and #42 were treated with respect and dignity. This affected two residents (#39 and #42) of four residents reviewed for dignity and respect (#14, #27, #39 and #42). The facility census was 58. Findings include: Interview on 11/06/23 at 9:05 A.M. with Resident #39 reported an (unnamed) agency State tested Nursing Assistant (STNA) pushed a tray cart into Resident #39 which caused a cut to the arm. The STNA had an attitude and complained about things. Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, cognitive communication deficit, lymphedema, anxiety disorder, rheumatoid arthritis, tracheostomy status, chronic respiratory failure, and morbid severe obesity due to excess calories. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had no cognitive impairment. Resident #39 was dependent on staff for toileting, dressing and bed mobility. Set-up assistance was required for locomotion using a motorized wheelchair. Review of the skin/wound evaluation dated 08/17/23 revealed a new area was noted. Two bruises with a small skin tear were in the center of Resident #39's right posterior forearm. Review of Resident #39's progress notes for August 2023 revealed on 08/17/23 there was an altercation between Resident #39 and an unnamed agency STNA. Resident #39 reported talking to a different unnamed non-agency STNA while the agency STNA pushed the food cart. The non-agency STNA brought Resident #39's dinner tray into the room. The agency STNA followed behind the non-agency STNA and stated, what the [expletive] is your problem. The argument escalated and Resident #39 asked the agency STNA to leave the room and the agency STNA replied, I don't have to. Shortly thereafter, Resident #39 was in the hallway and the agency STNA stated, excuse me. Resident #39 indicated to wait, and then the agency STNA rammed the food cart into Resident #39 which caused bruising and a small skin tear to the right forearm. Resident #39 and the agency STNA were told to quit yelling and cursing, and the agency STNA was asked to leave the area. Review of SRI #238223 dated 08/17/23 revealed the alleged wrong doer was STNA #464. The witness statement dated 08/17/23 from STNA #464 indicated while passing dinner trays, Resident #39 was talking bad about STNA #464 to STNA #443 so STNA #464 confronted Resident #39 by asking was there a problem with me. Resident #39 started cursing and calling STNA #464 a black [expletive] while demanding STNA #464 leave the room. As STNA #464 continued to pass meal trays, Resident #39 continued to curse and call STNA #464 names in the hall. Resident #39 tried to take the food cart and a tray almost fell , so STNA #464 moved the cart out of Resident #39's way so the dinner trays would not be destroyed. The witness statement dated 08/17/23 from Resident #39 indicated words were had in the hallway with STNA #464, then while in Resident #39's room talking with STNA #443, STNA #464 entered the room yelling and asked what Resident #39's problem was. Resident #39 and STNA #464 yelled and cursed at each other. Resident #39 asked STNA #464 to leave the room three times and STNA #464 responded not having to. Resident #39 then left the room and sat in the hallway. STNA #464 came up behind Resident #39 and said, excuse me. Resident #39 stated, hold on, because of the power chair, then STNA #464 ran the food cart into Resident #39's arm which caused a cut. Resident #39 and STNA #464 yelled and cursed at each other again before both left the area. The witness statement dated 08/17/23 from STNA #443 indicated being in Resident #39's room when STNA #464 entered yelling and getting in Resident #39's face asking if Resident #39 had a problem while swearing at Resident #39 who then told STNA #464 to get out of the room, but STNA #464 continued to yell and swear. STNA #464 continued to yell and swear at Resident #39 while pushing the food cart of dinner trays. The food cart was then pushed into Resident #39 which caused a cut on Resident #39's arm and spilled drinks on the dinner trays while STNA #464 was still yelling and swearing. STNA #443 went to find the (unnamed) nurse. The witness statement dated 08/17/23 from Licensed Practical Nurse (LPN) #423 indicated STNA #443 reported an altercation between Resident #39 and STNA #464. When LPN #423 arrived in the hallway both Resident #39 and STNA #464 were yelling and cursing. Resident #39 reported STNA #464 hit Resident #39 with the food cart. Resident #39's arm had a scant amount of blood, a small skin tear, and scattered bruising. LPN #423 separated Resident #39 and STNA #464 by having them leave the area. The witness statement dated 08/17/23 from STNA #436 indicated while in a substation in the area Resident #39 and STNA #464 were heard arguing followed by a crash in the hallway and continued arguing. Resident #39 reported STNA #464 hit Resident #39 with the food cart. Interviews were conducted with all residents able to answer questions which resulted in no concerns except for Resident #42. The interview with Resident #42 dated 08/18/23 from Resident #42 indicated feeling mistreated by STNA #464 who Resident #42 felt was rude. Review of Resident #39's progress notes for August 2023 revealed after the altercation on 08/17/23, Resident #39 declined law enforcement notification and reported doing well and feeling safe. Resident #39 was apologetic for the incident and reported being upset by STNA #464 for being lazy and doing anything while watching other nursing assistants run around. Interview on 11/07/23 at 3:14 P.M. with Administrator revealed there were no witnesses who saw STNA #464 hit Resident #39 with the cart so it could not be determined if it was purposeful. STNA #464 reported Resident #39 tried to grab the cart, but Resident #39 denied it. Resident #39 was not aggressive, so it was unlikely Resident #39 grabbed the food cart. It was more likely STNA #464 was impatient and did not wait long enough for Resident #39 to move out of the way of the food cart. Administrator verified STNA #464 was an agency aide who was no longer permitted to return to the facility, and due to the altercation on 08/17/23 was terminated from the agency because of poor customer service. Resident #42 was no longer in the facility but reported on the date of the incident, STNA #464 was rude because STNA #464 entered the room, set the dinner tray down and left without speaking to Resident #42. Interview on 11/07/23 at 3:21 P.M. with STNA #443 stated being in Resident #39's room on 08/17/23 talking to Resident #39 about Resident #39 not liking STNA #464's demeanor. STNA #464 barged into Resident #39's room and asked what Resident #39's problem was. Resident #39 tried to get STNA #464 to leave the room while STNA #464 stated it was [expletive] and [expletive] this but did not witness STNA #464 call Resident #39 any names. This deficiency represents non-compliance investigated under Complaint Number OH00147304.

Based on record review, review of facility policy and interviews, the facility failed to ensure Dietary Manager (DM) #200, Dietary Employee (DE) #203, DE #204 and DE #205 were properly screened according to abuse prevention policy and procedures. The facility also failed to implement the policy to avoid hiring DE #203 having a disqualifying criminal conviction. This had the potential to affect all 61 residents living in the facility. Findings included: Review of the personnel records for Dietary Employee (DE) #203 revealed a hire date of 10/05/22. Review of the dietary staffing schedules for May 2023 through July 2023 revealed DE #203 worked as a dietary aide on the A.M. and P.M. shifts as well as working as a Cook. Review of the online Attorney Generals Sexual Offenders for Ohio database search by the surveyor revealed DE #203 was a Tier Three Sexual Offender. Review of the facilities Bureau of Criminal Identification and Investigation (BCI) log revealed DE #203's name did not show up on the log nor did three additional dietary employees including the current Dietary Manager (DM) #200, DE #204 and DE #205, as well as for DE #203. Review of additional personnel records for DM #200 revealed a date of hire (DOH) of 02/16/23. DOH for DE #205 was 08/07/22 and DOH for DE #204 was 05/30/23. Interview was conducted on 07/11/23 at approximately 11:00 A.M. with the Director of Human Resources and Payroll (DHRP) #104 who revealed she did the background checks for facility staff, but had not been responsible for the background checks for the contracted staff working in the dietary department and that was why DE #203, DE #204, DE #205 and DM #200 were not showing on the BCI log. On 7/10/23 at 12:49 P.M. an interview with the Administrator revealed he had discovered the dietary contract company had not done background checks on all the employees contracted to work in the dietary department at the facility. After reviewing the files, the Administrator determined he did not have criminal background BCI checks on three additional employees including Dietary Manager #200 with a hire date 02/16/23, Dietary Employee #205, hire date 08/07/22, and Dietary Employee #204 with a hire date 05/30/23. The Administrator stated he sent them out immediately to have the BCI background check done. The Administrator also stated he had immediately checked the three employees against the Nurse Aide Registry and Ohio Attorney Generals Sexual Offenders Registry and found no concerns. The Administrator informed the surveyor DE #203 was terminated from employment at the facility upon discovery of his sex offender registry status. Review of the facility's Human Resources (HR) Checklist for Onboarding stated a background and physical must be done before the start date of the employee. Review of the facility policy titled Abuse Prevention Program, dated 08/2006, stated it was the policy of the facility to conduct employee background checks of all employees. Review of the facility policy titled Preventing Resident Abuse, dated 12/2013, stated it was the policy of the facility to conduct background investigations to avoid hiring persons who have been found guilty (by a court of law) of abusing, neglecting, or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00144289.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Dietary Employee (DE) #203, who was a registered tier three sex offender was not employed in a position that included direct resident contact. This had the potential to affect all 61 residents residing in the facility. Findings included: Record review of Dietary Employee (DE) #203's personnel file revealed the employee was hired as a cook through the facility dietary services contract company who assigned him to work in the dietary department at the facility. DE #203's first date of employment with the facility was 10/05/22. Review of the facility's dietary staffing schedule dated 05/28/23 through 07/07/23 revealed DE #203 worked 21 shifts in the facility dietary department as an A.M. and P.M. dietary aide and three shifts as an A.M. and P.M. cook. Review of the Job Flow: Dietary Aide AM and Job Flow: Dietary Aide PM job descriptions provided to the surveyor by Director of Operations of Ohio (DOO) #300 from the dietary contract company revealed dietary aides worked both inside the kitchen, in the resident dining room and delivered trays, snacks and ice chests to the resident units. Additional duties included greeting residents, assisting with seating, putting on resident clothing protectors, taking food orders from residents and turning food orders in to the kitchen during meal service. Review of a document printed out by the facility on 07/06/23 at 3:09 P.M. titled Ohio Attorney General's Office Offender Watch sex offender management, mapping and email alert program revealed DE #203 was a level three Child Victim Offender. Review of a document titled Notice of Registration Duties of Sexually Oriented Offender or Child-Victim Offender ([NAME]) Adult Offender Information revealed DE #203 had been previously convicted of second-degree sexual conduct (multiple variables) in the state of Michigan on 06/09/2003 and on 06/23/2003 a conviction in the state of Michigan of criminal sexual conduct second degree (person under 13). Review of a document titled Ashtabula County Sheriff's Office, dated 07/06/23, revealed DE #203 had no current warrants out for his arrest and noted his employment at the facility through the dietary contract company was verified by the Sheriff's Office. There was no information on the letter to indicate the facility he was employed at was a nursing home nor that the facility admitted residents under the age of 18. On 07/06/23 at 2:45 P.M. interview with the Administrator revealed about two months ago he had heard some scuttlebutt that DE #203 had possibly been a sexual offender. In response to the scuttlebutt the Administrator checked the Ohio Attorney General's website and said he found no findings when running DE #203's name so did not pursue the matter any further. The Administrator stated he had no verifying evidence he had run the check, but stated if he had verified DE #203 was a tier three sexual offender, he would have fired him immediately. The surveyor requested confirmation of background checks being completed for DE #203 and all dietary staff. The Administrator then indicated he received confirmation DE #203 had been convicted and was a tier three Child Victim Offender. The Administrator then indicated this was the first knowledge he had of DE #203's prior convictions and stated he had not been alerted by the dietary contract company, as they were the entity responsible for doing the background checks for their individual employees, including DE #203. Interview on 07/07/23 at 11:55 A.M. with Director of Operation of Ohio (DOO) #300, who was a director for the dietary contract company, revealed both DOO #300 and DE #203 told the Administrator they had paperwork from the county Sheriff's office saying it was OK for DE #203 to be employed in the dietary department and he had confirmed after talking to the Sheriff's Department it was no concern DE #203 was working in a nursing facility kitchen. However, DOO #300 stated he could not confirm if there had been a complete background check done on DE #203 because DE #203 was hired on 10/05/22, he had only taken over the DOO position about two and a half months ago and the previous DOO (DOO #400) had taken the employee files upon leaving. DOO #300 stated he would try to get DE #203's file from the Corporate Office in New Jersey. An interview was conducted on 07/10/23 at 11:53 A.M. with Lieutenant (LT) #700 who stated she was the Lieutenant for Ashtabula County with responsibility for approving or disproving employment placement for persons with charges of sexual offenses. LT #700 explained she had approved DE #203 for employment in the kitchen at the facility because his conviction was [AGE] years ago, and the type of sexual offence did not exclude him from employment at the facility working in the kitchen because he would just stay in the kitchen. LT #700 said kitchen jobs were one of the few placements she could employment find for sex offenders. LT #700 verified DE #203 was a tier three child sex offender. LT #700 did not verbalize understanding nor acknowledge the facility admitted residents under the age of 18 when the surveyor asked if she was aware adolescents were part of the demographic at the facility or of the employee's interaction with facility residents outside the kitchen based on the job duties of the employee's position. Interview on 07/11/23 at approximately 11:00 A.M. with the Director of Human Resources and Payroll (DHRP) #104 revealed she did the background checks for facility staff, but had not been responsible for the background checks for the contracted staff working in the dietary department. DHRP ##104 said she was not aware DE #203 was a tier three registered sex offender until 07/06/23 or 07/07/23 when she was informed by the Administrator. DHRP #104 stated DOO #300 and DE #203 told the Administrator they had paperwork from the county Sheriff's office saying it was OK for DE #203 to be employed in the dietary department. DHRP # 104 explained that having the tier three child sex offender in the facility was concerning to her because the facility admitted residents under the age of 18 and this would exclude him from employment in a nursing home. Interviews were conducted on 07/11/23 from 11:15 A.M. to 11:25 A.M. with Licensed Practical Nurse (LPN) #147, State tested Nursing Assistant (STNA) #126, and STNA#150. During the interviews, each staff member informed the surveyor it was the dietary aides' responsibility to bring the tray carts from the kitchen to the resident units for those residents eating on the units instead of in the dining room, so dietary aides (including DE #203) did come out of the kitchen into the resident population. On 07/11/23 from 11:22 A.M. to 11:49 A.M. observations of the main dining room, general facility environment, the kitchen environment, and the lunch dining room service in the facility revealed the kitchen was connected to the resident's dining room via a door and the dietary aide from the kitchen was observed bringing a beverage cart into the dining room while multiple residents sat waiting to be served. The kitchen was adjacent to the therapy gym and common area for resident activities. Interview on 07/11/23 at approximately 12:30 P.M. with Dietary Manager (DM) #200 revealed she became aware of DE #203's conviction as a sex offender about two months ago and did bring it to the attention of the former boss of the kitchen (Director of Operations of Ohio #400). DM #200 added DE #203 had been dating a nurse aide at the facility and they had gotten into an argument and the nurse aide told staff in the facility DE #203 was a sex offender. DM #200 verified DE #203 worked as both a cook and dietary aide and the dietary aide position did require DE #203 to be outside of the kitchen and around the facility to deliver tray carts, snacks and hydration to residents. Interview on 07/11/23 at 4:30 P.M. with the Administrator verified DE #203 was not appropriate for employment in the facility due his disqualifying offense and indicated prior Dietary Manager (DM) #900 had been responsible for completing the background checks for DE #203. The Administrator explained it would have been the responsibility of the contract company and DM #900 to run background checks on the dietary employees to ensure they did not have any disqualifying convictions for employment in the facility. Interview on 07/11/23 at approximately 5:55 P.M. with the Administrator verified the facility accepted and admitted residents under the age of 18 with the youngest accepted age being [AGE] years old. Review of the facility policy titled Abuse Prevention Program, revised August 2006, revealed the facility would not knowingly employ any individual who had been convicted of abusing, neglecting or mistreating individuals. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00144289.

Based on observation and interview the facility failed to maintain residents' personal refrigerators in a clean and sanitary manner. This affected three (Resident's #15, #19 and #30) of four residents reviewed for safe, clean, and comfortable homelike environment. The facility census was 48. Findings include: Observation and interview on 08/09/22 at 10:31 A.M. revealed Resident #30 had a dirty personal refrigerator with food and liquids spilled and was overcrowded with half eaten items. The resident stated she was responsible for cleaning her refrigerator but hadn't done it in a while. Observation and interview on 08/09/22 at 10:55 A.M. with Resident #19 revealed the personal refrigerator was not plugged in. The resident stated the refrigerator had stopped working. There were a few nonperishable items in it. The refrigerator needed cleaning and repair. License Practical Nurse (LPN) #203 verified these findings. Observation and interview on 08/09/22 at 10:57 A.M. with Resident #15 revealed the refrigerator was very dirty and had spilled liquid in the bottom. The resident stated the refrigerator did not work. It was filled with perishable food items even though it was not in working order. LPN #203 verified these findings. Interview on 08/09/22 at 11:06 A.M. with LPN #203 verified refrigerator cleaning was a problem. The facility needed to clarify and communicate whose responsibility it was to clean the residents' personal refrigerators. Interviews on 08/09/22 at 1:36 P.M. and 2:55 P.M. with State tested Nurse Aide (STNA) #204 and STNA #205 revealed they were not sure who was responsible for cleaning the refrigerators. Sometimes they helped the residents' clear items and wipe up spills. This deficiency substantiates Complaint Number OH 411.

Based on observation, interviews with staff and family and review of the medical record, police report, Emergency Medical Services (EMS) report, hospital report, self-reported incident (SRI) investigation and the facility Wandering, Unsafe Resident policy, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #45), who had impaired safety awareness and [DIAGNOSES REDACTED]. This resulted in Immediate Jeopardy when Resident #45 eloped from the facility on 12/21/19 at approximately 4:45 P.M. without staff knowledge. Actual Harm occurred when Resident #45 was found approximately two and one-half miles from the facility laying in the roadway after almost being struck by a vehicle. Resident #45's body temperature was 85.7 degrees Fahrenheit (F) and he had a hematoma to his hand. This affected one of four residents reviewed for elopement risk and wandering behaviors. The facility had identified three residents (Residents #20, #26 and #45) at high risk for elopement and 11 residents (Residents #4, #8, #9, #25, #7, #24, #17, #19, #44, #41, #22) at moderate risk for elopement. The facility census was 44. On 01/06/19 at 4:55 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 12/21/19 at 4:45 P.M. when Resident #45, who was at risk for elopement, left the facility without staff knowledge and wandered approximately 2.5 miles from the facility. Resident #45 was observed by a bystander laying in the roadway after sustaining a fall. The resident was almost struck by a passing motorist. The resident was transported to a local hospital by EMS and noted to have right finger pain, a hematoma (swelling of clotted blood) on the posterior right hand and a body temperature of 85.7 degrees F. The Immediate Jeopardy was removed on 01/08/20 when the facility implemented the following corrective action: · On 12/21/19 at 5:10 P.M. staff identified Resident #45 was missing. It was communicated by Licensed Practical Nurse (LPN) #100 to all staff on duty (LPN #104, State tested Nurse Aides (STNA) #102, #103, #105 and #106) that Resident #45 was missing. Staff was assigned to systematically look in all areas of the facility for Resident #45. One staff was assigned to visually inspect outside grounds for Resident #45. Alert and oriented residents were asked if they had seen the resident. It was determined Resident #45 was last seen on 12/21/19 at 4:45 P.M. by STNA #102. · On 12/21/19 at 5:20 P.M. the Administrator, Director of Nursing (DON) and local police were notified. · Resident #45 was found approximately 2.5 miles from the facility by the local police department on 12/21/19 at 7:00 P.M. and was transferred to the local hospital. · On 12/21/19 by 9:00 P.M. all residents were reassessed for elopement risk by the Administrator who is a Registered Nurse (RN). Three residents (Residents #20, #26 and #45) were identified as high risk for elopement and 11 residents (Residents #4, #8, #9, #25, #7, #24, #17, #19, #44, #41, #22) were identified as moderate risk for elopement. The Elopement Binders containing the resident's emergency identification face sheet, photograph and description were updated and placed at each nurse's station and in the main office. · On 12/22/19 by 12:00 P.M. Regional MDS Nurse #142 updated all care plans and Kardex to include elopement risk assessments and interventions for all residents identified as an elopement risk. · On 12/22/19 at 6:30 P.M. the Administrator and Maintenance #101 in-serviced all staff on the Elopement Policy, revised (MONTH) 2007, and on the Elopement Binders located on the nurse's desk on each nurse's station and in the main office. · On 12/27/19 at 10:20 [NAME]M. the DON conducted an elopement drill with Dietary Staff #107, Dietary Staff #108, STNA #110, Activity Staff #128, the Administrator, LPN #100, LPN #122, STNA #129, Maintenance #101 and Social Services Director (SSD) #130. · On 01/06/20 at 5:00 P.M. Vice President (VP) of Operations #140 and VP of Clinical #141 were notified of the Immediate Jeopardy by Regional Nurse #143 and discussed immediate interventions to be put into place 24 hours a day seven-days a week (24/7). A head count was conducted by the Administrator, and all residents were accounted for. The facility implemented 24/7 coverage to the front door by Regional Minimum Data Set (MDS) Nurse #142, Maintenance #101 and the Administrator. The understanding was that no nursing staff would be utilized for the 24/7 coverage to monitor the front door. The as needed (PRN) maintenance staff, facility management or volunteers from other departments will cover the shifts. · On 01/06/20 beginning at 5:00 P.M. the Administrator, Maintenance #101 and Regional MDS Nurse #142 began educating all staff on how to set the alarm, how to monitor the door and make sure the alarm is set, how to use walkie talkies, not leaving the door unattended for any reason, to notify the Administrator if the alarm is not working properly, head count for residents on all units to be conducted by nursing every hour, how to and how often to audit the front door alarm. The front door alarm will be audited by maintenance every shift at 7:00 [NAME]M. and 7:00 P.M. until the new secure system is installed. All in-servicing was completed on 01/07/20 by 9:00 P.M. · On 01/06/20 at 5:00 P.M. Regional RN #143, the Administrator, Maintenance #101, VP of Operations #140, VP of Clinical #141 and Regional MDS Nurse #142 met with corporate to discuss ways to enhance security. Until the final decision is made, the door will be monitored by staff as indicated 24/7. · On 01/06/20 beginning at 6:00 P.M. audits began for head count of residents hourly by nursing staff, checking door alarm function every shift at 7:00 [NAME]M. and 7:00 P.M. by maintenance and/or by the staff monitoring the door, staff demonstrating continued use of setting and turning off the alarm during the 7:00 [NAME]M. and 7:00 P.M. checks along with trouble shooting and to notify the Administrator with problems. This will have no stop date until the new secure system is installed. · On 01/06/20 at 8:00 P.M. all night shift (7:00 P.M. to 7:00 [NAME]M.) staff was educated by Maintenance #101 on monitoring the door and making sure it was alarmed with return demonstration. The door remains under 24/7 monitoring. · On 01/07/20 at 1:40 P.M. a quote for a new secure system was received. Authorization from owners to install has been approved, and the keypad system will be installed on 02/03/20. 24/7 monitoring of the door will continue until the system is installed. Although the Immediate Jeopardy was removed on 01/08/20, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of monitoring to ensure compliance. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the Wandering/Elopement Risk assessment dated [DATE] at 3:23 P.M. revealed Resident #45 was a high risk for wandering. The resident was forgetful, independent with mobility, and had a history of [REDACTED]. Review of the facility admission documentation dated 12/20/19 revealed Resident #45 was admitted for a short-term respite for ten days with a primary [DIAGNOSES REDACTED]. Review of facility admission referral documentation provided by the previous facility dated 12/02/19 revealed the daughter had reported Resident #45 was having trouble with memory and confusion, went missing, and was found wandering outside in sub-freezing weather for over an hour at a previous facility. Review of a baseline care plan dated 12/20/19 revealed Resident #45's focus was cognition, social services and safety. He was confused, an elopement risk and had dementia. The listed intervention was to be roomed by the nurses ' station. Resident #45 was independent with bed mobility, transfers and walking. Review of an SRI dated 12/22/19 revealed on 12/21/19 Resident #45 exited the facility unauthorized and unknown to staff. Further review of the SRI investigation timeline revealed the resident was observed by STNA #102 on 12/21/19 at 4:45 P.M. standing by a window at facility Door #10 (Fieldhaven, short hall) and commented on the snow outside. At 5:10 P.M., STNA #102 attempted to deliver Resident #45's meal tray but was unable to find him. At 5:15 P.M., the facility searched the building and outside perimeter. At 5:20 P.M., the local police department, Director of Nursing, and Administrator were notified. Staff then initiated a search using vehicles. At 5:30 P.M., the resident's family was notified. At 6:00 P.M., the car search expanded to within a three-mile radius. At 7:05 P.M., the facility was informed by the local police department Resident #45 was found and transported to the local hospital. At 10:55 P.M., the physician was notified. Review of the police report dated 12/21/19 at 5:25 P.M. revealed Resident #45 was reported as an endangered missing person. He had walked away from the facility, had dementia and was last seen at 4:45 P.M. wearing a flannel shirt, shoes and a hat, was known to leave other facilities, and had to be locked down in the past. At 6:33 P.M., Resident #45 was located at a mini-mart (approximately 2.5 miles from the facility) where he had fallen in the roadway, injured his hand, and was very cold to the touch. Review of the National Climatic Data Center geographical information for 12/21/19 available via http://www.ncdc.noaa.gov revealed the outside maximum temperature was 36 degrees Fahrenheit (F), the minimum was 24 degrees Fahrenheit (F), and an average wind speed was 7.0 miles per hour (mph). Review of EMS documents dated 12/21/19 at 6:29 P.M. revealed the response team was dispatched to the mini-mart and upon arrival observed people around the resident who was sitting upright on the ground. According to witnesses, the resident was almost struck by a car, tripped over the curb and fell . Resident #45 had been missing from the facility for approximately two hours. The resident complained of right finger pain, had a hematoma on the posterior right hand and a body temperature of 85.7 degrees F. Review of the local hospital emergency room documents dated 12/21/19 at 7:13 P.M. revealed Resident #45 arrived at the emergency department via ambulance after a fall. The report indicated the resident was walking by a liquor store, fell forward and was almost hit by a car after he fell The note indicated the resident had dementia and was unaware of where he was, he complained of pain in the center of his chest, and his body temperature was 85 degrees F. The ER note indicated the resident eloped from a nursing facility approximately three hours prior. [DIAGNOSES REDACTED]. Review of the daily staffing log for the date of the elopement indicated there was one nurse and three STNAs working in the facility. On Resident #45's unit (Fieldhaven) there was one assigned STNA and the one nurse assigned was floating between the two facility areas of Fieldhaven and Shorehaven. The facility reported 21 residents on Fieldhaven including three residents with ventilators, and 22 residents on Shorehaven. The in-facility census was 43. Observation upon entering the facility on 01/06/20 at 5:51 [NAME]M. revealed an alarm sounded when the front door was opened and ceased sounding when the door closed. No staff were observed in the main lobby. Observation on 01/06/20 at 5:53 [NAME]M. revealed an alarm sounded when the front door was opened and ceased sounding when the door closed. LPN #104 approached the main lobby from the Fieldhaven hallway. Interview on 01/06/20 at 6:00 [NAME]M. with STNA #114 confirmed Fieldhaven, where Resident #45 resided, had one STNA most of the time, and work does not always get completed. STNA #114 indicated there were a few residents who wandered and the STNA verified rounds were not able to be completed timely but were done as close to the two hours as possible. STNA #114 confirmed the facility alarm in place at the time of the elopement could not be heard when in a resident's room. Interview on 01/06/20 at 7:06 [NAME]M. with Maintenance #101 revealed there were two alarms installed on all the facility doors. The first alarm system in place was quieter and not always heard by staff in resident rooms but could be heard at the nurses' station. It would sound when the doors opened and stopped sounding when the doors closed. The second alarm system was louder and required staff to input a code to arm and disarm it but would not self-reset if staff failed to re-arm it. Maintenance #101 verified the second louder alarm was placed on 12/21/19 after the incident took place with Resident #45. Interview on 01/06/20 at 7:46 [NAME]M. with LPN #100 verified she was the only nurse working in the building at the time Resident #45 was missing around 5:15 P.M. on 12/21/19. LPN #100 confirmed one STNA was working on Fieldhaven, Resident #45's unit. She indicated after searching for Resident #45 without success. the police, DON and Administrator were notified. LPN #100 confirmed the second, louder alarms were not in place at the time of the incident. LPN #100 verified the alarm in place at the time of the elopement was quieter and more difficult to hear if staff were in resident rooms. Interview on 01/06/20 at 8:38 [NAME]M. with STNA #109 confirmed at the time Resident #45 eloped, the resident areas of Fieldhaven and Shorehaven would often have one aide assigned, and it was difficult to get work done and hear door alarms if in resident rooms. The addition of the second alarm, which was much louder, was made after the elopement and could be heard while providing care in resident rooms. Interview on 01/06/19 at 12:21 P.M. with the DON verified on 12/21/19 around 5:10 P.M. she received a phone call from the facility that Resident #45 was missing. The DON confirmed there was one STNA and one floating nurse on duty at the time of the incident and verified the reported facility census of 43 and three of the residents were ventilator dependent. The DON verified Resident #45's interventions for wandering were for the resident's room to be by the nurses' station and the STNAs were to make rounds (every two-hour checks), as well as an alarm on the door. The DON confirmed the second louder door alarms were placed after the elopement occurred on 12/21/19. Interview on 01/06/20 at 2:09 P.M. with Resident #45's daughter verified the facility assured the family in response to warnings about Resident #45's wandering, that they could keep him safe. The resident's daughter confirmed a call on 12/21/19 was received around 5:30 P.M. indicating Resident #45 was missing. Resident #45's daughter further specified when picking up Resident #45's belongings (unsure of the date) an alarm system had been installed that was not previously in place, and upon exiting the building with a staff member the alarm did not sound. Resident #45's daughter verified the staff member did not use a code for the door and stated the alarm had been shut off and not re-set. Interview on 01/07/20 at 6:35 [NAME]M. with LPN #126 confirmed Fieldhaven always had one aide on night shift and had three residents with ventilators. LPN #126 verified she had worked as the only nurse in the facility for part of the shift on 12/27/19. LPN #126 confirmed the minimum care was completed to try to keep residents safe, but no extra work could be done. Interview on 01/07/20 at 8:41 [NAME]M. with SSD #130 verified Resident #45's family and referring facility provided information about Resident #45's wandering, and the family expressed concerns about it prior to admission. SSD #130 verified the family was told Resident #45 would be by the nurses' station and staff would do rounds and two-hour checks. Interview on 01/08/20 at 6:48 [NAME]M. with LPN #126 verified an in-service was received on properly setting and re-setting the door alarms and to make sure the door was working every hour. Interview on 01/08/20 at 6:51 [NAME]M. with STNA #119 confirmed there was usually one aide on the Fieldhaven assignment and indicated it was not enough. STNA #119 verified the original alarm at the time of the elopement could not be heard in resident rooms, but the second alarm, applied after the elopement, was louder. Interviews on 01/14/20 from 1:02 P.M. through 2:51 P.M. with Human Resources #150, STNAs #105, #109, #111, RN #121, LPN #165, Activities #128, Maintenance #101, Dietary #160 and #161, SSD #130, the DON, and Receptionist #146 revealed appropriate knowledge of the facility elopement policy and procedure, responsibilities related to alarms on facility doors, twenty-four hour monitoring of the facility front door, and frequent monitoring of residents in the facility. Review of facility policy entitled, Wandering, Unsafe Resident, undated, revealed the resident's care plan will indicate the resident is at risk for elopement or other safety issues; interventions to try to maintain safety, such as a detailed monitoring plan will be included.

Based on observation, record review and interview the facility failed to ensure interventions were in place and implemented as planned and adequate supervision was provided to prevent falls for Resident #15 and Resident #38. Actual harm occurred on 02/21/19 at 9:15 P.M. when Resident #38, who had a history of [REDACTED]. This affected two residents (Resident #15 and #38) of two residents reviewed for falls. Findings include: 1. Record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a post fall evaluation investigation dated 01/26/19 at 12:30 A.M. revealed Resident #38 was observed on the floor in her room pounding on the door. Resident #38 had no injuries noted. The facility investigation revealed following the incident a new intervention was implemented for staff was to complete 15-minute checks. Record review revealed on 01/26/19 a physician order [REDACTED]. Review of the facility documentation for Resident #38's 15-minute checks revealed the 15-minute checks were completed on 01/26/19 and 01/28/19. There was no additional documentation of any 15-minute checks being completed for Resident #38 after 01/28/19. Review of care plan dated 02/05/19 revealed Resident #38 was at risk for falls related to balance issues, medication use and history of falls prior to admission. Review of a post fall evaluation dated 02/09/19 at 5:30 P.M. revealed Resident #38 was observed on the floor in her room laying on her stomach. The fall investigation revealed Resident #38 had last been observed 20 minutes prior to incident (although the resident had order was to be on 15-minute checks at the time of the fall). Interventions documented that were in place prior to fall included 15-minute checks. New interventions implemented after the fall were to encourage the resident to be in dining room for meals and continue current interventions. Review of a fall assessment dated [DATE] revealed Resident #38 was at high risk for falls. Review of a post fall evaluation dated 02/21/19 at 9:15 P.M. revealed staff responded to a noise in Resident #38's room and observed Resident #38 seated on the floor with her legs straight out in front of her. Resident #38 complained of right leg pain and her right leg appeared shorter than the left and was rotated outward. Resident #38 was sent to the hospital for evaluation. Interventions documented on the post fall evaluation that were in place prior to the fall included 15-minute checks. However, the evaluation did not include evidence the 15 minutes checks were being completed prior to this fall as care planned and ordered. New intervention listed after the fall for Resident #38 noted the resident was sent to the hospital, initiate neurological checks and continue current interventions. Review of hospital x-ray report dated 02/22/19 at 12:08 A.M. revealed the resident had a trimalleolar (ankle) fracture with widening of the medical clear space. Review of 30-day Minimum Data Set (MDS) 3.0 dated 02/22/19 revealed Resident #38 had intact cognition with delusions. The assessment revealed Resident #38 required extensive assist from two persons with transfers and toileting. Review of a post fall evaluation dated 03/02/19 at 11:30 P.M. revealed Resident #38 was observed on the floor in a sitting position. Interventions listed as in place prior to fall noted 15-minute checks. New interventions included after the fall included the use of non-skid socks and to continue 15-minute checks. Interview on 03/13/19 at 5:12 P.M. with State tested Nursing Assistant (STNA) #600 revealed she usually worked on Resident #38's unit. The STNA revealed she was not aware Resident #38 was to have every 15-minute checks. She revealed she remembered several months ago there were 15-minute forms to document on but that she had not seen the forms recently. STNA #600 then indicated she thought the resident's 15-minute checks were discontinued months ago. Interview on 03/13/19 at 5:15 P.M. with STNA #601 revealed she routinely worked on Resident #38's unit. The STNA indicated she was not aware Resident #38 was on 15-minute checks and revealed she had not completed 15-minute checks for several months. The STNA revealed when the resident had been on 15-minute checks it had only been for a couple days. She stated there had not been 15-minute forms to be completed so she thought this had been discontinued a while ago. Interview on 03/13/19 at 5:20 P.M. with Licensed Practical Nurse (LPN) #602 revealed she did not believe Resident #38 was on 15-minute checks although she had been for a couple days a while ago after a fall. LPN #602 revealed Resident #38 was currently in the hospital but that she was the nurse for her on 03/12/19 and verified 15-minute checks were not completed on this date as she was unaware the resident had an order for [REDACTED].>Interview on 03/14/19 at 9:08 A.M. with the Director of Nursing verified Resident #38 had a current order to be on 15-minute checks and that the order had been initiated on 01/26/19. The DON verified the only evidence of staff completing the 15-minute checks was on 01/26/19 and 01/28/19. The DON also verified there was no evidence the 15-minute checks were being completed at the time of the above falls. 2. Record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 02/15/16 revealed Resident #15 had a potential for falls due to balance issues, antidepressant use, and recent history of falls. Resident #15 was unsteady and used a wheelchair. Interventions included 15-minute checks to ensure the pressure sensitive alarm was intact and functioning as Resident #15 was shutting off her alarm. An intervention dated 01/04/19 revealed Resident #15 was always to have a Dycem (a non-slip rubber- like plastic) to wheelchair and an intervention, dated 01/10/19 for a Dycem to the edge of bed at all times. Review of physician's orders [REDACTED]. Review of the POS [REDACTED].M. revealed Resident #15 was observed on the floor. Interventions listed prior to the fall on the investigation were 15-minute checks. Interventions included after the fall for Resident #15 was to initiate a grabber to pick up items and continue current interventions. Review of the POS [REDACTED].M. revealed staff heard Resident #15 yelling for help and upon entering the room Resident #15 was observed sitting on the floor. The resident stated she slid out of her wheelchair. Interventions listed prior to fall noted 15-minute checks. Intervention after the fall included to add Dycem to Resident #15's wheelchair and continue current interventions in place. Review of the POS [REDACTED]. Interventions listed prior to the fall on the investigation for Resident #15 included 15-minute checks and a Dycem to the wheelchair. Intervention implemented after the fall included anti-roll backs to the wheelchair and continue current interventions in place. Review of fall assessment dated [DATE] revealed Resident #15 was at moderate risk for falls due to history of falls, multiple falls, loss of balance, agitated behavior and decreased muscle coordination. Review of Resident #15's 15-minute documentation revealed 15-minute documentation was completed from 01/01/19 to 01/30/19. There was no evidence of the 15-minute checks being completed after 01/30/19. Interview on 03/13/19 at 5:12 P.M. with STNA #600 revealed she usually works on Resident #15's unit and that she was not aware Resident #15 was currently on 15-minute checks. She revealed she remembered a month ago she had 15-minute forms to document the 15-minute checks as Resident #15 turns off her alarm and self-transfers but that she had not seen the forms recently. STNA #600 revealed she thought the 15-minute checks were discontinued. STNA #600 verified that she did not complete 15-minute checks today, 03/13/19. Interview on 03/13/19 at 5:15 P.M. with STNA #601 revealed that she usually works on Resident #15's unit and that she was not aware Resident #15 was on 15-minute checks. She had not completed 15-minute checks since there were no 15-minute forms to be completed so she thought this had been discontinued a while ago. She verified she did not complete 15- minute checks on this date, 03/13/19. Interview on 03/13/19 at 5:20 P.M. with LPN #602 revealed she did not think Resident #15 was on 15-minute checks to her knowledge but that she used to be because she shuts off her alarms and self- transfers. LPN #602 revealed Resident #15 continued to shut off her personal alarm to her chair and bed. LPN #602 verified that 15-minute checks were not completed on 03/13/19 per Resident #15's care plan recommendation to prevent falls. Observation on 03/13/19 at 5:09 P.M. revealed Resident #15 was up in her wheelchair. The resident was not observed to have a Dycem to her wheelchair or bed at that time. Interview on 03/13/19 at 6:30 P.M. with STNA #600 verified Resident #15 who was up in her wheelchair did not have a Dycem to her wheelchair or on her bed. STNA #600 verified Resident #15 was to have a Dycem to her bed and wheelchair as a fall intervention. Interview on 03/14/19 at 9:08 A.M. with the DON verified Resident #15 had fall interventions in her care plan for 15-minute checks and a Dycem to the wheelchair and bed. The DON also verified that 15-minute checks had not been completed since 01/30/19. Review of facility policy titled, Falls- Clinical Protocol, dated (MONTH) 2012 revealed the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on record review, observation and interviews the facility to ensure Resident #92 received care and services to prevent a new pressure ulcer to her right gluteal area and to heal the pressure ulcers present on admission. The facility also failed to ensure comprehensive assessments were completed of Resident #92's pressure ulcers. Actual harm occurred when Resident #92 who was admitted with two Stage III pressure ulcers and was dependent on staff for turns, repositioning, toileting and hygiene developed an additional Stage III pressure ulcer to the right gluteus, as well as worsening of an existing pressure ulcer present upon admission. This affected one of two residents reviewed for pressure ulcers. Findings included: Record review for Resident #92 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Skin Wound Evaluation for Resident #92 dated 02/25/19 revealed she was admitted with a posterior right thigh pressure ulcer, a Stage III. A Stage III pressure ulcer is a full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present but, fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Undermining and tunneling may occur. Slough and/or eschar (devitalized/dead yellowish, tan, black, brown tissue) may be visible but does not obscure the depth of tissue loss. This ulcer was documented as 6.0 centimeters (cm) long by 5.0 cm wide and no depth measurement was listed on the evaluation. Resident #92 was documented as having a Stage III pressure ulcer on her left gluteal fold, measuring 10.0 cm long by 8.0 cm wide and 6.0 cm in depth. The narrative wound description indicated that the left gluteal fold was beefy red with slough (dead, yellow, soft tissue) and the posterior left below knee amputation pressure ulcer had a red wound base with slough and a black area noted at the lateral border. There was no additional description on the evaluation to include any drainage, odor or the condition area around the pressure ulcer. The initial plan of care dated 02/25/19 indicated Resident #92 was incontinent of bowel and had a urinary catheter, a bladder drainage system. The plan of care also indicated that Resident #92 needed a pressure reducing mattress and said she had been going to the wound clinic for care of her pressure ulcers. Review of the physician order [REDACTED]. For the left gluteal fold, the physician order [REDACTED]. The Skin Wound Assessments dated 02/27/19, 03/04/19 and 03/06/19 indicated Resident #92 had a right thigh (posterior) Stage III pressure area measuring 6.0 cm in length by 5.0 cm in width by 0.1 cm depth, and a left gluteal fold Stage III pressure area measuring 10.0 cm in length by 8.0 cm in width by 6.0 cm in depth. There was no further wound description or assessment documented. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #92 was alert and oriented and had no memory or cognitive deficits and she needed extensive assistance from staff for bed mobility, transfers, toileting and hygiene. This assessment indicated Resident #92 was admitted with two Stage III pressure ulcers. Resident #92 was observed on 03/11/19 at 9:40 P.M. laying on her back in bed watching television. Resident #92 was laying on a pressure reducing mattress and was covered with a blanket. Resident #92 said she entered the facility on 02/25/19 with two pressure sores and now had four wounds being treated by a wound clinic. Resident #92 said that she had been living at home with her husband and her pressure sores became infected at home. She said she then needed to be in a care facility for antibiotic therapy, wound healing and physical therapy. Resident #92 explained that she was incontinent of urine, so she used a urinary catheter in order to stay dry. Resident #92 said she was incontinent of stool and would have to sit in her stool in the bed for over 30 minutes before the staff were able to come and change her. Resident #92 said she could not turn to her side without help and said the staff never came in to assist her to turn off her back unless she asked them. Resident #92 said she was concerned her wounds were going to get worse because she was not being kept clean and turned every two hours. Resident #92 said she did not receive the care she needed because there was just not enough staff to care for all the residents in a timely manner on her unit. Resident #92 said she went to the wound clinic on 03/11/19 and was told she had a new pressure ulcer since they last saw her on 02/18/19. Observation was conducted on 03/12/19 at 9:24 A.M. and 11:24 A.M. and revealed Resident #92 laying on her back in bed. On each observation, Resident #92 said she had not been turned off her back by staff. Further observations the same day at 3:55 P.M., 4:07 P.M. and 5:45 P.M. revealed Resident #92 laying on her back in bed and she said staff had not been in to assist her to turn and reposition. Interview was conducted on 03/13/19 at 10:12 A.M. with Licensed Practical Nurse (LPN) #605 who revealed Resident #92's hard chart should have copies of the wound clinic reports. Record review revealed no pressure ulcer documentation that described the resident's wounds from the wound clinic. There was only a copy of the of the physician orders [REDACTED]. Interview was conducted on 03/13/19 at 10:17 A.M. with Registered Nurse (RN) #606 who identified herself as the part-time wound nurse at the facility. RN #606 revealed that Resident #92 was followed by the local wound clinic, so RN #606 would only complete her dressing change on Wednesdays and take her measurements at that time. RN #606 clarified that Resident #92 did not have a Stage III pressure ulcer on her right posterior thigh. She said she had been documenting her measurements on the wrong thigh on the Skin Wound Assessment reports. RN #606 verified the documentation was incorrect from 02/25/19 through 03/06/19. RN #606 stated that the wound clinic documentation must be wrong because she was not aware of a Stage III pressure area on Resident #92's right gluteus. RN #606 said that she had not looked at any of the wound reports from the wound clinic since the resident's admission. She said that would be the responsibility of the floor nurse who did dressing changes on Fridays. She said the wound clinic saw Resident #92 every Monday. Interview was conducted on 03/13/19 at 10:20 A.M. with LPN #607 who was working on Resident #92's unit. The interview revealed that LPN #607 had only been working in the building for two weeks and was not aware of the size or location of Resident #92's pressure ulcers or if the facility had any documentation from the wound clinic. She said maybe RN #801, the nursing instructor, would know. Observation was conducted on 3/13/19 at 10:35 A.M. of Resident #92's dressing changes with RN #801, who identified herself as a nursing instructor who was at the facility with student nurses. RN #801 was not an employee of the facility. RN #801 revealed she was only changing Resident #92's dressings and said she was not recording the measurements as that was the responsibility of RN #606. RN #801 verified Resident #92 did have a third open area to her right gluteus which was pin point in size and looked like a tiny blister that popped and was open. The Skin Wound assessment dated [DATE] and authored by RN #606 at 10:43 A.M. indicated Resident #92's left thigh (posterior) Stage III pressure ulcer worsened and was larger, measuring 7.0 cm in length by 5.7 cm in width by 0.1 cm in depth, a left gluteal fold Stage III pressure area measuring 6.0 cm in length by 5.1 cm in width and 6.0 cm in depth. There was no documentation for the pressure ulcer identified on Resident #92's right gluteus area as noted by RN #801. The narrative wound description stated that wound clinic provided treatment for [REDACTED]. There was no further description of the wounds. Interview was conducted on 03/13/19 at 11:04 A.M. with LPN #605 verified the comprehensive plan of care to address all of Resident #92's skin impairments was not completed yet. LPN #605 verified there were no detailed reports from the wound clinic in the facility to coordinate care for Resident #92. LPN #605 stated she was not aware if Resident #92 had a new pressure ulcer to her right gluteus. Interview was conducted on 03/13/19 at 2:10 P.M. with the spouse of Resident #92 who was at the bedside. The spouse explained that he cared for his wife at home, but it was becoming unmanageable for him, so he wanted her placed in a care facility to get better. The spouse said he regretted bringing her to the facility due to the staff shortage and lack of care causing his wife to lay in bed, wet with urine for 1.5 hours on two occasions when her urinary catheter was out. He said he and Resident #92 requested the urinary catheter be put back in so she could stay dry. The spouse stated that he is in the facility six to eight hours a day every day and has observed her sit in stool for over one hour. He said he had to go insist staff come into her room to clean her. The spouse said that the staff had not come in to turn and reposition her until today. He said his wife was told by staff to turn herself in bed they did not have to do it for her. The spouse appeared to frown, and his eyes filled with tears as he said some nights there was no one at the nurse's station or in the halls to answer his wife's need to be cleaned because there was only one nurse and one nurse's aide helping other residents. The spouse said he regretted bringing her to the facility because she now had another pressure ulcer and an injury to her knee needing treatment at the wound clinic. He said he believed the lack of sufficient staff to provide care contributed to her new pressure ulcer wound. Interview was conducted via telephone on 03/13/19 at 4:24 P.M. with Clinical RN Manager #802 from the wound clinic. The interview revealed that Resident #92 had been going to the wound clinic since 02/04/19 for the treatment of [REDACTED]. Clinical RN Manager #802 explained that Resident #92 presented on 03/11/19 with a new pressure ulcer, a Stage III pressure area of the right gluteus measuring 0.2 cm length by 0.2 cm width by 0.1 cm deep, requiring treatment. Observation of Resident #92's wounds was conducted on 03/14/19 from 10:19 A.M. to 10:53 A.M. with RN #801, the Director of Nursing (DON), LPN #604 and Resident #92's spouse. The staff verified there was a right gluteal pin point size pressure ulcer with a red wound base. There was a left ischium gluteal fold pressure ulcer which was large and deep and was packed with gauze. There was bloody drainage from this pressure ulcer after removal of the gauze packing. There was a left lower posterior leg pressure ulcer with a reddened base with eschar (black/brown dead tissue) The resident had no complaints of pain during the observation. The Multi Wound Chart Details provided via fax from the wound clinic where Resident #92 was treated on 03/14/19 at 8:27 A.M. The details were dated 03/11/19 and reported as follows: Wound #1, left ischium Stage III pressure injury, date acquired 12/03/18 measuring 6.0 cm in length by 7.0 cm in width by 4.1 cm in depth; Wound #2, left lower leg Stage III pressure injury date acquired 12/03/18 measuring 4.5 cm length by 5.0 cm width by 0.3 cm depth; Wound #3: right gluteus Stage III pressure injury dated acquired 03/11/19 measuring 0.2 cm length by 0.2 cm width by 0.1 cm depth. Interview was conducted on 03/14/19 at 4:12 P.M. with the Director of Nursing (DON). Resident #92's pressure ulcer documentation was reviewed with the DON. The DON who verified the documentation on the wound report and stated the facility had not made any attempt to collect the wound clinic reports until it was requested by the state agent during the annual survey. The DON verified the pressure ulcer wound documentation/assessments were incomplete and did not include descriptions of the area around the ulcer, any odor and the presence of any drainage.

Based on observation, record review and interview the facility failed to prevent the development of suspected deep tissue injury (SDTI) pressure ulcers to Resident #1's coccyx and left heel. The facility also failed to ensure timely pressure ulcer care and interventions were implemented following the development of the ulcers. Actual harm occurred when Resident #1, who was comatose and totally dependent on staff for all care, developed two SDTI (intact skin with localized areas of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) pressure ulcers to the coccyx and left heel within 12 days of admission to the facility. The pressure ulcer to the coccyx subsequently progressed to a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer. This affected one resident (Resident #1) of three residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/23/17 revealed the resident was in a comatose state and totally dependent on staff for all care including toileting and bed mobility. The MDS assessment revealed the resident had no pressure ulcers present at that time. Review of the resident's physician's orders [REDACTED]. Record review revealed a skin assessment, dated 10/25/17 indicating two new areas of skin breakdown, both assessed to be SDTI pressure ulcers. The skin assessment revealed an area to the coccyx measuring 5.4 centimeters (cm) in length by 6.5 cm in width with 0.1 cm in depth, and an area to the left heel measuring 5.2 cm in length by 2.5 cm in width with no depth documented. The assessment form identified an SDTI as developing from pressure and/or shear. The assessment revealed the coccyx pressure ulcer had an onset date of 10/24/17 and the pressure ulcer on the left heel appeared to have resulted from the foot-drop boot. There were no nursing progress notes or documentation contained on the skin assessment dated [DATE] indicating dressings or other wound care interventions were in place prior to or at the time the pressure ulcers were identified. Review of the resident's treatment administration record revealed the first documented application of a dressing was dated 10/27/17 (three days after the pressure ulcers were identified). Review of a wound assessment, dated 11/03/18 revealed the coccyx wound was assessed to be unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) measuring 5.5 cm in length by 4.0 cm in width with 0.2 cm depth. The facility assessed the pressure ulcer to the left heel to heal on 12/06/17. The most recent assessment of the coccyx wound, dated 01/24/18 revealed the coccyx pressure ulcer was assessed to be a Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) measuring 4.5 cm in length by 2.6 cm in width with 2.7 cm depth. Observation of a wound dressing change procedure for Resident #1 on 01/31/18 at 10:19 A.M. revealed the pressure ulcer on the coccyx continued to be a Stage IV pressure ulcer. Interview with the Director of Nursing (DON) on 01/30/17 at 3:44 P.M. revealed skin integrity was to be checked on admission, on shower days, and with each check for incontinence. She confirmed Resident #1 was assessed to have two SDTI pressure ulcers that were both over five cm in length at the time they were found, 12 days after admission. The DON verified the area to the heel was caused by the foot drop boot. The DON also verified there was a delay in wound care, treatments and skin interventions being implemented between 10/24/17 the date the ulcers were identified and 10/27/17.

Based on observation, record review and interview the facility failed to appropriately address symptoms of pain for one resident (Resident #59) during treatment administration. Actual harm occurred when Resident #59 was observed screaming that he was in pain and pushing staff away during a dressing change to the right heel. This affected one of four residents reviewed for pain. Findings include: Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] indicated Resident #59 had severe cognitive impairment. Resident #59 required extensive assistance with bed mobility, transfers, and hygiene. Resident #59 was dependent for toileting and bathing and always incontinent of bowel and bladder. The MDS indicated Resident #59 had an unstageable pressure ulcer to the right heel that was a venous and arterial ulcer. Review of a skin/wound note dated 08/31/15 at 12:00 P.M. indicated Physician #119 stated that she was in to see Resident #59 for a right heel pressure area which measured 5.2 centimeters (cm) in length by 3.7 cm in width by an undetermined depth. A review of the September, 2015 physician's orders [REDACTED]. A review of the September, 2015 Medication Administration Record [REDACTED]. An observation of wound care to the right heel of Resident #59 on 10/05/15 at 1:35 P.M. performed by Physician #119 revealed Resident #59 screamed out that he was in pain during the entire dressing change, stating there are tears in my eyes while pushing staff away during the treatment. Interview with State tested Nurse Aide (STNA) #110 on 10/06/15 at 2:38 P.M. revealed anytime they touch Resident #59 he has pain, not just with dressing changes. Interview with STNA # 118 on 10/06/15 at 4:09 P.M. revealed Resident #59 always complained of pain with dressing changes. Interview with Licensed Practical Nurse (LPN) #106 on 10/06/15 at 4:30 P.M. revealed the [MEDICATION NAME] Patch had helped with Resident #59's pain but did not manage it completely as he still had pain. An interview with LPN #93, the facilities corporate clinical nurse who was present during the dressing change, verified on 10/06/15 at 4:55 P.M. Resident #59 continued to have pain with the dressing change observed on 10/05/15.

Based on observation, record review and interview the facility failed to implement interventions and provide treatment per physician's orders to prevent the deterioration of a pressure ulcer for Resident #59. Harm occurred when Resident #59's in-house acquired bilateral heel wounds deteriorated from reddened Stage I pressure ulcers to unstageable pressure ulcers with 100 percent eschar (full thickness tissue loss in which actual depth of the ulcer was completely obscured) causing per the resident, terrible pain in the right heel. This affected one resident (Resident #59) of three resident's reviewed for pressure ulcers. Findings include: Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the nursing admission screening history, dated 02/16/15 stated bilateral heels, back/mid spine, and, coccyx red. There was no stage or measurements documented. A review of the physician's orders revealed orders, dated 02/16/15 to float heels up off of the bed with pillow or support at all times when in bed and a pressure reduction mattress to bed at all times to preserve skin. A Braden scale for predicting pressure sore risk, dated 02/23/15 assessed the resident to be at moderate risk for skin breakdown with a score of 14. A review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. The resident had no behaviors noted. The resident required extensive assistance with bed mobility, hygiene and dressing. The resident was frequently incontinent of bowel and occasionally incontinent of bladder. The MDS stated the resident had three Stage I (observable, pressure-related alteration of intact skin) pressure ulcers upon admission and was at risk for developing pressure ulcers. The Care Area Assessment (CAA) dated 03/01/15 revealed the resident was admitted with Stage I pressure ulcers to the bilateral heels and mid spine. The CAA revealed he utilized a pressure relieving mattress to his bed with heels floated, cushion to his wheelchair and was turned and/or repositioned at least every two hours with perineal care and linen changes as needed. Barrier cream was applied for excoriation to groin and buttocks. Record review revealed there were no documented assessments of the pressure ulcer to the mid spine after 03/01/15. A review of the nurse's notes revealed an entry, dated 03/09/15 at 7:39 P.M. indicating the resident had an area on the right medial heel area of impaired skin integrity noted 0.5 centimeters (cm) in length by 0.5 cm in width by less than 0.1 cm in depth. A call was placed to the physician's cell phone and message left to update. A treatment of [REDACTED]. The next nurse's note relevant to the resident's skin integrity was dated 03/16/15 at 3:09 P.M. stating that the physician was in to see the resident for the right heel. The note indicated that the area was not currently open, it was now red non-blanching, and a new order was noted to discontinue the hydrogel and continue to pad and protect. The physician also looked at the left heel. The note stated that left heel currently remains intact. The next nurse's note relevant to the resident's skin integrity was dated 03/23/15 at 2:32 P.M. stating that the physician was in to see the resident. The right medial heel was noted to be dark purple non-blanching area measuring 0.9 cm in length by 0.4 cm in width by 0 cm in depth. The physician reported the area was a pre vascular ulcer. No new orders were given at this time, and the resident's left heel remained intact. The next nurse's note relevant to the resident's skin integrity was dated 03/30/15 at 2:46 P.M. stating that the physician was in to see the resident for the right heel. The measurements obtained were 0.8 cm in length by 1.8 cm in width by 0 cm in depth and noted during rounds a new dark purple non-blanching area to right dorsal foot measuring obtained 0.4 cm in length by 1.1 cm in width by 0 cm in depth. A new order was noted to apply a foam dressing to right dorsal foot. The next nurse's note relevant to the resident's skin integrity was dated 04/06/15 at 6:51 P.M. stating that the physician was in to see the resident for the right heel impaired skin integrity with measurements obtained 2.1 cm in length by 2 cm in width with an determined (UTD) depth, and an area to the right lateral and dorsal foot 1 cm in length by 0.4 cm in width by UTD cm in depth pre vascular ulcers. The next nurse's note relevant to the resident's skin integrity was dated 04/20/15 at 4:43 P.M. stating the physician was in to see the resident and was unable to obtain measurements or apply dressings during rounds related to the resident was agitated yelling at staff no get out of here shove it up your ass. The next nurse's note relevant to the resident's skin integrity was dated 04/27/15 at 4:19 P.M. stating that the physician was in to see the resident for the right heel ulcer, measurements obtained indicated the ulcer was six cm in length by four cm in width by UTD depth. The ulcer was described to have 100 percent black eschar present. The right lateral foot ulcer measures 0.5 cm in length by 0.4 cm in width by 0 cm depth purple area non-blanching, and to right dorsal foot 2 cm in length by 1.8 cm in width by 0 cm in depth purple non-blanching area. The next nurse's note relevant to the resident's skin integrity was dated 05/11/15 at 4:17 P.M. stating the physician was in to see the resident for vascular areas to the resident's bilateral feet. The right lateral foot currently resolved, the right dorsal foot measurements obtained were 1.8 cm in length by 1.9 cm in width with no depth; purple non-blanching area and to right heel measurements obtained 3 cm in length by 4.5 cm in width by UTD depth, black eschar, and the ulcer to the left dorsal foot measured 0.8 cm in length by 1 cm in width by 0 cm in depth purple non-blanching area. The next nurse's note relevant to the resident's skin integrity was dated 05/18/2015 at 3:29 P.M. stated the physician was in to see the resident and the measurements were obtained. The left dorsum foot 0.8 cm in length by 0.9 cm in width by 0.1 cm in depth, and right dorsum foot 1.8 cm in length by 1.5 cm in width by UTD depth. The right heel measured 3 cm in length by 4.5 cm in width by UTD depth. The next nurse's note relevant to the resident's skin integrity was dated 05/25/15 at 6:21 P.M. and stated vascular ulcers remain. The left dorsal foot area measures 1.2 cm in length by 1.4 cm in width by UTD depth due to an area of brown dry crust with no drainage, no odor, temperature normal to touch and the wound margins were intact. The resident had no complaints of pain voiced during treatment changes. The right dorsal foot measured 3.2 cm in length by 1 cm in width by UTD depth due to an area of dry brown crust with no drainage noted, no odor, temperature was normal to touch, and the wound margins were intact. The resident had no complaints of pain voiced with treatment. The ulcer to the right heel measured 4.2 cm in length by 4.2 cm in width by UTD depth due to the wound was covered by 100 percent black eschar. The wound margins were intact with no drainage, no odor, temperature normal to touch, and no complaints of pain were voiced during the dressing change. The next nurse's note relevant to the resident's skin integrity was dated 06/1/15 at 3:46 P.M. stating the physician was in to see the resident. Right dorsal foot measurements obtained 3.2 cm in length by 1.5 cm in width by UTD depth due to an area of dry brown crust. The right heel vascular ulcer measured 4.5 cm in length by 3 cm in width by UTD depth due to the area was covered 100% black eschar. The left dorsal foot 0.3 cm in length by 0.3 cm in width and UTD depth due to an area of dry brown crust. A nurse's note dated 06/08/15 at 1:18 P.M. stated the physician was in to see the resident for vascular areas to left dorsal foot measuring 0.2 cm in length by 0.2 cm in width by UTD depth due to an area of dry brown crust. The right dorsal foot measured 3.2 cm in length by 1.5 cm in width by UTD depth due to an area of dry brown crust. The right heel measured 4.5 cm in length by 3 cm in width by UTD depth due to an area of dry black eschar. A nurse's note dated 06/15/15 at 2:47 P.M. stated the physician was in to see the resident. The left dorsal foot area measured 0.7 cm in length by 0.7 cm in width with an area of dry brown crust. The right dorsal foot area measured 2 cm in length by 1.1 cm in width with dry brown crust. The right heel area measured 4.5 cm in length by 3.8 cm in width by UTD depth due to dry black eschar. A nurse's note dated 06/22/2015 stated that the physician was in to see the resident. The left dorsal foot vascular ulcer measured one cm in length by 0.9 cm in width with dry crust. The ulcer to the right dorsal foot area was resolved. The right heel ulcer measured 5.2 cm in length by 3.7 cm in width by UTD depth due to area covered by 100% black eschar. A review of the 02/16/15 through 03/31/15 treatment administration record (TAR) revealed no documented evidence the resident refused offloading heels per physician's orders. A review of the April 2015, May 2015 and June 2015 TAR revealed the treatment to apply a foam dressing to the right dorsal foot with dressing change to right heel to be completed every Monday, Wednesday, and Friday was not completed as ordered on the following days: 04/03/15, 04/06/15, 04/10/15, 04/20/15, 05/04/15, 05/22/15, 06/01/15, 06/03/15, 06/08/15, 06/12/15, 06/19/15, 06/24/15, and 07/03/15. The treatment to pad and protect the left heel with an abdominal (ABD) pad and secure with wrap every Monday, Wednesday, and Friday was completed as ordered on: 04/03/15, 04/06/15, 04/10/15, 04/20/15, 05/04/15, 05/22/15, 06/01/15, 06/03/15, 06/08/15, 06/12/15, 06/19/15, and 06/24/15. The treatment to pad and protect the mid spine with an ABD pad folded in half and secure with tape to preserve skin integrity every Monday and Thursday was not completed as ordered on: 04/06/15, 04/20/15, 05/04/15, 05/07/15,, 05/14/15, 06/01/15, 06/08/15, 06/11/15, and 06/25/15. The treatment ordered to pad and protect the right heel, apply ABD pad and secure with wrap was not completed as ordered on: 04/03/15, 04/06/15, 04/10/15, 04/20/15, 05/04/15, 05/22/15, 06/01/15, 06/03/15, 06/08/15, 06/12/15, 06/19/15, and 06/24/15. There was no documented evidence the resident refused to have his heels floated with the exception of 06/16/15, 06/22/15, and 07/06/15. A review of the May 2015, June 2015 and July 2015 Medication Administration Record [REDACTED]. and 06/10/15 at 5:17 P.M. On 07/08/15 at 3:48 P.M. an observation of Resident #59 revealed the dressings that were ordered to the resident's bilateral feet were slid up on to his lower legs, his heels were lying flat on the mattress, he was on a standard pressure reduction mattress which was rated for a Stage II pressure ulcer or below. The resident's heels were not floated and there were no pillows on the bed to float heels. This was verified on 07/08/2015 at 4:01 P.M. by Licensed Practical Nurse (LPN) #11. On 07/09/15 at 1:55 P.M. the resident was observed with his heels directly on the mattress and no pillows on the bed. This was verified on 07/09/15 at 2:00 P.M. by LPN #12. Interview with the Resident 07/09/15 at 1:50 P.M. revealed the resident stated his right heel hurts very bad. On 07/09/15 at 2:45 P.M. LPN #12 and State tested nursing assistant (STNA) #13 were observed to prepare to complete the resident's dressing change. Upon entering the resident's room, the resident began yelling, don't touch it, it hurts terribly. LPN #12 stated I gave him [MEDICATION NAME] (an appetite stimulant). LPN #12 then stated I know it's an appetite stimulant, but it should help. STNA #13 stated he always complains of pain, his heel is really black, it's terrible. LPN #12 verified the resident frequently complains of pain to the heels. STNA #12 and LPN #11 also indicated the resident frequently refused to offload his heels. On 07/09/15 at 3:15 P.M., interview with LPN #10 revealed Resident #59 was assessed to have Stage I pressure ulcers to his bilateral heels after his admission to the facility. LPN #10 indicated she was aware the physician noted the areas were vascular, however, they all presented on pressure points. LPN #10 revealed no vascular studies had ever been completed to assess for the extent of vascular insufficiency. She also verified the resident did not have appropriate pressure reduction interventions in place for his wounds as noted during the above observations. LPN #10 verified the treatments were not signed as completed on numerous occasions between April 2105 and July 2015. During the interview, LPN #10 stated the resident frequently refused to offload his heels, but verified that there was no documented evidence of such, with the exception of three days since admission. LPN #10 verified the resident had only received [MEDICATION NAME] for pain relief on 05/26/15 at 3:19 AM. and 06/10/15 at 5:17 P.M. and exhibited pain to the heel areas and increased pain with dressing changes with no evidence an effective pain management program had been initiated.

Based on observation, record review and interview the facility failed to implement an effective pain management program for Resident #59 related to alterations in skin integrity. Harm occurred when Resident #59's in-house acquired bilateral heel wounds deteriorated causing per the resident, terrible pain in the right heel with no evidence of a pain management program being implemented. This affected one resident (Resident #59) of three resident's reviewed for pressure ulcers. The facility also failed to complete x-rays as ordered by the physician for Resident #12, one of four residents reviewed for medication administration and for Resident #14, one of one resident reviewed for ventilator use of 11 residents with ventilators in the facility. The facility census was 52. Findings include: 1. Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the nursing admission screening history, dated 02/16/15 stated bilateral heels, back/mid spine, and, coccyx red. A review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. The resident had no behaviors noted. The resident required extensive assistance with bed mobility, hygiene and dressing. The resident was frequently incontinent of bowel and occasionally incontinent of bladder. The MDS stated the resident had three Stage I (observable, pressure-related alteration of intact skin) pressure ulcers upon admission and was at risk for developing pressure ulcers. Record review revealed from admission through current date, the resident developed additional ulcers to his bilateral feet and the ulcers present deteriorated from Stage I pressure ulcers to unstageable pressure ulcers. See additional findings under F314 related to actual ulcer measurements and descriptions. A nurse's notes entry, dated 04/20/15 at 4:43 P.M. revealed the physician was in to see the resident and was unable to obtain measurements or apply dressings during rounds related to the resident was agitated yelling at staff no get out of here shove it up your ass. A review of the 02/16/15 through 03/31/15 treatment administration record (TAR) revealed no documented evidence the resident refused offloading heels per physician's orders [REDACTED]. A review of the May 2015, June 2015 and July 2015 Medication Administration Record [REDACTED]. and 06/10/15 at 5:17 P.M. On 07/08/15 at 3:48 P.M. an observation of Resident #59 revealed the dressings that were ordered to the resident's bilateral feet were slid up on to his lower legs, his heels were lying flat on the mattress, he was on a standard pressure reduction mattress which was rated for a Stage II pressure ulcer or below. The resident's heels were not floated and there were no pillows on the bed to float heels. This was verified on 07/08/2015 at 4:01 P.M. by licensed practical nurse (LPN) #11. On 07/09/15 at 1:55 P.M. the resident was observed with his heels directly on the mattress and no pillows on the bed. This was verified on 07/09/15 at 2:00 P.M. by LPN#12. Interview with the Resident 07/09/15 at 1:50 P.M. revealed the resident stated his right heel hurts very bad. On 07/09/15 at 2:45 P.M. LPN #12 and State-tested Nurse Aide (STNA) #13 were observed to prepare to complete the resident's dressing change. Upon entering the resident's room, the resident began yelling, don't touch it, it hurts terribly. Licensed Practical Nurse (LPN) #12 stated I gave him [MEDICATION NAME] (an appetite stimulant). LPN #12 then stated I know it's an appetite stimulant, but it should help. STNA #13 stated he always complains of pain, his heel is really black, it's terrible. LPN #12 verified the resident frequently complained of pain to the heels. STNA #12 and LPN #11 also indicated the resident frequently refused to offload his heels. On 07/09/15 at 3:15 P.M., interview with LPN #10 revealed the resident had only received [MEDICATION NAME] for pain relief on 05/26/15 at 3:19 AM. and 06/10/15 at 5:17 P.M. and exhibited pain to the heel areas and increased pain with dressing changes with no evidence an effective pain management program had been initiated to decrease and/or effectively manage the resident's pain related to his impaired skin integrity. 2. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #14 had chest x-ray completed 06/10/15 that indicated left lower lobe atelectasis (partial or complete collapse of the lung). She had a physician's orders [REDACTED]. She had a chest x-ray completed 06/12/15 that indicated there was some clearing of the left lung base. There were physician's telephone orders dated 06/18/15 and 07/02/15 that included orders for a chest x-ray for history of pneumonia. There was a second telephone order dated 07/09/15 that included a second request for a chest x-ray for re-evaluation for history of pneumonia. There was no evidence that the chest x-rays ordered on [DATE] or 07/09/15 were completed. The above finding was verified with the Licensed Practical Nurse (LPN) #10 on 07/14/15 at 9:51 A.M. 3. Resident #12 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Resident #12 was observed during medication administration with licensed practical nurse (LPN) #11 on 07/13/15 at 8:20 A.M. in her room with a [MEDICAL CONDITION] and on a ventilator. She was attempting to get out of bed and told the nurse she was trying to go to work. Record review to verify the medications administered revealed a physician order [REDACTED].#12's history of pneumonia along with some laboratory testing. On 06/18/15, the physician wrote another order for the chest x-ray and indicated it was ordered last week and wanted to know the results. On 06/25/15, the physician wrote this was the third week he was re-ordering a chest x-ray and wanted to know what was the problem. On 07/09/15, the physician wrote an order to get the results of the chest x-ray that was originally ordered on [DATE] for pneumonia. The above orders were reviewed with the assessment nurse, Licensed Practical Nurse (LPN) #10 on 07/13/15 at 9:00 A.M. and the test results were requested. At 9:13 A.M., LPN #10 provided the chest x-ray results. She verified the chest x-ray was not completed until 06/25/15 and the results were not faxed to the physician until until 07/10/15, almost a month after the original chest x-ray order.

Based on record review, staff and resident interview the facility failed to ensure Resident #49 was free from emotional/psychological abuse. The facility also failed to ensure Resident #17 and Resident #53 were free from verbal abuse. This resulted in harm to Resident #49, who was documented as crying following an incident of abuse being reported. The resident wrote the facility staff a letter describing his continued anger and pain two months after the original incident and currently continued to voice his pain related to the incident and ongoing thoughts and concerns over the incident. These affected three residents (Resident #49, #53 and #17) of five residents reviewed for abuse. Findings include: 1. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment/Minimum Data Set (MDS) 3.0 assessment, dated 06/16/15 revealed a cognitive score of 15, with scores of 13-15 indicating the person was alert and oriented. This assessment revealed no behaviors and no symptoms of [MEDICAL CONDITION]. The mood section indicated he had trouble sleeping and felt bad about himself 12-14 days of the last two week reference frame, which was nearly everyday. Review of the facility's self-reported incidents (SRIs) revealed an allegation made, dated 11/11/14 as an allegation of neglect. The report indicated Resident #49 was upset and crying and did not want the alleged perpetrator, State-tested Nurse Aide (STNA) #21 to care for him anymore. Resident #49 reported he was going to make a quick trip to the kitchen when STNA #21 told him to put socks on and tried to block the doorway. He restated his case that he was just going to walk to the kitchen and come right back to his room. Resident #49 reported STNA #21 then did move and he went to the kitchen. He stated he sat in his doorway when he returned and STNA#21 came out of another resident room and dropped soiled linen on his feet and said, Opps I dropped urine soaked linen on your feet, you should have had your socks on and then laughed and walked away. He indicated STNA #22 witnessed the incident and she said, oh my gosh, are you ok. STNA #22 did later report in her statement that STNA#21 had dropped the soiled linen on Resident #49's feet and said she was sorry. STNA #22 said she asked Resident #49 if he was okay and then he went into his room. There was no documentation from STNA #22 related to STNA #21's tone or attitude towards Resident #49. The facility investigation contained interviews with numerous other residents and they asked these residents if STNA #21 had ever mistreated them in any way. Resident #17, who was alert and oriented with a cognitive score of 13 on her 06/08/15 MDS, indicated STNA #21 had smacked her hand before. Resident #40, who had a cognitive score of 15 on her 05/25/15 MDS, indicated STNA #21 was opinionated and tells her No at times. Resident #23, with a cognitive score of 15 on her 04/23/15 MDS, indicated STNA #21 had an attitude at times. Resident #15, with a cognitive score of 15 on her 04/03/15 MDS, said STNA #21 could be a little forceful. Resident #26, with a cognitive score of 15 on his 05/25/15 MDS, said STNA #21 was grumpy and had her days. Resident #80, with a cognitive score of 15 on his 01/14/15 MDS, indicated STNA #21 was mean and rude. Resident #80 was discharged from the facility on 03/10/15. There were no investigations completed by the facility for any of these identified resident concerns involving STNA #21. The facility did not substantiate the allegation made by Resident #49's even though the resident was alert and oriented and other residents voiced concerns about the same STNA. The facility summary indicated the opposite and said there were no other residents who had said they had been abused by STNA #21 but they felt she was sometimes short, opinionated or forceful. The only intervention listed by the facility was to in-service staff on infection control issues and and to bag soiled linen when leaving a resident room. Resident #49 wrote a letter to the facility staff on 01/10/15, almost two months later, and reiterated the same incident and indicated he was writing the letter about this incident because the pain and more so, the anger, was not going away. There was no evidence of any facility response to this letter. On 07/14/15 at 2:10 P.M., Resident #49 was interviewed privately in his room. He verified the incident which occurred back in November 2014 when STNA #21 dropped the soiled linen on his feet, wet with urine. He said he felt it was done on purpose since STNA #21 had stopped him and told him to put socks on when he was walking to the kitchen and blocked his path. After he again explained he was going to walk to the kitchen the STNA did move out of his way. He said he walked for exercise to the kitchen and came back and sat in the doorway of his room. He said STNA #21 came out of resident room a couple doors away with an arm full of soiled linen and dropped it on his feet. He said he only knew it was soiled because STNA #21 told him it was soiled with urine and smirked and sarcastically said, Opps I dropped the soiled linen on your feet, maybe you should have put your socks on and walked away laughing. The resident shared, at the bariatric meeting on 11/12/14, he reported the incident to the leader of the meeting (unsure of her name but she no longer worked at the facility) and she reported it to administration. He said the facility suspended STNA #21 and then she did return to work. She was not supposed to come in his room but she would come in and bring his tray or go into the bathroom and say she had to unlock the bathroom door on the other side into another resident's room. Resident #49 said he did report this and the facility finally moved STNA #21 to work on the other side of the building and he does not see her now. He said it really bothered him that the facility only instructed staff on proper infection control and linen handling and did not acknowledge what the STNA did to him. He said he still thinks about it every day and that he burst out crying at Thanksgiving in front of everyone when thinking about the incident, he was so embarrassed. He said he could only keep it inside so long and he said it has been the most gut wrenching experience of his whole life. An interview was conducted with the Administrator and the director of nursing (DON) on 07/14/15 at 2:35 P.M. They verified the residents voicing concerns about STNA #21 were alert and oriented residents and verified they unsubstantiated an incident of abuse or neglect had occurred. The administrative staff indicated they did not think Resident #49 had ever complained about other staff members before like this but did complain about other things like his medications. They verified they had not gone back to re-interview the other residents who had negative comments about the care and abuse from STNA #21 to see what they meant or about any specific incidents that had happened to them. The Administrator and DON returned at 4:20 P.M. on 07/14/15 and indicated that STNA #21 had been permitted to work on the side of the building where Resident #49 resided but she was not supposed to care for him. They indicated they later moved STNA #21 to work on the other side of the building because Resident #49 reported he did not want to see her anymore. They were made aware that Resident #49 had reported that STNA #21 had come into his room even after she was not supposed to and that was why he asked for her to be moved to the other side of the building. On 07/20/15 at 2:15 P.M. an interview with the administrator revealed STNA #21 was permanently moved to the Shorehaven unit on 01/30/15 which eliminated contact between Resident #49 and the STNA. There was no evidence/documentation found to indicate STNA #21 provided any further care to Resident #49 since this date. A telephone interview was conducted with STNA #21 on 07/20/15 at 2:50 P.M. STNA #21 indicated she did recall an incident involving Resident #49. She said she had been in another resident ' s room and came out with her arms overflowing with dirty linen. She said some of the dirty linen fell off of the bottom of the pile and fell on Resident #49's feet. She said he had been in his wheelchair, partially sticking out into the hallway. She said she apologized profusely and offered to wash his feet but he said he was fine. She did not recall Resident #49 being upset or mad or anything. She indicated there had been no previous incidents with Resident #49 on that day or any time before this incident. She was not made aware of the problem until a few days later when she was called to the front office and was asked to write a statement. STNA #21 said they put her off work to do an investigation. She had a second meeting with the facility the next Monday and said she was suspended for the handling of the soiled linen. She again told them it was an accident and said she does what she can for all residents. STNA #21 said she never returned to work Shorehaven Unit on a regular basis. She only worked Shorehaven if she came in early like 3:00 A.M. but said she never went into Resident #49's room. She only answered his call light at the room door to make sure he was okay if no other staff were around. STNA #21 said she never provided care again to Resident #49. Review of the psychiatric services notes from 12/09/14 revealed Resident #49 was anxious, irritable, complained of not sleeping well, upset, irritable, low frustration tolerance and was moody. He was listed as having impaired cognition, limited insight and judgment. This assessment indicated he was worse. The plan was to increase his Trazadone from 100 milligrams (mg) to 150 mg at bedtime to help him sleep. The next psychiatric visit on 02/18/15 revealed staff reported increased sleeping in the daytime. He was cheerful, denied feeling sad, and was anxious at times but indicated his [MEDICATION NAME] medication worked. He still reported not sleeping at night. His cognition was intact and he had fair judgment and insight. The plan was to discontinue the Trazadone and [MEDICATION NAME] mg at bedtime for sleep. The next progress note on 03/12/15 indicated Resident #49 complained of staff problems, talked about going home and legal problems. This note indicated Resident #49 was improving. The last psychiatric progress note was on 07/08/15. It indicated staff reported no problems with Resident #49. He was documented as having a normal mood, intact cognition with fair insight and judgment. They discontinued [MEDICATION NAME] and discharged him from psychiatric services and indicated the target symptoms he had were chronic and recurrent. The facility also provided notes from social service designee (SSD) #30 on 07/20/15. These notes began on 12/15/14 and said she met with Resident #49 for a follow-up from the previous investigation (of the incident involving STNA #21). Resident #49 indicated he was not happy with the results of the investigation and wanted STNA #21 terminated and not just moved to the other unit. This SSD reassured Resident #49 that STNA #21 would not be caring for him any longer. The next SSD note was on 12/20/14 and indicated Resident #49 was in good spirits but was still upset with STNA #21. The last note from SSD #30 on 01/30/15 indicated she met with Resident #49 again and he had no complaints and seemed to be in good spirits, however he did say he was still upset with STNA #21 and the linens issue. The SSD indicated she did tell Resident #49 that STNA #21 was not allowed to take care of him and she worked on Shorehaven unit and Resident #49 said that was okay. There were no other social service notes to documentation of further ongoing concerns related to STNA #21. 2. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17's most recent MDS 3.0 assessment, dated 06/08/15 revealed a cognitive score of 13, with scores of 13 to 15 indicating the person was alert and oriented. This assessment indicated Resident #17 required extensive assistance with one to two staff for all of her activities of daily living. A facility Self Reported Incident (SRI) was reviewed from 09/19/14 involving Resident #17, with allegations listed as emotional and verbal abuse. The facility concluded the allegation was unsubstantiated. The facility SRI indicated Resident #17 had said, (expletive) F*** you, to State-tested Nurse Aide (STNA) #18 and then the other STNA in the room, STNA #35, said, (expletive) F*** you, back to Resident #17 and then said she was kidding. The witness statement from Resident #23 (cognitive score of 15 on her 04/23/15 MDS) indicated she lived across the hall from Resident #17 and said it was approximately 9:30 P.M. and she was laying on her bed. She said she saw STNA #18 push Resident #17 into her room with STNA #35. Resident #23 said she heard Resident #17 say you are hurting me and she heard both aides arguing with Resident #17 to get her pants off. She said STNA #18 said Resident #17 had kicked her and she said she was not going to take her pants off and Resident #17 called STNA #18 a [***] and then STNA #18 left the room. STNA #35 was still in the room and she and Resident #17 were arguing and the resident cussed her and said, (expletive) F*** you, and STNA #35 said FU and then, (expletive) F*** you too, and then said she was kidding. The interview statement taken from Resident #17 on 09/19/14 said she called STNA #18 a (expletive) F***ing[***] and the aide got real close to her face and as the aide backed away she said she kicked her in the face. The statement from STNA #35 written on 09/21/14 indicated she came in to work as there had been a call off and STNA #18 was working alone. She said they had put Resident #17 to bed and she was cussing and kicking at STNA #18. She said as the two STNAs walked out of the room Resident #17 said, (expletive) F*** you, and STNA #35 said she said FU too and then said she was kidding. She indicated it was a stressful evening but she was joking with Resident #17. The statement from STNA #18 on 09/18/14 indicated she had worked over on 09/18/14 and Resident #17 had wanted to go to bed at 8:30 P.M. but agreed to wait until 9:00 P.M. when STNA #35 was coming into work as Resident #17 was a two person transfer. When STNA #35 got to work it was so busy they didn't put Resident #17 to bed until almost 10:00 P.M. Resident #17 was mad and cussing because she had to wait forever. STNA #18 said they transferred her to bed and tried to take her pants off. Resident #17 said she hurt her leg and kicked her in the face. STNA #18 said she asked STNA #35 to finish the care and left the room. She said Resident #17 started cussing at STNA #35 so she walked out and as she was walking out Resident #17 said, (expletive) f*** you, and STNA #35 said, (expletive) f***, I mean FU too and said the resident's name. The statement from Licensed Practical Nurse (LPN) #24 on 09/22/14 indicated STNA #18 and #35 had reported to her about 9:30 P.M. that Resident #17 was crazy and had been cussing at them. They did not report that STNA #35 had cussed back at Resident #17. Other residents were interviewed and no one else said STNA #35 swears except Resident #23 and Resident #17. The facility indicated the incident was unsubstantiated and their interventions were to first speak to Resident #17 about her language towards the staff but then also did write up STNA #35 for being unprofessional around residents and encouraged her to take a break if she if feeling overwhelmed. They indicated they also educated STNA #18 to notify the nurse of any incident. An interview was conducted with the Administrator and the Director of Nursing (DON)on 07/14/15 at 2:35 P.M. They verified they had unsubstantiated the incident even though the statements taken from the witness across the hall and the two STNAs themselves verified STNA #35 had cussed at Resident #17. The administrator verified their conclusion was unsubstantiated because on re-interview, Resident #17 said STNA #35 only cusses in front of her and not at her even though the two STNAs admitted it happened. 3. Record review revealed Resident #53 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment the resident had limited cognitive abilities. Review of the Self-Reported Incident report (SRI) dated 01/22/15 revealed an allegation of verbal abuse involving Resident #53 that had occurred on 01/22/15 at 9:20 A.M. The summary of incident completed by the administrator stated two nurses, Registered Nurse (RN) #16 and RN #17 overheard State-tested Nurse Aide (STNA) #18 yell shut up to Resident # 53. The document indicated STNA #18 was leaning over the resident's bed asking the resident why are you yelling, I just changed you and the resident responded I don't know. The summary stated STNA #18 was asked to leave the facility immediately pending an investigation. Review of the witness statement from RN #16 revealed she had heard Resident #53 in her room yelling out. She said she and RN #17 who was in training heard someone yell shut up to the resident. She said she immediately went to resident's room and saw STNA #18 with her hand on the handrail of the resident's bed. She was leaning over the bed stating why are you yelling, I just changed you. Resident #53 stated I don't know. She said that she immediately notified the administrator and Director of Nursing (DON)about what she heard. Review of the witness statement of RN #17 revealed she heard Resident #53 yelling out that someone told her to shut up loudly. Review of STNA #18's witness statement revealed Resident #53 was screaming and that she said her name three times to see what she was screaming for. She said her voice was gone so she had to yell to get her attention. The resident said that she was bored and felt like yelling so STNA #18 said she asked she asked her to please stop screaming and walked out of the room. On 07/14/2015 at 2:51 P.M. an interview with the Administrator was conducted regarding the incident. She stated she marked the allegation as suspected abuse and terminated STNA #18 but, because she felt the evidence was inconclusive she marked it as unsubstantiated. She said when she interviewed Resident #53 that she was confused and did not remember anything about the alleged incident. At this time the administrator revealed she did think verbal abuse had occurred and for that reason she terminated the employee.